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Cutaneous Horn
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https://t.me/med1917
One day, I noticed a horn growing on my grandmother’s
forehead (Fig.92.1).
A 79-year-old female patient, Ms. K, had a hard horn-like
growth on her forehead, which worried her son, daughter-inlaw, and granddaughter who brought her in. Upon closer
examination, various skin lesions caused by photoaging due
to long-term sun damage were observed. Deep wrinkles,
solar lentigo, actinic keratosis, and other skin changes due to
photoaging were present, and a small cutaneous horn caused
by actinic keratosis was found on her forehead.
A cutaneous horn is a conical protrusion of excessive keratinization on the skin surface, clinically similar to an animal’s
horn. While an animal’s horn is histologically composed of
epidermal hyperkeratosis, dermis, and central bone, a human
cutaneous horn is formed by a signicant increase in the thickness of the epidermal stratum corneum, thus composed only of
keratin. Cutaneous horn is not a pathological diagnosis but a
clinical term for a unique lesion that occurs as a result of various benign, malignant, and precancerous diseases. The underlying conditions that can cause a cutaneous horn include
actinic keratosis, squamous cell carcinoma, basal cell carcinoma, verruca vulgaris, seborrheic keratosis, Bowen’s disease,
keratoacanthoma, condyloma acuminatum, dermatobroma,
angiokeratoma, and many other diseases. The mechanism of
occurrence is not yet clear, but it is thought to be inuenced by
triggering factors such as inammation caused by repeated
physical stimulation. Histologically, benign, precancerous, or
malignant lesions may appear at the base of the cutaneous
92
Fig. 92.1 A cutaneous horn on the forehead due to actinic keratosis
horn and the patient’s treatment plan, or prognosis is inuenced by these underlying diseases. According to reports so
far, the underlying disease originates from benign lesions in
the highest proportion, precancerous lesions are mostly actinic
keratosis and a small number of Bowen’s diseases, and malignant lesions are mostly squamous cell carcinoma and rarely
basal cell carcinoma. When we removed the cutaneous horn
on grandma K’s forehead with a CO2 laser, she was very
pleased, saying, “I was worried about dying in this state, but
it’s gone well!” (Figs.92.2 and 92.3).
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_92
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Fig. 92.2 Before removal of cutaneous horn
92 Cutaneous Horn
Fig. 92.3 After CO2 laser treatment for cutaneous horn
Xerotic Eczema: Xerosis Cutis
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https://t.me/med1917
I’m afraid of winter. During this season, my whole body
starts to itch, starting from my legs, and when it gets so
bad, I end up having to go to the hospital.
K, a 65-year-old man, is afraid of winter. During this season, his entire body, including his lower legs, becomes dry
and itchy like crazy. If it gets worse, dermatitis like eczema
eventually develops, requiring hospital treatment for a while.
He came for a consultation today because he is curious about
the reason and desperately needs a solution (Fig.93.1).
Xerotic eczema refers to a skin disease that causes eczematous changes when the skin is very dry. It typically occurs in
middle-aged and elderly people who frequently bathe with
hot water and strong soap during the winter or dry seasons
and is also called “winter itch,” “eczema craquelé,” and
“asteatotic eczema.” It is thought to occur due to a decrease
in surface lipids of the skin, but the exact cause of the skin
changes seen in xerotic eczema is still unclear. In severe
cases, the amino acid content of the skin may decrease. The
decrease in laggrin-derived natural moisturizing factors of
the epidermis is also considered a major factor. It is especially common on the shins, arms, anks, and back of the
hands, and it begins as an erythematous patch accompanied
by ne scales, and as it progresses, the lesions grow larger
and are characterized by dry skin with the appearance of ne
skin cracks similar to cracks that occur in old ceramics.
Sometimes, lesions appear in the shape of a coin, and this
“xerotic nummular eczema” has less exudation compared to
typical nummular eczema. If appropriate treatment for
xerotic eczema is not carried out, systemic pruritus can
occur. Whether the skin dryness is congenital, endogenous,
or exogenous, it can cause itching, and by rubbing or scratching the skin, repeated minor trauma and inammation can
occur on the skin. This occurs, and as a result, the collapse of
the lipid balance on the skin surface becomes more severe.
Xerosis cutis always precedes xerotic eczema. Dry skin
refers to a condition in which there is insufcient or no moisture in the skin (less than 10%). Clinically, it refers to a skin
93
Fig. 93.1 Xerosis cutis and xerotic eczema observed on the lower leg
condition that appears scaly and has a rough surface with
slight erythema and cracks. The causes of dry skin can be
divided into external and internal factors. External factors
include dry environment or weather like wind, chemical substances such as detergents and organic solvents, excessive
bathing or washing, ultraviolet rays, drug treatments like
retinoids, physical stimuli, etc. Internal factors include pathological causes such as elderly skin, sensitive skin, ichthyosis, psoriasis, atopic dermatitis, hypothyroidism, diabetes,
chronic renal failure, etc. The mechanism of dry skin is very
complex and involves various biochemical and physiological
changes, so it is difcult to understand simply. Important
factors related to skin dryness are natural moisturizing factors, stratum corneum lipids, sebum, and the normal presence or absence of keratinocyte shedding. That is, the
decrease in the moisture retention function of the stratum
corneum, called the skin barrier, is the biggest cause of dry
skin. The concept of the skin barrier is expressed as a brick
wall (barrier) made of bricks and mortar, which blocks the
intrusion from the outside, where each brick is a keratinocyte
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_93
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Figs. 93.2 and 93.3 Xerosis cutis
93 Xerotic Eczema: Xerosis Cutis
Fig. 93.4 Xerotic eczema on the leg
and the mortar lling between the bricks is thought to be a
lipid layer composed of free fatty acid, cholesterol, and
ceramide. If the skin barrier is damaged, it cannot prevent the
evaporation of moisture and its moisturizing ability is
reduced, resulting in a state that is easily damaged by various
external factors. Xerosis cutis is the most common cause of
pruritus in the elderly, where the skin barrier is damaged and
transepidermal water loss (TEWL) is increased. The recovery ability of the epidermal barrier decreases after the age of
55, which is related to the increase in epidermal pH
(Figs.93.2, 93.3, 93.4, 93.5, 93.6–93.9, 93.10, 93.11, 93.12
and 93.13).
During treatment, it is necessary to ask detailed questions
about the presence of underlying disease, family history, and
living environment, which also helps eliminate the cause and
determine the direction of treatment. For example, detailed
examinations may be needed as hypothyroidism, diabetes,
etc. can accompany xerosis cutis. Although diagnosis is possible by visual inspection, histologically, it shows the
Fig. 93.5 Xerosis cutis on the leg
histological ndings of mild subacute eczema with varying
degrees of inammatory cell inltration in the dermis.
Congenital skin diseases, malnutrition, drugs, metabolic or
systemic diseases, cancer, and iatrogenic causes should be
considered.
To treat dry skin or xerotic eczema, it is necessary to rst
identify the cause and correct it. Especially if there are skin
diseases or systemic diseases that cause dry skin, it is
93 Xerotic Eczema: Xerosis Cutis
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385
Figs. 93.6–93.9 Xerosis cutis and xerotic eczema
Figs. 93.10 and 93.11 Xerotic nummular eczema
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Figs. 93.12 and 93.13 Chapped hands
93 Xerotic Eczema: Xerosis Cutis
important to treat the cause. The basic principle of dry skin
treatment is to supply and maintain moisture in the stratum
corneum. Improvements in the environment that prevent
skin from drying out are needed, and effective moisturizers
should be used appropriately. Topical steroids and antipruritics are needed for areas with severe symptoms. If the dryness is due to heating, it is good to control the humidity,
and the indoor temperature should be kept stable. Reduce
the time and frequency of bathing, avoid using hot water,
and use mild soap or weakly acidic synthetic cleansers to
reduce damage to the stratum corneum. Do not excessively
scrub, and it is good to apply a moisturizer immediately
after bathing. Avoid clothes that cause a lot of friction on
the skin and use basic products for dry skin that have good
moisturizing effects for cosmetics. I told Mr. K that he
needs to change his bathing habits and use effective moisturizers, and if the eczema is severe, he should get treatment immediately.
Dermographism: Dermatographism
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https://t.me/med1917
94
Even if I just pop a pimple, the area swells up and I can
even draw hives pictures on my skin (Fig.94.1).
A 17-year-old male student, J, came to get acne treatment,
and after I extracted the acne with a comedo extractor on the
rst day, the sudden change in J’s facial skin surprised the
new Teacher Park, but J himself said, “I’m always like this!
Don’t be surprised. It will disappear after about 30minutes.”
He even boasts that he can draw hives pictures on his skin.
The most common type of urticaria caused by physical factors is dermographism (dermatographic urticaria), which is a
phenomenon where the triple response of Lewis to stimuli is
exaggerated, unlike normal physiological reactions, and erythema and wheal appear in the scratched area within a few
minutes. In simple dermographism, scratching the skin with
moderate pressure causes wheal and are on the skin without
itching. However, symptomatic dermographism easily causes
linear wheal and surrounding erythematous are with itching
to appear within 2–5 min even at the slightest mechanical
stimulation, such as lightly scratching, grazing, or rubbing the
skin, and lasts for about 30min to 3h. It appears in 1.5–4.2%
Fig. 94.1 Dermographism wheal observed after acne extraction
of the population, but the number of people who complain of
symptoms is much less, so most do not require treatment. It is
thought to be mediated by immunoglobulin E because it can
be passively transferred to normal people. The onset of initial
symptoms appears suddenly and can be triggered by viral
infections, antibiotics (penicillin), thyroid disease, diabetes,
menopausal disorders, food, mental stress, hot baths, etc., but
in many cases, the cause is unknown, and it persists for weeks
to years. Urticaria can occur even with mild stimuli, so hives
can occur anywhere on the body at any time, and scratching
due to itching can cause more severe hives. In cases of acute
urticaria, dermographism can be accompanied or secondarily
developed, and in cases of chronic urticaria, the frequency of
accompanying dermographism is known to be higher.
Mucosal invasion and angioedema are not known to occur,
but recently, cases of dermographism occurring in the lips
and oral cavity have been reported. Delayed dermographism
refers to cases where urticaria does not occur immediately
after scratching the skin, but wheal appears after 1–6h and
lasts for 24–48h, which is rare. A simple test that stimulates
the skin with a tongue depressor should be considered for
diagnosis in any patient complaining of acute or chronic urticaria. For comparison, the doctor can also perform it on his
own arm at the same time (Figs.94.2, 94.3, 94.4–94.6, 94.7,
94.8, 94.9, 94.10 and 94.11).
The main treatment for physical urticaria is to avoid trig-
gering factors, so detailed information about the physical
stimuli that cause it and specic methods that can be applied
in daily life should be provided. Patients with dermographism are advised to avoid environments that cause skin rubbing or scratching, such as hot or dry environments. However,
in most cases, the threshold for physical stimuli that cause
symptoms is low, so it is difcult to completely avoid physical stimuli, so medication is needed to control symptoms.
Dermographism is not lifelong, and “suddenly appears one
day, and suddenly disappears one day,” so it is usually recommended not to be too afraid and to receive treatment, but
in the case of Mr. J, it was thought that treatment would not
be necessary as he understands his symptoms well.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
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94 Dermographism: Dermatographism
Fig. 94.2 Dermographism
Figs. 94.4–94.6 Dermographism is caused by articial skin stimulation: (1) initially, a red line appears within 3–15seconds, (2) then the ery-
thema spreads widely, (3) and a wheal on the line surrounded by erythema appears in the place of the red line
Fig. 94.3 Dermographism induction test
Fig. 94.7 Patient who took a photo of the rst occurrence of
dermographism
94 Dermographism: Dermatographism
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Figs. 94.8 and 94.9 Symptoms of dermographism caused by scratching during daily life
389
Figs. 94.10 and 94.11 Dermographism lesions induced on the skin
Skin Foreign Body: Skin Splinter and
https://t.me/med1917
Skin Thorn
95
There are many things on the sole of my foot that feel like
thorns (Fig.95.1).
Mr. A in his 40s came in with many strange things on the
sole of his foot that felt like thorns, even though he doesn’t
remember being pricked by a thorn. Upon closer inspection,
there were indeed many thorns embedded. I remember a
patient with cactus thorns who came in during my busy
younger days when I saw hundreds of patients a day. I was
too busy and sent him to a larger hospital, which I later
regretted. Am I a real doctor? If I can’t even treat a patient
with thorns in their skin, am I a doctor? Since then, no matter
how busy I am or how long it takes, I’ve decided to always
remove thorns embedded in the skin. Do I have to cure a serious disease to be a real doctor? I believe that this is also
important. However, to remove thorns well, it’s not enough
to just have passion. You need to be prepared with a magnifying glass and light of sufcient magnication to be able to
grasp and remove the thorns with a needle or small forceps.
I remember my early days of opening a clinic. A man in
his 20s said he had a large needle in his thigh for a long time.
The area was slightly bruised, but the skin was ne and there
was no hole or wound where the needle had penetrated. He
had visited several hospitals, all of which recommended psychiatric treatment. I had the same thought, but since it was a
time when I took X-rays myself, I took one just in case and
was surprised. There was a long needle about 10cm deep
inside, which I removed, and it made me think a lot
afterwards.
Mr. A who came in today said he went to a resort, had a
few drinks, took off his shoes, and stepped on something he
didn’t know. I feel a sense of accomplishment as I diligently
remove the thorns. It’s also very refreshing to have removed
them all (Figs. 95.2, 95.3–95.5, 95.6, 95.7, 95.8–95.10,
95.11 and 95.12).
Fig. 95.1 The foot of a patient who says there are many things that feel
like thorns
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_95
Fig. 95.2 Thorns on the sole of the foot
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