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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_141_библиотеки_им_акад_М_И_Перельмана
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Figs. 95.3–95.5 Removing thorns from the sole of the foot
95 Skin Foreign Body: Skin Splinter and Skin Thorn
Figs. 95.6 and 95.7 Pencil lead stuck in the nger
Figs. 95.8–95.10 Large thorn stuck in the leg
95 Skin Foreign Body: Skin Splinter and Skin Thorn
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Figs. 95.11 and 95.12 Brown glass piece stuck in the sole of the foot—10× magnied photo
393
Cold Urticaria
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96
Just dipping my hand in cold water for a moment causes
hives after a while I can’t stand it. How am I going to get
through this winter? (Fig.96.1).
As winter approaches again, Mr. M, a 37-year-old man, is
really afraid of this symptom that has appeared 5years ago.
“Even if I just wash my hands with cold water, hives appear
on my hands and it’s insanely itchy, and if I stay in the cold
for a while, my face, hands, ankles, knees, thighs, etc., everywhere becomes itchy. How am I going to get through this
winter?”
Cold urticaria, which causes hives on the exposed parts when
exposed to cold and chill, is a type of physical urticaria,
accounting for 1–3% of all chronic urticaria. There are various clinical manifestations such as acquired cold urticaria,
familial cold urticaria, cold reex urticaria, and delayed
cold-induced urticaria, but most of them appear as acquired
and very rarely occur genetically. The cause is not yet clear,
but it is thought to be mediated by immunoglobulin E, and
passive transfer is possible in about half of the patients.
Usually, hives appear when exposed to cold air, cold water,
ice, etc. and often occur when the body warms up again after
exposure. In very severe cases, there can be symptoms such as
dyspnea, tachycardia, and headaches, and swimming or coldwater baths that expose the whole body to cold can be lifethreatening. It is common for other types of physical urticaria
to be accompanied in patients with physical urticaria, and dermographism, heat urticaria, pressure urticaria, and cholinergic
urticaria are accompanied in 1/3 of patients with cold urticaria.
Especially, cold-induced cholinergic urticaria, which shows a
skin rash in the form of cholinergic urticaria due to cold stimuli, is a rare form of acquired cold urticaria and is observed in
0.9% of cold urticaria. Familial cold urticaria is inherited as an
autosomal dominant unlike common cold urticaria, and the
main skin symptoms are more of a burning sensation than itching, and systemic symptoms such as headaches, chills, fever,
and joint pain appear, and it is characterized by an increase in
white blood cells in blood tests. Localized cold urticaria is a
subtype of acquired cold urticaria, and it refers to a disease in
which hives occur only in specic parts after cold water, ice,
and sudden temperature changes (Figs.96.2, 96.3 and 96.4).
Fig. 96.1 Cold urticaria that occurred after exposure to cold water
© 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_96
Fig. 96.2 Cold urticaria observed on the wrist and back of the hand
after exposure to cold water
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Figs. 96.3 and 96.4 Cold urticaria
96 Cold Urticaria
Figs. 96.5–96.7 Urticaria that appears after a while when ice is placed on the arm
Figs. 96.8 and 96.9 Examples of positive reactions to the ice cube test
If cold urticaria is suspected, an ice cube wrapped in a
cling lm is placed on the arm for about 3–5min, and the
occurrence of hives is observed (ice cube test). In some
patients, it may take about 20 min for a reaction to appear. If
there is no response, an additional measure is to turn on a fan
on the area for 10min or immerse the arm in cold water for
5–15min (cold-water immersion test).
According to recent drug treatment recommendations for
chronic urticaria patients in Korea, the main goal of chronic
urticaria treatment is not to suppress the cause of urticaria
but to alleviate symptoms. Therefore, it is suggested to rst
avoid triggering factors or aggravating factors and to control
symptoms through step-by-step drug treatment. For Mr. M,
avoiding the cause or aggravating factors of urticaria is most
important in treatment, but complete avoidance of cold
exposure is not possible, so caution is needed. However, it
was explained that the quality of life should be improved
and the severity of urticaria should be reduced through the
appropriate selection of antihistamines (Figs. 96.5–96.7,
96.8 and 96.9).
Pyogenic Granuloma: Granuloma
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Pyogenicum
97
Something like a red dot appeared on my nger and suddenly grew into a small lump, and it bleeds a lot if it is
touched wrong (Fig.97.1).
Mr. Q, a man in his 20s, came for treatment because he
was worried that a red dot suddenly grew into a small lump
on his thumb a while ago and it bleeds every time it is
touched. “At rst, I thought I had hurt my nger a bit, but the
wound didn’t heal and suddenly the esh grew red, and it
bleeds a lot when touched and it doesn’t stop well!” he
expressed his concern.
Pyogenic granuloma is a common benign vascular tumor
found on the skin or mucosa, which occurs in the form of a
soft or slightly hard nodule or polyp of red or dark red color
and has a characteristic of easily causing bleeding. This disease was rst described in 1897, and it was called “granuloma pyogenicum” because it was presumed to be caused by
infection and looked like granulomatous inammation in
1904, but it was later proven to be a hemangioma where
capillaries proliferate in lobular form without infection and
Fig. 97.1 Pyogenic granuloma observed from the thumb
not a granulomatous inammation. Thus, it was described
as “lobular capillary hemangioma” according to the characteristic histological ndings of this lesion, but the name
“pyogenic granuloma” is still widely used. It occurs mainly
in children and young adults and occurs frequently on the
skin and oral mucosa of exposed areas such as the face,
arms, hands, and ngers. In rare cases, it can also occur in
the subcutaneous fat layer, veins, and digestive organs. It
usually occurs as a single lesion, but there have been reports
of multiple occurrences. Reports on the gender ratio vary,
but according to Korean research, there are more female
patients than male patients. Clinically, the lesion appears as
a slightly hard or soft nodule of red or dark red color, often
showing a pedunculated shape. It grows rapidly over several
weeks, usually reaching a size of 0.5–2cm in diameter, but
then remains the same size without any changes. The surface of the lesion is smooth and may appear wet or have
scales, and sometimes shows supercial ulcers and crusts,
and easily bleeds even with minor trauma. If the surface is
cut off by trauma, it grows back quickly. Recently, there
have been reports of numerous lesions similar to pyogenic
granulomas occurring on the body after taking isotretinoin
for acne treatment. Also, in some cases, lesions can occur in
the mouth, especially the gums, which are most commonly
found in pregnant women and are called granuloma gravidarum or epulis gravidarum, and most of them naturally disappear after childbirth. Other clinical variants include
intradermal or subcutaneous pyogenic granulomas, which
mainly occur on the arms, and intravenous pyogenic granulomas, which occur on the neck and arms of young adults. If
a lesion of pyogenic granuloma occurs on the sole or nail of
the hand or foot, it can sometimes be mistaken for melanoma (Figs.97.2, 97.3, 97.4, 97.5, 97.6, 97.7, 97.8, 97.9,
97.10, 97.11 and 97.12).
The causative factors of this disease have been reported to
be associated with trauma, hormonal changes due to pregnancy, and vascular malformations. The mechanism of
occurrence is not clear, but it often occurs after trauma, so it
is thought to be a reactive hyperproliferative vascular
© 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_97
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Fig. 97.2 Pyogenic granuloma on the palm
97 Pyogenic Granuloma: Granuloma Pyogenicum
response to external stimuli such as trauma, or it is thought to
involve endocrine factors or angiogenic factors because it
occurs frequently in pregnant women and also occurs from
existing vascular malformation lesions. Histologically, it
shows the characteristics of a hemangioma where capillaries
proliferate in a lobular form, and recently, in addition to clinical and histopathological diagnosis of pyogenic granuloma,
dermoscopic diagnosis is being used effectively. It is important to distinguish between Spitz nevus, which has a nodular
shape with a red hue, and amelanotic malignant melanoma,
as well as other conditions that may appear clinically similar,
such as clear cell acanthoma, cutaneous lymphoma, Kaposi’s
sarcoma, and basal cell carcinoma. Pyogenic granuloma
often recurs after treatment with surgical excision, curettage,
or a combination of shave excision and cauterization.
Figs. 97.3 and 97.4 Pyogenic granuloma on the lip
Figs. 97.5 and 97.6 Pyogenic granuloma on the face
97 Pyogenic Granuloma: Granuloma Pyogenicum
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Figs. 97.7 and 97.8 Pyogenic granuloma on the nger
399
Fig. 97.9 Pyogenic granuloma observed on the nger
Although it is known not to disappear spontaneously if left
untreated, there have been reports of it disappearing spontaneously within 6–18 months, sometimes leaving scars.
Rarely, after removal of pyogenic granuloma, multiple small
satellite vascular lesions may occur, especially in the shoulder area or upper torso, and occur frequently in children.
They may appear regardless of recurrence of pyogenic granuloma and may disappear spontaneously. Surgical excision,
Fig. 97.10 Pyogenic granuloma on the lip
Fig. 97.11 Pyogenic granuloma on the scalp
which has a low recurrence rate, is recommended for the
treatment of pyogenic granuloma, but in children, general
anesthesia is required and there are risks of complications
and scarring from surgery. Therefore, alternative methods
such as electrocautery, laser treatment, cryotherapy, chemi-
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Fig. 97.12 Pyogenic granuloma that easily bleeds even with minor
trauma
cal cauterization, sclerotherapy, ligation therapy, topical retinoids, and imiquimod application are being suggested. Mr. Q
had laser treatment and will return tomorrow for wound
dressing. He leaves the clinic feeling relieved after learning
the name of this strange condition and having the lump completely removed by laser (Figs.97.13, 97.14, 97.15–97.18).
97 Pyogenic Granuloma: Granuloma Pyogenicum
Fig. 97.13 Spitz nevus mistaken for pyogenic granuloma
97 Pyogenic Granuloma: Granuloma Pyogenicum
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Fig. 97.14 CO2 laser treatment for pyogenic granuloma
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Fig. 97.15–97.18 CO2 laser treatment for pyogenic granuloma—completely removed by focusing after coagulation contraction by defocusing
Acquired Ichthyosis
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98
My child’s skin is so dry that it cracks like sh scales, but
it’s not a genetic ichthyosis (Fig.98.1).
The father of H, a 15-year-old male student, came to
receive a prescription for moisturizer and treatment drug
because the child’s skin was so dry that it cracked like sh
scales. He says, “The skin symptoms are similar to ichthyosis, which is genetically caused, but dryness symptoms
started to appear in puberty.”
Ichthyosis is a skin disease in which the skin becomes dry
and cracked and thickened in the shape of sh scales.
Acquired ichthyosis is a skin disease that is clinically and
histologically similar to ichthyosis vulgaris, which is genetically inherited, but it mainly appears in adults after puberty.
The skin lesions tend to improve when the underlying disease is treated, or the triggering drug is discontinued.
Diseases and conditions that can cause acquired ichthyosis
include malignant tumors such as malignant lymphoma,
Kaposi’s sarcoma, lung cancer, breast cancer, and cervical
cancer; metabolic diseases such as hypothyroidism and renal
failure; malabsorption or nutritional deciency states that
cause deciency of essential fatty acids and vitamin A; taking drugs such as niacin, triparanol, lovastatin, butyrophenone, cimetidine, clofazimine, etretinate, and isotretinoin;
immune deciency diseases caused by viruses; and other
conditons such as sarcoidosis, leprosy, systemic lupus erythematosus, polycythemia vera, dermatomyositis, bone marrow transplantation, and diabetes. The clinical features of
acquired ichthyosis are similar to those of ichthyosis vulgaris
caused by autosomal dominant inheritance, with ne scales
covering the whole body and the skin is generally dry. The
scales on the limbs are thicker and rougher than the scales on
the torso, and most of the extensor region of the limbs and
torso are invaded, but exural surfaces such as the cubital
fossa, popliteal fossa, and armpits are not invaded (Fig.98.2).
Most genetic ichthyosis appears in infancy or child-
hood, so if a scaly lesion suspected of ichthyosis is
Fig. 98.1 Acquired ichthyosis observed on the face
© 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_98
Fig. 98.2 Acquired ichthyosis of the face
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