Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_141_библиотеки_им_акад_М_И_Перельмана
.pdf
22
https://t.me/med1917
Figs. 6.9 and 6.10 Lichen nitidus—10× magnication
6 Lichen Nitidus
Angular Cheilitis: Angular Stomatitis
https://t.me/med1917
7
The corners of my lips have been cracked for almost a
month and are not healing. It’s driving me crazy because
it’s healing and then tearing, and healing and then tearing (Fig.7.1).
A 62-year-old female, B, has had cracked lips for almost
a month, and no matter how much ointment she applies, it
doesn’t heal. “It heals and then cracks again, I’m going crazy.
I never had this problem when I was young, is it because I’m
getting older? Could it be related to the dental treatment I
received recently?” she asks (Fig.7.2).
Angular cheilitis, also known as angular stomatitis or
Perlèche, is a skin inammation that forms cracks at the corners of the mouth. It is caused by aging, physical stimulation,
infection, nutritional deciency, immune deciency, or a
combination of these factors. It can occur due to excessive
moisture or dryness and is often accompanied by secondary
infections of Candida or Staphylococcus. As people age and
drool, saliva accumulates and can cause candidiasis, especially in those who wear dentures. In children, it often occurs
when they suck their ngers, chew gum, or eat lollipops frequently. Other causes can include anorexia nervosa, riboavin deciency, Down syndrome, oral candidiasis, diabetes,
AIDS, chronic mucocutaneous candidiasis, Crohn’s disease,
Sjogren’s syndrome, orthodontic treatment, ossing, druginduced dry mouth, atopic dermatitis, psoriasis, irondeciency anemia, and tonsillectomy. Clinically, it presents
as severe pain, cracking, ulcers, scabs, and triangular erythema on one or both edges of the lips. In severe cases, moist
cracks appear from the corners of the mouth to outward and
downward. The unique clinical symptom of cracks forming
downward from the corners of the mouth makes it easy to
diagnose, but tests for bacterial and Candida infections may
be needed (Figs.7.3–7.5, 7.6, 7.7, 7.8 and 7.9).
The condition of the teeth and dentures should be examined at the dentist, and if dentures are worn, candidiasis
should be checked. If candidiasis is conrmed, it is treated
with a topical antifungal, and if it does not heal well, a topical steroid may also be used. Mupirocin ointment is used if a
Fig. 7.1 Angular cheilitis (angular stomatitis) Fig. 7.2 Angular cheilitis
© 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_7
23
24
https://t.me/med1917
7 Angular Cheilitis: Angular Stomatitis
Figs. 7.3–7.5 Angular cheilitis
Fig. 7.6 Dry lips and angular cheilitis after taking isotretinoin for acne
treatment
Fig. 7.7 Exfoliative cheilitis and angular cheilitis observed in atopic
dermatitis
7 Angular Cheilitis: Angular Stomatitis
https://t.me/med1917
Figs. 7.8 and 7.9 Angular cheilitis—10× magnication
25
Staphylococcus infection is conrmed. If there is an underlying systemic disease causing the condition, it should be identied and treated concurrently, and in severe cases, surgical
treatment may be necessary. Recently, there have been
reports of treatment effects due to ller and botulinum toxin
procedures. I told Mrs. B that this condition is caused by
various factors and does not heal on its own if not treated, but
in clinical experience, there are almost no cases that are difcult to treat, and most of them improve quickly with drug
treatment, so don’t worry too much and come to the hospital
a few times.
Perioral Dermatitis
https://t.me/med1917
8
There’s always something around my mouth that feels
burning, stinging, and itchy. It’s really annoying (Fig.8.1).
Ms. D, a woman in her 30s, came for treatment because
she has been having small acne-like things around her mouth
for several months, and her skin feels hot and tight, and
sometimes itchy. Sitting in the examination room, she said,
“I didn’t even have acne when I was a student, what on earth
is this around my mouth? It’s so annoying”.
Perioral dermatitis is a skin disease characterized by a
papulosquamous inammatory eruption around the mouth
consisting of papules and pustules accompanied by erythema
and scale. It usually occurs in women of childbearing age
(16–45 years old), and it is rare in men. The incidence is
highest in the 20s and 30s, but it can also occur in children.
The cause is unknown, but ultraviolet rays, stress, Candida,
Demodex, or Fusobacterium infection, irritants and allergens, hormones, steroid creams, etc. are thought to be the
cause, and there are also reports of research results that
abnormal skin barrier function is accompanied. Perioral dermatitis is an inammatory disease in which erythematous
Fig. 8.1 Perioral dermatitis
papules and pustules occur around the mouth, usually on the
nasolabial folds, upper lip, and chin, and rarely involves the
vermilion border of the lips. In the early stages, small, nonitchy erythematous papules develop, and the papules are
irregularly clustered and symmetrical. If the invasion is more
severe, small papules and pustules of 1–2 mm are fused
extensively around the mouth. About 20% can occur around
the nose, forehead, eyelids, and glabella, not around the
mouth. Unlike acne, comedones cannot be found, and there
is no telangiectasia that can be seen in rosacea. Typical
symptoms are that the skin feels hot and prickly, and a tightening sensation is common, and itching may also be accompanied. The appearance of the lesion usually shows a
subacute course that lasts for several weeks or months, causing cosmetic problems. Sometimes, if perioral dermatitis is
mistaken for eczema or seborrheic dermatitis and treated
with a strong steroid, it can worsen severely due to this.
Untreated perioral dermatitis can persist or uctuate between
improvement and worsening, especially tending to worsen
before menstruation. Granulomatous perioral dermatitis, a
special form of perioral dermatitis, occurs around the mouth
like perioral dermatitis but occurs regardless of age and gender, shows granulomatous changes, and its incidence is very
low. It is known to occur relatively frequently in children,
and its characteristic is small nodules of skin color without
scales and erythema rather than erythematous papules or
pustules. Perioral dermatitis is diagnosed clinically by skin
lesions conned around the mouth, clustered patterns, and
histological ndings. The lesion is characterized by a persistent erythematous rash consisting of small papules, vesicles,
and papular pustules that appears symmetrically around the
mouth and does not involve approximately 5mm around the
vermilion border of the lips. Patch tests, bacteriological tests,
fungal tests, and Demodex tests can be performed. Perioral
dermatitis should be differentiated from acne, rosacea, seborrheic dermatitis, sarcoidosis, eruptive syringoma, contact
dermatitis, and lip licker’s dermatitis (Figs.8.2, 8.3–8.6).
© 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_8
27
28
https://t.me/med1917
8 Perioral Dermatitis
Various factors are involved in the occurrence of perioral
dermatitis, but there is no doubt that the use of local steroids
causes or worsens lesions in most patients, so the use of steroids must be stopped. It is also important to refrain from
Fig. 8.2 Perioral dermatitis
using cosmetics such as soap, moisturizers, cleansing products, deep cleansing products, astringent lotions, day/night
creams, wrinkle prevention creams, skin conditioners, and
cheek tints. Generally, there is a mild recurrence with appropriate treatment for several months, but it is usually controlled with local metronidazole gel and second-generation
tetracyclines or macrolide antibiotics. There have been
reports of good effects with the application of adapalene gel
0.1% once a day for 4weeks, and the use of 20% azelaic acid
cream for 2–6weeks, and it is known that topical application
of tacrolimus 0.1% and pimecrolimus 1% is effective, and
four sessions of photodynamic therapy (ALA-PDT) at
1-week intervals have been reported to be effective.
Granulomatous perioral dermatitis can also be treated with
oral isotretinoin. I explained this disease to Ms. D in detail,
prescribed effective oral medication and topical cream, and
decided to observe her symptoms periodically until there
was complete improvement.
Figs. 8.3–8.6 Perioral dermatitis
Metal Allergy: Allergic Contact
https://t.me/med1917
Dermatitis DuetoMetals
9
I’m insanely itchy around my belly button when I wear
jeans (Fig.9.1).
A 12-year-old boy, H, came to the clinic with his mother,
saying that whenever he wears jeans, his lower abdomen
becomes very itchy and small blisters appear on his skin. In
this case, nickel allergy is almost 100% caused by the metal
in the jeans. “I’m really worried that it gets itchy like this
when he just wears jeans. Is there any way?” she asks
(Fig.9.2).
The metal button used as a fastener on jeans consists of
two components, the jeans button and the tack. The jeans
button tack is xed and attached with the fabric and the lower
part of the jeans button, and when this metal part comes into
contact with the skin of the abdomen, it can cause allergic
contact dermatitis due to the nickel contained in the metal.
Recently, as many people wear jeans without a belt, the jeans
button tack can cause allergic contact dermatitis more frequently than a belt buckle. Although one might think that
underwear between the skin and the metal button could prevent contact dermatitis caused by nickel, in hot and humid
conditions, nickel can be transferred to the skin through
sweat, causing widespread allergic contact dermatitis around
the navel.
Nickel is a main component of stainless steel and is contained in many accessories and household items we use, such
as watches, earrings, necklaces, glasses, and mobile phones.
Nickel is one of the most common causes of allergic contact
dermatitis, showing a higher frequency than allergies caused
by all other metals combined, and ranks very high among
occupational allergic contact dermatitis. Nickel allergy can
occur at any age, can last for several years once it occurs, and
can even last a lifetime. The overall incidence is higher in
Fig. 9.1 Allergic contact dermatitis due to metal that occurs when
wearing jeans
© 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_9
Fig. 9.2 Severe dermatitis caused by wearing jeans, making it impossible to wear them
29
30
https://t.me/med1917
Fig. 9.3 Cases showing positive for nickel in patch test
women, and piercing ears to wear earrings at a young age is
recognized as a signicant issue contributing to increased
nickel sensitization. In Korea, not only is nickel the most
common metal causing allergic contact dermatitis, but the
sensitization rate is also continuously increasing. Patch test
results reported a positive rate for nickel of 29.1–34.1%,
which is about 1.7–2 times higher than in Europe and North
America. The main reasons for the high sensitization rate
and positive patch test rate for nickel in Korea compared to
other countries are thought to be the development and
increased use of various metal accessories, increased use of
mobile phones, and delayed regulation of nickel release from
metal products.
Nickel dermatitis often occurs in women due to items
commonly worn on the body, such as earrings, necklaces,
watches, bracelets, bra clips, and jeans buttons. In men, it
often occurs due to occupational exposure to plating, printing machines, or metal tools. The common sites of onset for
women are areas that easily come into contact with metals in
daily life, such as the earlobes (earrings), back of the neck
(necklaces), wrists (watches or bracelets), and areas where
suspender or bra clips touch. In men, it has been reported that
the initial lesion occurs on the hands in 60% of cases. The
affected areas often become red or blistered due to severe
itching, the skin becomes dry, thickens, or discolors. Nickel
ingested through food can also cause pompholyx. The diagnosis of allergic contact dermatitis due to nickel can be easily
made by characteristic clinical ndings occurring at the contact site of nickel and patch testing (Fig.9.3).
Once the sensitization state of a patient with allergic contact dermatitis occurs, it usually lasts for a very long time,
so recurrence cannot be prevented as long as there is
repeated contact with the antigen. The most important thing
in preventing allergic contact dermatitis is to remove or
avoid contact with the causative substance conrmed by
9 Metal Allergy: Allergic Contact Dermatitis DuetoMetals
Fig. 9.4 A dimethylglyoxime spot test is being performed on the
inside metal button of jeans brought by a patient with nickel allergy.
This is a case showing a positive (+) reaction
patch testing. Also, contact with other substances that crossreact with this causative substance should be avoided.
Allergic contact dermatitis is caused by absorption into the
skin when the metal becomes soluble in a base state due to
sweat or other human secretions or chemicals rather than by
the metal itself. For example, people who are hypersensitive
to chromium salt solution can use objects plated with chromium without discomfort, and people who reacted to nickel
plating in a sweaty or humid situation can wear nickelplated objects without problems in a cool season with less
sweat. Also, stainless steel is a nickel alloy, but it is rmly
combined and does not rust in sweat, so even people who
are sensitive to nickel can use it. Therefore, by understanding the physical and chemical properties of these metals or
metal salts and recognizing the substances contained in each
metal, symptoms can be prevented from appearing and
worsening. The dimethylglyoxime spot test is a method of
testing the amount of nickel released from alloys containing
nickel or surface-coated metal products. Put 1 drop each of
1% dimethylglyoxime solution and 10% ammonia solution
on a cotton swab and immediately rub the surface of the
metal for 30s. If the cotton swab turns red (ranging from
light pink to deep red), it is determined that the amount of
nickel released exceeds the standard set by the EU for nickel
leaching from metals (Figs. 9.4, 9.5, 9.6, 9.7, 9.8, 9.9, 9.10,
9.11, 9.12, 9.13, 9.14, 9.15, 9.16, 9.17, 9.18, 9.19 and 9.20).
The treatment for allergic contact dermatitis caused by
nickel involves avoiding objects containing nickel as much
as possible, and in cases where this is not possible, wrap
them with tape or coat them with polyurethane. It is also benecial to control factors that exacerbate nickel dermatitis,
such as hyperhidrosis and obesity, and lesions that have
already occurred are treated with antihistamines and topical
steroids. In cases where it is difcult to completely remove
9 Metal Allergy: Allergic Contact Dermatitis DuetoMetals
https://t.me/med1917
Fig. 9.5 Allergic contact dermatitis caused by the metal button on
jeans
31
the antigen from patients with allergic contact dermatitis, it
is better to replace it with a less sensitive substance, which is
called antigen replacement. In the case of jeans, one could
wear clothes that do not contain the antigen, i.e., pants that
do not use metal buttons like jeans, but considering that jeans
are a popular fashion item loved by many people, jeans products that do not contain nickel components in the skin contact area (tack) of the buttons or rivets of jeans, or that are not
made of metal, should be available. However, in reality, it is
often difcult or impossible to nd such products, so it is
thought that consideration is needed to develop such products for nickel allergy patients and denitely sell them separately. I told H’s mother to avoid clothes with tack buttons
made of metal on the inside of the pants and metal accessories and to get treatment immediately if symptoms appear.
Figs. 9.6 and 9.7 Allergic contact dermatitis caused by the tack button on jeans
32
https://t.me/med1917
9 Metal Allergy: Allergic Contact Dermatitis DuetoMetals
Figs. 9.8–9.13 Metal products found in the pockets of a patient suspected of having allergic contact dermatitis caused by metal, including the
tack of the metal button on the pants, the metal buckle of the belt, and the metal products in both pants pockets
Соседние файлы в папке Библиотека им академика М.И. Перельмана