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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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9 Metal Allergy: Allergic Contact Dermatitis DuetoMetals
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Figs. 9.14 and 9.15 Allergic contact dermatitis caused by the metal components of a wristwatch
33
Figs. 9.16 and 9.17 Allergic contact dermatitis that occurred on the earlobe (earrings)
Figs. 9.18 and 9.19 Allergic contact dermatitis caused by the metal components of bracelet and necklace
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Fig. 9.20 Allergic contact dermatitis triggered by the metal button on
jeans
9 Metal Allergy: Allergic Contact Dermatitis DuetoMetals
Moth Dermatitis: Poisonous Moth
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Dermatitis and Caterpillar Dermatitis
10
We went camping as a family, and a moth ew into our
tent. After coming in, my daughter’s arm and mine
became very itchy (Fig.10.1).
“We went camping last weekend and everyone else is
ne, but the two of us are so itchy.” said Mrs. M, a woman in
her 40s, as she and her daughter showed their arms. When
asked, “Did you use the same tent?” she replied, “Yes! We
were both in the tent and a small moth ew in.”
Among the moths belonging to the order Lepidoptera and the
family Lymantriidae, there are about 150 species worldwide
known to harm humans due to their poisonous hairs, and in
Korea, there are a total of 16 genera and 44 species, 11 of
which cause dermatitis. The moth species of the genus
Euproctis, which are found in Korea and have a nationwide
distribution, and which caused problems in the early 1970s,
are Euproctis ava and Euproctis subava. When their poi-
sonous hairs come into contact with the skin, they cause itch-
Fig. 10.1 Poisonous moth dermatitis occurred simultaneously in
mother and daughter due to poisonous moths that entered the tent
ing, erythematous papules or patches, and edematous wheal,
and rarely, fever, headache, and chills have been reported.
The condition caused by the contact of these hairs, which are
present in both the larvae and adults of these moths, with the
human body, causing dermatitis at the contact site, is called
moth dermatitis or caterpillar dermatitis (Figs. 10.2, 10.3,
10.4 and 10.5).
A few minutes after contact with the poisonous hairs,
urticarial papules appear, and the fact that the lesions are
concentrated in a specic area of the skin helps in diagnosis.
Most patients complain of severe and persistent itching, and
some experience severe burning and pain. Scratching
spreads the lesions around, and scattered papules can merge
to form plaques, form vesicles, or cause secondary eczematous lesions, showing various clinical manifestations. Even
without direct contact with the caterpillar, the hairs carried
by the wind can attach to the skin and cause systemic
lesions, and in these cases, the incidence of ocular problems, respiratory symptoms, and other non-dermatological
symptoms is often high. Severe systemic symptoms such as
fever, nausea, vomiting, tachycardia, respiratory distress,
systemic bleeding tendency, peripheral neuropathy, limb
paralysis, shock, and convulsions can occur, but they are
extremely rare. The poisonous hairs are most prominent
when the caterpillar transforms into an adult, and these hairs
can cause dermatitis.
The process of irritation is generally thought to be initi-
ated by the physical stimulation and foreign body reaction
caused by the penetration of the sharp venomous hair itself,
and subsequently, a chemical stimulation reaction is induced
by the histamine in the venomous hair. Histologically, moderate spongiosis accompanied by extracellular leakage of
inammatory cells, mainly monocytes, is observed, and
inltration of monocytes, polymorphonuclear leukocytes,
and eosinophils around the upper dermal vessels is clearly
observed (Figs.10.6 and 10.7).
© 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_10
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Figs. 10.2 and 10.3 Moth dermatitis observed on the neck
10 Moth Dermatitis: Poisonous Moth Dermatitis and Caterpillar Dermatitis
Figs. 10.4 and 10.5 Moth dermatitis occurring on the arm
Fig. 10.6 Poisonous moth dermatitis on the body
Fig. 10.7 Poisonous moth dermatitis on the back
10 Moth Dermatitis: Poisonous Moth Dermatitis and Caterpillar Dermatitis
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If contact with a poisonous moth has occurred, do not rub
it, but wash it off with running water to remove as much
venomous hair as possible from the skin, and lightly apply
calamine lotion or steroid lotion topically. In severe cases,
antihistamines and steroids are taken orally, and steroid
cream is applied, showing symptom disappearance in about
5–7days. If a poisonous moth enters the room, turn off the
lights and brighten the outside to lure it out, or cover it with
a wet tissue to catch it. Catching or hitting a poisonous moth
with your hands can scatter the venomous hair, which is dangerous. Also, when doing outdoor activities, wear long
clothes and a hat to avoid exposure to caterpillar larvae. Mrs.
M said, “I thought it was because of the moth, and indeed it
was!” She readily agreed to have her photo taken, and mother
and daughter posed together. I said, “Thank you!”
Senile Comedones
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11
I’m 60 years old and recently I’ve been feeling rough
things around my eyes and cheekbones, like when I had
acne, it feels like sand. What could this be? (Fig.11.1).
Mr. E, a 60-year-old man, came for a consultation because
he was worried about several rough things on his facial skin
that felt like sand, like when he had acne. After a close examination with a loupe, I told him that many comedones (blackheads) were observed, to which he replied, “Are you saying
I have acne at this age?”
Senile comedones are somewhat large comedones that
appear in clusters around the eyes and cheekbones in men
who have been excessively exposed to sunlight after middle
age. It was rst described by Favre in 1932 and became
known when Favre and Racouchot reported nodular elastosis
with cysts and comedones, known as “Favre-Racouchot syndrome,” in 1951. Long-term exposure to ultraviolet rays is
although considered as triggers, there are other risk factors
such as acne-inducing drugs, smoking, and radiation therapy.
It is common in the elderly who have been signicantly
exposed to ultraviolet rays and nicotine, and the common
sites of occurrence are around the eyes, cheeks, temples, and
nose, and comedones can also be found in the neck, not just
the face. Signs of long-term exposure to ultraviolet rays,
such as cutis rhomboidalis nuchae, are often found together.
Histologically, multiple open and enlarged comedones are
observed. Senile comedones can dilate more easily as the
pilosebaceous duct become lled with keratinocytes due to
sun damage to the elastic bers. However, inammatory
reactions that occur in acne vulgaris are rare. According to a
study investigating the incidence of senile comedones in 286
elderly inpatients aged 65–102, it was reported that senile
comedones were found in 26% of the inpatients (Figs.11.2,
11.3 and 11.4).
Diagnosis is possible by conrming the presence of some-
what large comedones that appear with other photoaging
symptoms around the eyes and cheeks of the elderly who are
heavily exposed to the sun. Nevus comedonicus, which
require differential diagnosis, originate from pilosebaceous
units and histologically, remnants of hair follicles, sebaceous
Fig. 11.1 Senile comedones Fig. 11.2 Senile comedones
© 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_11
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Figs. 11.3 and 11.4 60× magnication of senile comedones
glands, and follicular cysts are often observed. They can
occur from birth to middle age, usually appear by the age of
10, and there is no gender difference. They are characterized
by densely packed black keratinized papules and follicles
arranged in lines or plaques, showing characteristic histological ndings. Also, differential diagnosis with chloracne
is necessary, and if cysts and nodular elastosis are accompanied by senile comedones, it can be diagnosed as FavreRacouchot syndrome (Fig.11.5).
For treatment, educate to avoid excessive exposure to sunlight in the future and apply sunscreen meticulously. Since
most treatments aim at cosmetic improvement, they can be
treated in the same way as acne vulgaris. There are reports
that the method of removing comedones using standard dissecting forceps is good, but the contents can be easily
removed with a commonly used comedo extractor. Make
sure to squeeze out all the contents completely. Electrocautery
or lasers should not be performed as they can leave scars, and
topical retinoids can be used for drug treatment. Mr. E’s
senile comedones were deeply squeezed out with a comedo
extractor, and it was advised to apply sunscreen meticulously, for better I recommended regular extraction of comedones, peeling, phototherapy, and laser treatments for
cosmetic improvement (Figs.11.6, 11.7, 11.8 and 11.9).
11 Senile Comedones
Fig. 11.5 Favre-Racouchot syndrome
11 Senile Comedones
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Figs. 11.6 and 11.7 Senile comedones
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Figs. 11.8 and 11.9 Senile comedones
Steatocystoma Multiplex
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12
Since middle school, small round things have been growing on my chest and upper abdomen, gradually increasing and becoming unsightly (Fig.12.1).
A 21-year-old male, M, has been feeling small round
things on the skin of his chest and upper abdomen since middle school, but nothing was extruded even when he tried to
squeeze them. As time went by, the number increased and it
became unsightly, and occasionally one or two inammations caused trouble. He asked with a distressed expression,
“I want to know the exact diagnosis, and I don’t like the look
of it, can I get rid of it?”.
Steatocystoma are benign tumors differentiated into sebaceous ducts, occurring either singly or multiply. Among
them, steatocystoma multiplex are relatively rare diseases
that occur due to hamartomatous malformations of the pilosebaceous duct junction, with no difference in incidence
between men and women, and are inherited as autosomal
Fig. 12.1 Steatocystoma multiplex found on the body
dominant or sporadic after puberty. The exact ratio of hereditary and sporadic cases has not been reported. The onset age
for hereditary cases is usually at birth or within a few years
after birth, and sporadic cases occur in the teens or early 20s
when sebaceous gland activity is vigorous. Clinically, multiple cystic nodules of skin color or yellowish white to blue
hue mainly occur on the chest, upper arms, armpits, etc. and
can also be observed on the abdomen, face, scalp, external
genitalia, scrotum, and palms and soles. When the lesion is
punctured, a characteristic odorless yellow oil or cream-like
substance is discharged. Steatocystoma simplex is a case
where a steatocystoma occurs singly in adults without a family history, and there is only a numerical difference, and both
diseases show the same skin ndings and histopathological
ndings. Steatocystoma multiplex are multiple dermal cysts
whose walls are composed of epithelial cells with sebaceous
glands and contain sebum. The size is usually 2–6mm in
diameter, but can grow up to 3 cm, and there are many
smooth and hard cystic papules and nodules in the dermis. It
is attached to the upper skin and contains yellow oil or
cream-like substance. When located deep in the skin, it
shows the color of the skin, but when located shallowly on
the surface, it appears yellow. Generally, there are no symptoms, but it can be a cosmetic concern due to multiple cystic
nodules, and sometimes inammation can be induced.
Despite mainly occurring on the body, these days there are
many cases of people seeking treatment for cosmetic reasons. A rare subtype, steatocystoma multiplex suppurativum,
is characterized by the presence of many cysts that are prone
to inammation and rupture (Figs.12.2, 12.3, 12.4 and 12.5).
Steatocystoma multiplex are not difcult to diagnose with
characteristic clinical and histopathological ndings, but in
nonspecic cases where the size is large, similar to xanthoma
with multiple papules, showing extensive rash, occurring in
uncommon sites such as the scalp, etc., various clinical types
have been reported, and it is difcult to diagnose when typical clinical ndings are shown, but characteristic histological
© 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_12
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Fig. 12.2 Steatocystoma multiplex on the body
12 Steatocystoma Multiplex
Fig. 12.3 Steatocystoma multiplex observed on the body
Figs. 12.4 and 12.5 Steatocystoma multiplex observed on the neck
ndings are not observed. Cysts are mostly located in the
mid-dermis, histologically showing a wrinkled cyst wall
composed of several layers of stratied squamous epithelium
without a granular layer, and near the cyst wall, attened lobules of sebaceous glands can be seen, and vellus hairs may
be tangled inside the cyst. Usually, a thick homogeneous
eosinophilic horny layer protrudes irregularly toward the
inner lumen. Diseases to be clinically differentiated include
epidermal cyst, trichilemmal cyst, eruptive vellus hair cyst,
xanthomatosis, neurobroma, cystic acne, etc., and in cases
occurring on the face, differentiation is required from milium, syringoma, etc., and in ambiguous cases, differential
diagnosis is possible with histological ndings.
The best-known treatment for steatocystoma multiplex is
excision of the lesion, but there are many limitations to performing excision surgery when there are many lesions, and
scars can be a stumbling block. The previously used cryotherapy has difculties due to pain during the procedure and
pigmentation, and the method of puncturing and extruding
using an injection needle has been introduced as effective in
leaving fewer scars but has a high recurrence rate. Therefore,
methods such as minimal excision technique and cyst wall
removal, which involve incising the protruding part of the
lesion by about 1–3 mm and removing the cyst wall with
arterial forceps, inserting a vein hook commonly used in
ambulatory phlebectomy into the cyst membrane internally
or externally after incising the skin directly above the tumor
by 2–3mm, exposing it and then separating it with mosquito
forceps or scissors, using a sharp-tipped cautery point or a
radiofrequency (RF) instrument to incise the skin and extrude
the contents and remove the cyst pouch, treating with
OK-432 sclerotherapy effective for lymphangioma treat-
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