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12 Steatocystoma Multiplex
https://t.me/med1917
45
ment, dermabrasion using a suction-assisted cartilage shaver,
and dot peeling procedure using 100% TCA after puncture
with a 23-gauge needle are being introduced. According to a
report on a case of treating steatocystoma multiplex using
oral isotretinoin, most of the responders were steatocystoma
multiplex suppurativum, which is thought to be due to the
anti-inammatory action of retinoids. Although it has been
reported to be ineffective in cases without an inammatory
response, there have also been reports of cases that showed
therapeutic effects in Korea. Laser treatments include a
report that effective treatment was achieved without side
effects by creating an opening with a CO₂ laser and removing
the contents of the cyst with a sterile cotton swab, repeating
this process eight times at 1-week intervals, and introducing
treatment of steatocystoma multiplex using an Erbium-YAG
laser as one of the simple and effective treatment methods. In
addition, there have been reports of cases showing lesion disappearance with a combined therapy of 1550nm fractionated erbium-doped ber laser and 1450nm diode laser. In the
case of the CO₂ laser, it is possible to perform a method that
sufciently discharges only the contents of the cyst after
incising the lesion, but a more perfect treatment is possible
only after completely removing the cyst wall after discharging the contents by creating an opening with the CO₂ laser.
At this time, good results can be obtained by performing the
procedure using an ophthalmic curette (Meyerhoefer chalazion curette) and forceps. That is, by focusing with a CO₂
laser and drilling a small hole until the oily substance is discharged, inserting a thin ophthalmic curette through the
opening and gently pulling out the cyst pouch, or scraping up
the cyst wall on the bottom after discharging the contents and
gently peeling it off by applying gentle force with forceps to
hold the pouch. If a piece of the cyst pouch remains, it can
recur, so observation is necessary at intervals of 1–2months,
and reoperation can be performed depending on the case. For
Mr. M, there is a problem that the procedure takes a lot of
time because there are many numbers, so I explained that it
is safe to remove about 10 lesions per day and then dress the
treated area every other day for 2weeks after the procedure
(Figs.12.6, 12.7, 12.8, 12.9, 12.10, 12.11 and 12.12).
Figs. 12.6 and 12.7 Cyst exposed using a CO₂ laser to make a hole and a Meyerhoefer chalazion curette
Figs. 12.8 and 12.9 Steatocystoma multiplex on the arm and after cyst removal
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Figs. 12.10 and 12.11 The odorless yellow oil or cream-like substance discharged by the curette after puncturing the central part of the lesion,
and the sight of tangled ne soft hair being discharged together
12 Steatocystoma Multiplex
Fig. 12.12 Extracting the contents using an ophthalmic curette after
making a hole with a CO₂ laser and then removing the cyst sac
Polymorphous Light Eruption:
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Sun Allergy
Every year, in the spring, when I change from wearing
long-sleeved clothes to short-sleeved clothes, I get a rash
on my arms, chest, and neck, and it itches like crazy.
Ms. R, a woman in her 30s, suffers from severe itching
and rash on her arms, chest, and neck every spring when she
switches from wearing long sleeves to short sleeves. By the
end of summer, she develops a tolerance and the symptoms
almost disappear, but they recur every year, causing her great
distress. She laments, “Do I have to suffer from skin diseases
caused by sunlight all my life? The itching is driving me
crazy!” (Fig. 13.1).
Polymorphous light eruption is a recurrent skin disease
that manifests in various forms of rash due to ultraviolet radiation. It is the most common photosensitivity disorder, with
various lesions appearing on sun-exposed areas without any
specic triggers such as medication. The cause is believed to
be a delayed hypersensitivity reaction to new skin antigens
triggered by sunlight. The incidence is higher in women than
in men, with an average onset age of 23. It occurs in all races,
including Asians and African Americans, and there is a
genetic form of polymorphous light eruption (Actinic prurigo) in American Indians. Various forms of rash, such as
papular, papulovesicular, plaque, urticarial, eczematous, and
erythema multiforme like, appear a few hours or days after
sun exposure. The lesions usually appear in one form in individual patients and follow the original lesion form upon
recurrence. The lesions often occur on the arms, chest, and
neck, which were non-exposed areas during the winter, and
the itching is very severe. Rarely, itching may occur without
any lesions. Symptoms usually start in early spring, worsen
during the summer, and weaken in the fall. Rarely, it can
occur in winter due to ultraviolet reection from the snow.
During the summer, the skin develops desensitization or tolerance, and there is no recurrence by the end of summer.
The lesions usually appear suddenly within 30min to a
few hours of sun exposure. They disappear without scarring in about 1–7 days, but sometimes they persist for
13
Fig. 13.1 Polymorphous light eruption on the outer arm
2weeks or longer in severe cases. Rarely, systemic symptoms such as headache, nausea, and chills may occur. The
average duration of the disease is 10years, and it tends to
recur with exacerbations and remissions. The rash is
mainly caused by ultraviolet A, but it can also occur due to
ultraviolet B, and also it can be caused by both UVA and
UVB.UVA can pass through glass, so it can be induced
even while driving a car, and in the case of drivers, lesions
often appear on the left arm. Polymorphic light eruption is
related to the intensity of sunlight. Also, even though the
arms and legs have severe lesions, there are often no
lesions on the face and back of the hands that are usually
exposed to the sun. It should be noted that the lesions generally do not appear in the antecubital area that connects
the lower and upper arms, which are relatively less exposed
to sunlight (Fig.13.2).
Diagnosis is not difcult. Characteristics include delayed
onset of rash, characteristic shape, histopathological changes
distinguishable from lupus erythematosus, and clinical
© 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_13
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Fig. 13.2 Polymorphous light eruption observed on the arm and chest
13 Polymorphous Light Eruption: Sun Allergy
course disappearing in a few days. Skin biopsy, immunouorescence examination, and phototesting for both UVA and
UVB may be required for differential diagnosis. Some
patients may develop resistance to UV rays toward the end of
summer, but it can recur with excessive sunlight exposure in
the spring or summer of the following year. However, natural
healing or disappearance of the rash is observed after several
years (Figs. 13.3, 13.4, 13.5, 13.6, 13.7, 13.8, 13.9 and
13.10).
Direct sunlight exposure should be avoided, and sunscreen that blocks both UVA and UVB should be used. It
shows a relatively good response to steroid treatment, but if
it does not improve, the use of nicotinamide, antimalarial
drugs, thalidomide, beta-carotene, ω-3 polyunsaturated fatty
acids, azathioprine, and cyclosporine has been reported. The
exact mechanism is unknown, but it is known that the occurrence of lesions can be effectively suppressed by the preven-
Figs. 13.3 and 13.4 Polymorphous light eruption on the chest and arm
Figs. 13.5 and 13.6 Polymorphous light eruption observed on the left arm of the driver
13 Polymorphous Light Eruption: Sun Allergy
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Figs. 13.7 and 13.8 Polymorphous light eruption observed on the arm
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Figs. 13.9 and 13.10 Rarely observed polymorphous light eruption on the back of the hand
tive implementation of photochemotherapy and narrowband
UVB phototherapy. I explained to Ms. R that although it may
be painful, this disease does not last a lifetime, so do not
worry too much, avoid direct exposure to sunlight, use a sunscreen that blocks both UVA and UVB, and get immediate
treatment if you have any symptoms.
Erythema Multiforme
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Suddenly, many red spots that look like targets have
appeared on the back of my hands and feet (Fig.14.1).
A 30-year-old male, S, came in for a consultation because
he had some symptoms of body aches and strange-shaped
red spots suddenly appeared on the backs of his hands and
feet 2–3days ago and seemed to be spreading to his elbows
and knees. He said it was slightly itchy, but not very itchy or
stinging. Upon closer examination, the red spots on his hands
and feet were clearly shaped like targets (Fig.14.2).
Erythema multiforme is an acute, self-limiting, skin disorder dened solely by the shape of the lesion and clinically
presents with target-shaped lesions and histologically with
satellite cell necrosis. Since it was rst described in 1866,
there has been controversy over the scope and classication
of this disease, but erythema multiforme is relatively common and shows a mild course, recurs, and is mainly caused
by re-infection with the herpes simplex virus. StevensJohnson syndrome/toxic epidermal necrolysis shows a severe
course involving the skin and mucous membranes and is
mainly induced by drugs. It can occur in all age groups but is
most common in young and middle-aged people, and the
incidence varies by gender depending on the reporter. It
often occurs in the spring and is thought to be associated
with ultraviolet rays that trigger recurrent herpes simplex
infections. Most cases of erythema multiforme are associated with infection and can be caused by viral infections represented by the most common cause, herpes simplex virus,
bacterial infections such as M. pneumoniae infection and
tuberculosis, and fungal or protozoal infections such as coccidioidomycosis, histoplasmosis, and malaria. The skin rash
of erythema multiforme appears suddenly, and all lesions
occur within 3days in most cases. There are often no prodromal symptoms, but symptoms of a cold can appear. Lesions
typically appear symmetrically on the extremities (backs of
hands, feet, knees, elbows) and face but can also occur on the
14
Fig. 14.1 Erythema multiforme with distinct target-shaped lesions
Fig. 14.2 Erythema multiforme on the foot
© 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_14
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palms of the hands, thighs, buttocks, and trunk, and in severe
cases, hundreds of erythema can occur. It usually starts at the
extremities and spreads centripetally toward the center of the
body. Most are asymptomatic, but sometimes itching and
burning can be complained of. The characteristic feature is
the observation of target-shaped lesions consisting of three
layers: a central red-purple purpura or blister, surrounded by
an edematous ring, and nally an erythematous border.
However, not all lesions are typical, and usually less than
10% of the body surface area is involved. Mucosal lesions
are observed in about 70% and are conned to the oral cavity. Diagnosis is easy because of the characteristic target
lesions, but in cases that show atypical patterns, a biopsy
must be performed (Figs.14.3, 14.4, 14.5, 14.6, 14.7, 14.8,
14.9 and 14.10).
Individual lesions of erythema multiforme usually disappear naturally within 2weeks (1–4weeks), and some lesions
may show temporary dyschromia, but most cases recover
without sequelae. However, the problem is that recurrence is
14 Erythema Multiforme
Fig. 14.3 Erythema multiforme observed on the arm
Figs. 14.4 and 14.5 Erythema multiforme on the arm and wrist
Figs. 14.6 and 14.7 Erythema multiforme on the back of the hand
14 Erythema Multiforme
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Figs. 14.8 and 14.9 Erythema multiforme on the hand
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common and unpredictable. Topical ointments, analgesics,
antihistamines, etc. can be used for symptomatic treatment,
and recurrent erythema multiforme associated with herpes
simplex can be reduced by prophylactic or continuous use of
antiviral agents. However, there is still controversy over the
use of systemic steroids. Mr. S seems quite worried that not
only does herpes simplex recur, but this disease also frequently recurs, and the expression on his face when he leaves
the examination room is not very bright.
Fig. 14.10 Erythema multiforme on the palm of the hand
Herpes Simplex: Buttock Herpes and
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Buttock Herpes Simplex
15
Why do I get shingles four times, while other people only
get it once in their lives?
P, a woman in her 30s, came for treatment because she
had painful blisters on her buttocks. “Why do I get shingles
four times when others get it once in a lifetime? It’s strange,
isn’t it?” she said. As soon as I heard that, I quickly pulled
out a book with photos distinguishing between herpes zoster
and herpes simplex to explain in detail (Fig.15.1).
Herpes simplex is an infection caused by two types of
herpes simplex virus (HSV), which appears as clusters of
blisters on the skin or mucous membranes. It is mainly transmitted by direct contact with infected lesions or saliva. The
commonly occurring sites are very extensive, including the
lips, gums, around the mouth, face, genitals, hands, cervix,
and buttocks, and after primary infection, it remains dormant
or in a latent state, reactivating when the host’s immunity is
lowered. Most oral herpes is caused by herpes simplex virus
type 1, while most genital infections are caused by herpes
simplex virus type 2. However, both types can cause acute
and recurrent infections of the mouth and genitals, and the
virus can be transmitted even during asymptomatic periods,
which is a problem. Herpes simplex virus type 1 mainly lies
dormant in the trigeminal ganglion and type 2 mainly lies in
the sacral ganglion before being reactivated, and the degree
of reactivation is related to the amount of viral DNA latent in
the ganglion. Primary infection by herpes simplex virus type
1 usually occurs in childhood, but the infection rate increases
with age, and it is known that the majority of adults over 30
show a positive serum response to herpes simplex virus type
1. It is transmitted through direct skin-to-skin, skin-tomucosa, and mucosa-to-skin contact, tends to occur more in
high population density and low socioeconomic environments, and the recurrence frequency varies greatly, averaging about once a year, but decreases in frequency and severity
with age. Known major causes of recurrence include UV
exposure, hormonal changes such as menstruation, dental
treatment, fever, colds, immunosuppression, trauma, and
psychological stress. Herpes simplex virus type 2 shows a
close relationship with an individual’s sexual lifestyle, and
the infection rate is higher in women, but asymptomatic
infection is more common in men. Genital herpes simplex
virus infection is known to contribute to AIDS infection and
transmission (Figs.15.2, 15.3 and 15.4).
Fig. 15.1 Herpes simplex observed in the buttock Fig. 15.2 Herpes simplex on the lip
© 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_15
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Fig. 15.3 Scars from frequent recurrences of herpes simplex
15 Herpes Simplex: Buttock Herpes and Buttock Herpes Simplex
stomatitis, hand–foot–mouth disease, herpangina, erythema
multiforme, etc. Corneal examination using a slit lamp is
necessary when it occurs around the eyes. Tzanck smear,
virus culture, skin biopsy, and serological tests help in diagnosis. Virus culture testing is the best diagnostic method, and
positive results are conrmed within 48–96 h of culture.
Recently, molecular biological tests such as polymerase
chain reaction (PCR) have been used as an auxiliary
(Figs.15.5, 15.6, 15.7, 15.8, 15.9, 15.10, 15.11 and 15.12).
Although skin, mucous membrane, and internal organ
infections respond well to antiviral drugs, there is still no
treatment that can remove the herpes simplex virus from the
central nervous system. Antiviral drugs are usually administered orally in most cases, prescribed for the treatment of
primary and recurrent herpes simplex and for the suppression of recurrence. It is effective in both primary and recurrent cases, but the treatment effect is higher in primary
infections than in recurrent infections. The therapeutic effect
of antiviral drugs in recurrent herpes simplex is important
when administered at the onset of symptoms, and continuous
administration can signicantly reduce the number of recurrences in many patients. It is known that acyclovir, valacy-
Fig. 15.4 Hyperpigmentation caused by recurrent herpes simplex on
the thigh
Clinically, the lesions are characterized by clustered vesicles on erythematous bases on the skin or mucosa. Local
itching and burning sensation occur, with type 1 mainly
affecting the area around the mouth above the navel and type
2 mainly appearing on the genitals below the navel.
Symptoms vary depending on the site of infection and
immune status, but symptoms are more severe and the probability of complications is higher in primary than recurrent
infections. In addition to the herpes simplex around the
mouth, it also presents various clinical manifestations such
as gingivostomatitis, disseminated herpes simplex infection,
herpetic whitlow, genital herpes, eczema herpeticum, neonatal and fetal herpes, and central and peripheral nervous system infections.
The characteristic clinical manifestations of local itching
and burning sensation and the discovery of clustered vesicles
on the skin or mucosa make diagnosis easy, but differentiation is required for primary gingivostomatitis from aphthous
Fig. 15.5 Herpes simplex virus type 2 infection (buttock area)
Fig. 15.6 Buttock herpes simplex
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