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17 Nummular Eczema, Discoid Eczema

Fig. 17.21 Nummular eczema on the torso

Figs. 17.23 and 17.24 Nummular eczema—10× magnication

Fig. 17.22 Large nummular eczema on the leg

17 Nummular Eczema, Discoid Eczema

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Figs. 17.25 and 17.26 Nummular eczema—10× magnication

Chilblains, Pernio

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Every year, as autumn passes and winter approaches, the toes on both of my feet swell up red and become unbearably itchy.

A 19-year-old woman, Ms. H, came for treatment because every early winter, the tips of her toes on both feet swell up red and become severely itchy. “My hands and feet are usually cold, but from late autumn to early winter, they are itchy, painful, and swollen, and they get better after winter passes,” she said. Just a brief look at Ms. H’s feet brings back the memories of the annoyingly itchy chilblains from my childhood every winter (Fig.18.1).

Chilblain (pernio) is an abnormal local inammatory reaction that occurs in people who are hypersensitive to cold, clinically presenting as erythema and edematous lesions accompanied by itching and burning sensations on the extremities when exposed to cold and damp environments. It is the mildest form of cold injury, usually starting in late autumn or early winter and naturally disappearing in spring or summer. The cause is not clear, but it may occur due to repeated reduction in blood ow due to spasmodic contraction of blood vessels caused by cold, or due to inammatory reactions triggered by hypoxia in tissues caused by cold stimuli or trauma, resulting in vascular damage. Despite the absence of characteristic acute vascular damage ndings

Fig. 18.1 Chilblain lesions observed on the toes of both feet

such as brin deposition, inammatory cell inltration into the vascular wall, and thrombosis, some reports suggest that vasculitis is the cause of chilblain. Chilblain can occur at any age, but it often starts in adolescence and the incidence increases until the 30s. In children, it recurs every winter for several years and then recovers, while in the elderly, if the triggering factors are not avoided, it tends to get worse every year. It is more common in women than in men. In people who are hypersensitive to cold, it may occur even when exposed to cold above freezing point. Acute chilblains appear within 12–24 h after exposure to cold, as single or multiple red or purple swollen patches, mainly on the ngers, toes, heels, nose, ears, and lower limbs. It can be accompanied by pain, itching, or burning, and in severe cases, blisters or ulcers may form. In acute chilblains, the lesions usually last for 1–2 weeks and then disappear without any special sequelae, but in chronic chilblains, repeated exposure to cold causes the swollen lesions to become chronic and worsen, seasonal variations disappear, and in some cases, it can progress to occlusive vascular disease, accompanied by scars or atrophic lesions, which can persist and require caution. Histologically, it is characterized by signicant subepidermal edema, perivascular inltration of lymphocytes, and swelling of endothelial cells. In supercial cases, there is severe edema of the papillary dermis and prominent perivascular inltration of mononuclear cells in the upper dermis, while deep chilblains show the same vascular edema as supercial ones, but mononuclear cells inltrate the lower dermis and subcutaneous fat layer. In acute chilblains, differentiation from Raynaud’s phenomenon or frostbite is necessary. Raynaud’s phenomenon is characterized by clear boundaries of skin pallor and cyanosis followed by erythema, which usually disappears within a few hours of onset, while frostbite is characterized by tissue necrosis caused by freezing due to cold or cooling. In chronic chilblains, symptoms of vasculitis similar to occlusive vasculitis or chilblain lupus erythematosus are accompanied, so differentiation from these diseases is necessary (Figs.18.2, 18.3, 18.4–18.7, 18.8,

18.9, and 18.10).

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Fig. 18.2 Chilblains

18 Chilblains, Pernio

Fig. 18.3 Chilblains on the foot

Figs. 18.4–18.7 Chilblains on the toes

18 Chilblains, Pernio

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Chilblains are generally best prevented, avoiding exposure to cold, regular exercise, maintaining cleanliness and dryness of the affected area, and keeping it warm. Smoking cessation should be implemented, and not only the lesion area but also the whole body should be kept warm as a drop in core body temperature can cause peripheral vasoconstriction. So far, no clear treatment has been proposed. Topical steroid application, systemic administration, and intralesional injections have been attempted, but the results have varied, and other attempts such as phototherapy, high-dose vitamin D administration, and thymoxamine treatment have been reported but were ineffective. In severe cases, in addition to the treatment of underlying diseases, nicotinic acid, nifedipine, pentoxifylline, etc. can be used as treatments. Having had the tiresome experience of suffering from chilblains every year in my childhood in a place with a lot of snow, I explained in detail to Ms. H how to prevent chilblains by avoiding exposure to the cold along with the prescription of the treatment.

Figs. 18.8 and 18.9 Chilblains on the toes and ngers

Fig. 18.10 Chilblains on the heel

Leser-Trélat Sign, Eruptive Seborrheic

∗∗∗

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Keratoses

I heard that if such spots appear on the skin, it means there is cancer in the body. Is that really true? I’m very worried.

Mr. P, a man in his 50s, is worried about the sudden increase in black fungus-like spots on his back. When he came into the clinic, he asked with a gloomy expression, “I read on the internet that such spots are signs of cancer in the body. Is that true? I’m very worried” (Fig.19.1).

Since ancient times, the skin has been considered a “mirror of the internal organs,” and specic changes in the skin can be important clues in the diagnosis of malignant diseases like cancer. Therefore, recognizing the early signs of neoplasia in the skin can be of great value in preventing the progression of malignant diseases. Leser–Trélat sign refers to a sign in adults where the occurrence of seborrheic keratosis accompanied by itching suddenly increases over a short period of time, which is thought to be associated with the development of malignant tumors in the internal organs. The characteristic of this sign is that the number or size of new seborrheic keratosis lesions increases in a rash-like manner within a few weeks or months, and it has been reported as a skin change related to internal malignant tumors (paraneoplastic syndrome). In 1890, Leser of Germany and Trélat of France rst described eruptive hemangiomas that occurred together in patients with malignant tumors of the internal organs, and in 1900, Holländer rst reported the association between internal malignant tumors and multiple seborrheic keratoses, but this sign is now called the Leser–Trélat sign (Fig. 19.2).

The most commonly reported malignant tumors associated with the Leser–Trélat sign are stomach cancer, adenocarcinoma of the gastrointestinal tract, and lymphoma, and there are also a wide variety of others, including leukemia, breast cancer, lung cancer, and prostate cancer. The pathological mechanism of this sign has not been clearly eluci-

Fig. 19.1 The sudden spread of seborrheic keratoses on the back, a

sign of Leser–Trélat

Fig. 19.2 Suddenly appearing seborrheic keratoses on the body

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19 Leser-Trélat Sign, Eruptive Seborrheic Keratoses

dated, but the increase in the number and size of seborrheic keratoses is thought to be due to the induction of epidermal proliferation related to growth factors derived from the tumor. However, such signs have been reported even in situations where malignant tumors, such as in heart transplant patients, AIDS, and pityriasis rubra pilaris, are not found. According to a few studies comparing malignant tumor patients and healthy control groups, these signs were sometimes assumed to be the result of coincidence. Also, Safa and Darrieux reported that they tried to nd evidence of malignant disease for over 2 years in a 66-year-old woman showing these signs, but failed, suggesting that it can occur in healthy people without internal malignant disease. Turan etal. also could not detect any type of malignant disease in a 37-year-old woman with these symptoms despite detailed examination and 18 months of follow-up, and a literature review also showed inconsistent results regarding the relationship between Leser–Trélat signs and malignant tumors. The incidence of seborrheic keratosis and malignant tumors is high in the elderly population, so there is a very high possibility that they may occur coincidentally. Moreover, after the tumor is healed, the skin lesions should disappear, and if the malignant tumor recurs or metastasizes, it should reappear, but these facts are not clearly introduced in the literature, and there is only one paper that observes regression in 1/3 of seborrheic keratosis after treatment of primary cancer.

It is also difcult to trust that the seborrheic keratosis lesions have suddenly increased a lot, as it is entirely based on the patient’s subjective evaluation, and this sudden increase may be related to the consciousness and awareness level of patients diagnosed with cancer, and there is no clear boundary in the denition between eruptive seborrheic keratosis and ordinary seborrheic keratosis. In addition, almost all papers claiming that malignant tumors and these signs appear simultaneously are limited to case reports, and no substance released in response to or by the tumor has been clearly identied in studies on the mechanism of occurrence (Figs.19.3,

19.4, 19.5, 19.6, 19.7, 19.8, 19.9, 19.10, 19.11, 19.12–19.15,

19.16, and 19.17).

Therefore, it is argued that in cases of eruptive seborrheic

keratosis, testing for underlying internal malignant disease is unnecessary, but in order to clarify whether the Leser–Trélat sign truly exists, it is necessary to investigate the presence of malignant diseases in more cases composed of patients with eruptive seborrheic keratosis. However, after sufcient explanation, I recommended Mr. P to have a health checkup to see if there is any abnormality in his internal organs and decided to remove all the lesions on his back at once using a CO₂ laser. If you receive laser treatment, it will be clean after 1–2 weeks of suffering after treatment, and if you get a retouch every month, the skin will only leave a faint scar and become clean, so there is no need to worry.

Figs. 19.3 and 19.4 Seborrheic keratosis—60× magnication