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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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Lichen Simplex Nuchae, Lichen Nuchae
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https://t.me/med1917
20
The back of my neck itched so much that I scratched it
like crazy, and the skin became thick like leather and it
got even more itchy.
Ms. N, a woman in her 50s, was shocked at herself
scratching her neck like crazy because it was so itchy and
came to receive treatment. “Something bad happened at
home and I was very stressed, so my skin itched unbearably
and I kept scratching it, which made it look unsightly,” she
said with a painful expression (Fig.20.1).
Lichen simplex nuchae (lichen nuchae) is a localized neurodermatitis, a variant of lichen simplex chronicus, which is
caused by continuously rubbing or scratching the skin due to
chronic itching, resulting in a localized thickened area like
leather, primarily occurring on the nape of the neck. It is
especially common in middle-aged women or people with
atopic dermatitis. Intense scratching can cause wounds or
even bleeding, and many women tend to scratch this area
when they are tense. The entire epidermis and part of the
dermis become thick like leather, the skin loses its luster and
exibility, becomes hard, and the skin lines become distinct.
This localized, lichenied erythematous plaque often appears
as a single lesion, and severe itching is the main symptom,
often accompanied by abrasions. There are no specic tests
for diagnosis, and it can be diagnosed by excluding other
primary causes that induce lichenication. In patients who
chronically complain of itching, tests for metabolic diseases
or hematological diseases are needed. Histological ndings
include hyperkeratosis and acanthosis, irregular elongation
of the epidermal rete ridge, and excessive proliferation of the
epidermis, and inltration of inammatory cells around the
vessels in the dermis is observed (Figs. 20.2, 20.3, 20.4,
20.5, 20.6, 20.7, 20.8, 20.9, and 20.10).
Adequate rest and mental relaxation can help improve
symptoms. Treatment is not easy and recurrence is common,
so new lesions can occur even when existing lesions are
improving during treatment. It is important to stop the itching for treatment, as habitual scratching can worsen lichenication and exacerbate itching, leading to more scratching.
This vicious cycle must be broken, and the patient must be
Fig. 20.1 Lichen simplex nuchae
© 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_20
Fig. 20.2 Lichen simplex nuchae
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Figs. 20.3 and 20.4 Lichen simplex chronicus of the neck
20 Lichen Simplex Nuchae, Lichen Nuchae
Figs. 20.5 and 20.6 Lichen simplex nuchae appearing in atopic dermatitis
Figs. 20.7 and 20.8 Lichen simplex nuchae
20 Lichen Simplex Nuchae, Lichen Nuchae
https://t.me/med1917
Figs. 20.9 and 20.10 Example of lichen simplex chronicus with abrasions (scratches) on the shoulder and face
83
made aware of this. Antihistamines and anti-anxiety drugs
can be used to alleviate symptoms, and the application of
strong steroid ointment is effective. Occlusive dressing or
intralesional injections may be needed for severe lichenied
lesions. Phototherapy can be helpful, and antibiotics are used
if secondary bacterial infection occurs. I earnestly told Ms. N
that the vicious cycle of itching and scratching continues, so
she must endure, and I will prescribe medication to prevent
itching, so please do not scratch!
Malassezia Folliculitis, Pityrosporum
https://t.me/med1917
Folliculitis
21
Suddenly, I got something like acne on my chest and
back, and even though I was treated for a long time with
antibiotics for folliculitis, it didn’t get better.
Mr. H, a 20-year-old male, came for treatment because he
suddenly got a lot of acne or sweat rash on his chest and
back, was diagnosed with folliculitis, and continued to
receive antibiotic prescriptions, but it didn’t get better at all.
He is worried, asking, “Why is this continuing even though
I’ve been taking antibiotics for folliculitis for 2 months?”
(Figs.21.1 and 21.2).
Pityrosporum folliculitis was claimed by Potter etal. in
1973 to be a relatively common disease that has often been
misdiagnosed as acne in clinical practice, after conrming 7
cases clinically and histopathologically. It has since been
recognized as a type of independent folliculitis, and since
1985, it has been known as one of the relatively common
skin diseases in Korea. It is mostly caused by Pityrosporum
orbiculare, but in rare cases, P. ovale is also detected. The
term Malassezia furfur, referring to the mycelial form, and
Pityrosporum orbiculare, referring to the yeast form, were
used interchangeably, causing confusion. However, recently,
the two genera Malassezia and Pityrosporum have been ofcially consolidated into the genus Malassezia, which was
named earlier, and it is more often referred to as Malassezia
folliculitis. Malassezia yeast is often found in the upper
body, head and neck, and upper arms where sebaceous
glands are developed due to its lipophilic nature, and it is
known to start forming colonies mainly after puberty when
sebaceous gland development is prominent, and it is known
to be cultured from almost all adults. This yeast has been
known to be associated with skin diseases such as pityriasis
versicolor, seborrheic dermatitis, and Malassezia folliculitis,
and recently, its association with atopic dermatitis and psoriasis has been reported (Fig.21.3).
This disease often suddenly occurs in a wide area during
the summer and spreads, and it occurs more in men and commonly appears between puberty and the 30s. It is often misdiagnosed as acne or bacterial folliculitis, but unlike acne,
comedones are not found, and it often accompanies mild
itching and does not respond to antibiotics. However, in
Fig. 21.1 Malassezia folliculitis (Pityrosporum folliculitis)
© 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_21
Fig. 21.2 Malassezia folliculitis (Pityrosporum folliculitis)
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Fig. 21.3 Malassezia folliculitis
some cases, Malassezia folliculitis can coexist with acne. If
acne-like lesions appear on the chest, back, and shoulders of
men between puberty and their 30s during the summer, and
hundreds of them occur within a few days, a test should be
performed rst to differentiate Malassezia folliculitis.
Diabetes and the administration of antibiotics and steroids
can be triggering factors. Recently, it has been suggested that
it is desirable to classify steroid-induced acneiform eruption
as a subtype of Malassezia folliculitis or as the same disease
on a continuum with Malassezia folliculitis, based on the
fact that steroids are one of the important triggers of
Malassezia folliculitis, clinical similarities with steroid acne,
direct smear test ndings, and treatment responses. Also, if
acneiform eruptions on the face occur in conjunction with
lesions in areas where Malassezia folliculitis often occurs in
the summer, Malassezia folliculitis should be suspected, and
it has been reported that a direct smear test should be performed to rule out the possibility of Malassezia folliculitis in
patients who do not respond to conventional acne treatment
(Fig.21.4).
Malassezia folliculitis is characterized by 2–4 mm red
follicular papules or pustules, often accompanied by slight
itching, on the chest, back, neck, shoulders, upper arms, and
sometimes the face. The face is the most common site in
female patients, and the second most common in males, primarily occurring on the lower jaw, cheeks, and sides of the
face. This distribution differs from acne vulgaris, which is
more often located in the central part of the face. It can also
occur on the abdomen, buttocks, and thighs.
21 Malassezia Folliculitis, Pityrosporum Folliculitis
Fig. 21.4 Malassezia folliculitis
(1) Red follicular papules and pustules on the chest, back,
neck, shoulders, etc., accompanied by itching, (2) disappearance or signicant improvement of symptoms with oral and
topical antifungal agents, (3) discovery of budding yeast
cells in the expanded follicular infundibulum on pathological
tissue examination, and (4) discovery of clustered budding
yeast cells in KOH/Parker Ink direct smear examination. If
two or more of these four items are satised, it can be diagnosed as Malassezia folliculitis. Differential diagnosis is
needed from acne vulgaris, bacterial folliculitis, druginduced acne, miliaria rubra, and miliaria pustulosa
(Figs.21.5, 21.6, 21.7, 21.8, 21.9, 21.10, 21.11, and 21.12).
Malassezia folliculitis generally responds well to topical
antifungal agents. Topical application of azole antifungal
ointments, 2.5% selenium sulde solution, etc., or administration of itraconazole (200mg daily for 2–4 weeks) or uconazole (150 mg once a week for 2–4 weeks) is
recommended. As lesions and itching often recur without
intermittent treatment, preventive measures such as continuing topical treatment once or twice a week are necessary. I
explained to Mr. H that this disease invades the follicles, so
it doesn’t get better quickly even with medication, and it usually takes about 3–4 weeks after starting medication for
symptoms to improve slightly. Therefore, he should not be
impatient and should come to the hospital once a week for
observation until he is cured. I also explained that if comedones form as a result of folliculitis, they may require extrusion, just like acne.
21 Malassezia Folliculitis, Pityrosporum Folliculitis
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Figs. 21.5 and 21.6 Malassezia folliculitis
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Figs. 21.7 and 21.8 Malassezia folliculitis—neck and facial lesions
Figs. 21.9 and 21.10 Malassezia folliculitis—lesions on the neck and chest
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Figs. 21.11 and 21.12 Malassezia folliculitis (Pityrosporum folliculitis)
21 Malassezia Folliculitis, Pityrosporum Folliculitis
Mango Dermatitis, Mango Allergy
https://t.me/med1917
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Two days after eating mango, the area around my mouth
and my hands and arms are very, very itchy.
“Since last night, my hands, arms, and the area around my
mouth have been very itchy. I think I might have hives,” says
Ms. K, a woman in her 30s. Upon examining her skin, it’s
not hives but acute eczematous dermatitis that is found in
various places. In such cases, it is often contact dermatitis
caused by allergens or irritants, and it is necessary to ask if
they have recently eaten mangoes, cashew nuts, pistachios,
and Rhus (or Rhus chicken, Rhus shoots, etc.). “Ah! I did eat
a mango 2 days ago!” she says. When I tell her, “Mango is a
plant of the Rhus family!” she exclaims, “Oh my! I’m allergic to Rhus, so I don’t even go near Rhus trees!” (Figs.22.1
and 22.2).
Plants belonging to the family Anacardiaceae (cashew
family or sumac family) can cause not only allergic contact
dermatitis by contact but also systemic contact dermatitis
when eaten. Most food allergies appear immediately as
hives, but in this case, eczematous lesions like contact dermatitis can appear in a delayed manner. Recently, the focus
has been on mangoes, which are native to the East Indies and
are widely cultivated not only in tropical regions but also
worldwide. Mango trees belong to the family Anacardiaceae
and can cause allergic contact dermatitis due to roots, fruit
skin, juice, pollen, etc. and very rarely can cause anaphylaxis. The dermatitis caused by these components of mango
is called mango dermatitis. In the past, it mainly occurred
after traveling to Southeast Asia, but recently, as the sale of
mangoes in Korea has increased, it has become one of the
common causes of allergic contact dermatitis. Like other
plants in the Anacardiaceae, it is known that substances such
as urushiol, cardol, β-pinene, limonene, etc. cause allergic
contact dermatitis through type 4 delayed hypersensitivity
reactions. Also, like other tropical fruits, it has been reported
that mango allergies occur in patients sensitized to latex,
which often cross-reacts with latex (Figs.22.3, 22.4, 22.5,
22.6, 22.7, 22.8, 22.9, and 22.10).
Mango dermatitis, like when you are allergic to Rhus,
requires treatment with oral antihistamines and topical steroid creams for 5–7 days, and in severe cases, antihistamine
injections and steroids are sometimes administered systemically. As I explained to Ms. K, people who are allergic to
Rhus tree, like her, need to avoid not only mangoes but also
cashew nuts and pistachios.
Fig. 22.1 Mango dermatitis observed around the mouth
© 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_22
Fig. 22.2 Mango dermatitis observed on the arm
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Fig. 22.3 Mango dermatitis on the face
22 Mango Dermatitis, Mango Allergy
Figs. 22.4 and 22.5 Mango dermatitis on the arm and face
Figs. 22.6 and 22.7 Mango dermatitis on the face and neck
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Figs. 22.8 and 22.9 Mango dermatitis on the face and arm
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Fig. 22.10 Mango dermatitis observed on the back
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