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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5220_Библиотеки_им_академика_М_И_Перельмана.pdf
11.6 Nummular Eczema or Nummular Dermatitis or Discoid Eczema 175
Fig. 11.4 Atopic dermatitis involving ante cubital fossa
11.6 Nummular Eczema or Nummular Dermatitis
or Discoid Eczema
– Nummular eczema is characterized by intensely itchy erythematous or eczematous
plaques that are oval or coin-shaped and are sharply defined (Fig.
– Usually are multiple and bilateral in distribution.
11.5).
Fig. 11.5 Nummular eczema
176 11 Upper Extremity Including Hands
– Common in extremities; lower limbs more than upper extremities.
– There is a large variation in size: 1 to 10cm in diameter. The lesions are usually
multiple and symmetrically distributed (Leung et al.
2021).
11.6.1 Management
– Topical potent corticosteroids are usually helpful.
11.7 Psoriasis Vulgaris
– Psoriasis vulgaris is the most common type of psoriasis.
– Psoriasis vulgaris usually presents as well-demarcated, erythematous plaques with
a silver scaly surface. Size is variable (Fig.
– Common areas are extensor aspects of extremities such as back of elbow and
knees, scalp and sacral area (Kessler
11.6).
2022).
– Please see Chap. 3, ‘Papulosqumaous Disorders’ for more details on its clinical
presentation and management.
Fig. 11.6 Psoriasis vulgaris
11.8 Lichen Planus (LP) 177
11.8 Lichen Planus (LP)
– LP is characterized by intensely pruritic, purple, polygonal, flat-topped papules
(Micheletti et al.
– The exact etiology of LP is unknown.
2023) (Fig. 11.7).
Fig. 11.7 Lichen planus
178 11 Upper Extremity Including Hands
– The distribution of the eruption is symmetrical. Flexural wrists, arms and legs are
common sites.
– Wickham striae characterized by white, adherent reticulate scales are character-
istic of LP.
– Please see Chap. 3, ‘Papulosqumaous disorders’ for more details on clinical
presentation, diagnosis and management of lichen planus.
Hands
•
Granuloma annulare.
•
Palmoplantar psoriasis.
•
Pompholyx.
•
Hand eczema.
•
Cutaneous infections.
11.9 Granuloma Annulare (GA)
Granuloma annulare: It is a non-infectious granulomatous disease (Wang and
–
Khachemoune
2017).
– Several morphological forms exist. Localized, Generalized, Subcutaneous and
).
Perforating are the common ones (Zhang et al.
– Localized is most common with classical presentation of annular shaped, skin
colored or erythematous papules (Salasche
–
Exact etiology is unknown.
– Onset more common in females below 30 years old (Muhlemann and Williams
1984).
It has been reported to be associated with several conditions. Diabetes mellitus,
–
thyroid disease, malignancy and hyperlipidemia are among them (Piette and
Rosenbach
– Asymptomatic.
– Common sites: Dorsal hands or feet (Thornsberry and English 2013).
2016).
2022
2000) (Fig. 11.8).
11.9 Granuloma Annulare (GA) 179
Fig. 11.8 Granuloma annualare
180 11 Upper Extremity Including Hands
11.9.1 Diagnosis
– Diagnosis is usually made clinically. Tinea corporis is the main differential. Please
see the chapter on cutaneous infections for its characteristic findings and that helps
in differentiating both these conditions. Skin biopsy can be done if there is doubt.
11.9.2 Management
– Localized form of GA can subside on its own in 50% of the patients (Wang and
Khachemoune
– Several therapeutic modalities have been in use to treat GA for those who wish to
be treated. However, none of them is known to be definitely effective (Wang and
Khachemoune
– Ultrapotent corticosteroids such as clobetasol propionate are usually the first line
of drugs tried.
– Intralesional (IL) triamcinolone 5mg/ml have been used with success.
2017).
2017).
– There are also reports of GA responding to IL nasal saline and also subsiding
after a biopsy was done; (Kern
hypothesis that mechanical trauma may help in the resolution of GA.
–
Topical tacrolimus and cryotherapy can be tried when the above measures fail
(Wang and Khachemoune
– There are several other modalities that have been used with some success and
cases not responding to the above measures, can be referred to dermatologist, if
patient wants to be treated.
2017).
1960; Naveen 2014) all advocating the
11.10 Pompholyx (Dyshydrotic Eczema)
– It is a type of endogenous eczema.
– Manifests as vesicles only on the sides of the fingers or toes (Fig. 11.9).
– Can be associated with recurrences.
11.10 Pompholyx (Dyshydrotic Eczema) 181
Fig. 11.9 Dyshydrotic eczema
182 11 Upper Extremity Including Hands
11.10.1 Management
– Management includes usage of ultra-potent topical corticosteroids like clobetasol
propionate 0.05% ointment.
11.11 Hand Eczema (Figs. 11.10 and 11.11)
– Hand eczema is usually chronic and is manifested with hyperkeratosis and fissures
11.10). It is usually a combination of both endogenous and exogenous
(Fig.
eczema (contact dermatitis).
– Contact dermatitis on the hands may result from the objects used in everyday use
or occupational exposures.
– Given the multitude of things that come in contact with hands, often it may not
be easy to pin point exactly the allergen.
The dermatitis can be treated by ultra-potent topical steroids such as clobetasol
–
propionate 0.05% ointment and by avoidance of the offending agent, if one is
present and is identified.
– For severe chronic hand eczema refractory to potent topical corticosteroids,
alitretinoin can be used (Gawkrodger and Ardern-Jones
– Often it is appropriate to refer to a dermatologist if hand eczema is not responding
to topical medications.
2021).
11.11 Hand Eczema (Figs. 11.10 and 11.11) 183
Fig. 11.10 Hand eczema involving palmar side
184 11 Upper Extremity Including Hands
Fig. 11.11 Hand eczema manifesting on dorsal aspect
11.12 Palmoplantar Psoriasis (Figs. 11.12 and 11.13)
– Palmoplantar psoriasis is a variant of psoriasis that characteristically affects the
skin of the palms and soles.
– Hyperkeratotic, pustular or mixed morphologies can occur (Engin et al. 2017).
– Hyperkeratotic is the most common one. Erythema, fissuring and scaling are
noted. Itching and pain can be there.
– Usually, symmetrically distributed.