doi: 10.1111/j.1346-8138.2009.00677.

x Journal of Dermatology 2009; 36: 462–465

CASE REPORT

Dental infection associated with nummular eczema

as an overlooked focal infection
Tomoko TANAKA, Takahiro SATOH, Hiroo YOKOZEKI
Department of Dermatology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan

ABSTRACT
Nummular eczema is a common skin disease, but the pathoetiology has yet to be elucidated. We report here a case
of severe nummular eczema. Although the skin lesions were resistant to topical corticosteroids, the patient became
responsive to treatment and no recurrence was noted after the eradication of dental infections. We have experi-
enced 13 similar cases of nummular eczema with widely-distributed skin lesions. The cases had moderate to severe
odontogenic infections, which were detected by panorama X-ray screening test. In 11 patients, skin lesions partially
or completely improved after the dental treatment. Latent odontogenic infection may thus be an aggravating factor
in treatment-resistant nummular eczema.
Key words: complement, dental infection, focal infection, nummular eczema.

INTRODUCTION 2 years. However, the disease was resistant and

Nummular eczema is a common eczematous skin
disease characterized by oval exudative plaques con-
sisting of serous eczematous papules. While some
patients can be successfully treated dermatologically
(i.e. with topical corticosteroids), severe types of num-
mular eczema showing widely distributed coin lesions
are resistant to treatment and recurrence is frequent.
Local bacterial infection and ⁄ or xerotic skin have been
implicated in the disease1 but the actual pathoetiology
remains uncertain. However, older reports suggest
the possible involvement of focal infections in num-
mular eczema.2,3 We report here a case of treatment-
resistant nummular eczema that was successfully
treated by eradication of an odontogenic infection.
CASE REPORT
A 75-year-old man presented with a 3-year history
of itchy eruptions. He had been treated with topical
corticosteroids and systemic antihistamines for
unresponsive to the treatment. On examination, oval-
shaped, red to brown plaques consisting of miliary-
sized papules were distributed on the trunk and
extremities (Fig. 1a,b). Initially, he was treated with
topical corticosteroids, which were unsuccessful
and eruption frequently recurred. Patch testing to
metals was negative. However, panorama X-ray test
revealed the presence of severe odontogenic infec-
tions, such as pulpitis and root caries in several teeth.
After dental treatment, including tooth extraction, skin
symptoms improved markedly and no recurrence
was noted (Fig. 1c).
DISCUSSION
Focal infections have been implicated in some aller-
gic skin diseases, such as palmoplantar pustulosis.4
Although chronic tonsillitis and ⁄ or sinusitis have been
recognized as latent infectious foci, odontogenic
infection has not been well documented, probably
because dermatologists do not commonly focus on

Correspondence: Tomoko Tanaka, M.D., Department of Dermatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima,
Bunkyo-ku, Tokyo 113-8519, Japan. Email: tntm.derm@tmd.ac.jp
Received 26 November 2008; accepted 2 April 2009.

462  2009 Japanese Dermatological Association

 Dental infection in nummular eczema

(a) (c)

(b)

(d) (e)

Figure 1. Clinical manifestations. (a,b,d) Case 1 before dental treatment. Oval exudative eczematous plaques were distributed
on the trunk. (c,e) Case 1 after dental treatment. Marked improvement in skin lesions was observed. The case shown in (d,e)
transiently developed prurigo nodules during the course of the disease, as reported in 8.

physical changes in teeth and gums. However, odon-
togenic infection may be a causative factor in not only
palmoplantar pustulosis,5 but also chronic urticaria.6
Nummular eczema is an allergic skin disease of
unknown etiology. While some patients can be trea-
ted by improving xerotic skin, other patients have a
severe subtype of nummular eczema that does not
respond to dermatological treatment. Recent findings
suggest that metal allergies are a precipitating factor
in nummular eczema.7 Here, we report a case of
severe nummular eczema with widely distributed
eruptions. Although eruptions appeared to transiently
respond to topical corticosteroids, papules continued
to recur very frequently. After dental treatment, how-
ever, skin symptoms completely improved and recur-
rence was not seen.
We have experienced 12 similar cases (11 male,
two female; average age 55.2 years [range 22–75])
(Table 1). These were patients with nummular
eczema, who were resistant to conventional derma-

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T. Tanaka et al.

tological treatments, such as topical corticosteroids

and systemic antihistamines. Some patients received
systemic administration of corticosteroids. However,
papules frequently recurred after the cessation of cor-
ticosteroids. Skin lesions were widely distributed on
the trunk and extremities. None of the patients had a
history and ⁄ or skin symptoms characteristic of atopic
dermatitis. Under the panorama X-ray screening test,
patients were found to have moderate to severe
odontogenic infection, such as pulpitis, root caries
and periodontitis. A representative panorama X-ray
image of odontogenic infection is shown in Figure 2.
Patients received treatment for odontogenic infection,
including tooth extraction, at the dental units of our
university. Of the 13 patients, five showed marked Figure 2. Representative features of panorama X-ray of
responses to dental treatment. In some of these severe odontogenic infection. Translucent areas around
tooth roots were observed (arrows).
patients, tooth extraction resulted in a transient flare-
up phenomenon characterized by the appearance of complements may be an important factor suggesting
serous papules and severe pruritus followed by a latent focal infection. In contrast, levels of anti-
gradual improvement of skin lesions. The mean dura- streptolysin O (ASO) and anti-streptokinase (ASK)
tion for complete improvement after the dental treat- were within normal limits, with the exception of case
ment was 3.8 months. Six cases exhibited good 3 who had chronic tonsillitis. This is consistent with
response, but occasional recurrence of papules was previous reports that a-hemolytic streptococci, but
observed; however, they were much milder and were not b-hemolytic streptococci are the most frequently
more responsive to topical corticosteroids. The isolated bacteria from dental focal infections.5
remaining two patients did not respond to dental We previously reported four patients with chronic
treatment, and the severity of skin lesions did not nodular prurigo associated with odontogenic infec-
change before and after treatment. Laboratory find- tion.8 These patients exhibited unusual clinical
ings are summarized in Table 1. Interestingly, seven features in that skin lesions started with nummular
cases had elevated serum CH50. Hyperproduction of eczema-like lesions followed by transition to prurigo

Table 1. Clinical and laboratory findings

Disease IgE CRP ASO CH50
Case Age ⁄ duration Odontogenic WBC Eosinophils (295) (0.3) (159) ASK (26–49) Clinical
no. sex (months) infection ( ⁄ lL) ( ⁄ lL) (IU ⁄ mL) (mg ⁄ dL) (IU ⁄ mL) (<·2560) (U ⁄ mL) response
1 75 ⁄ M 30 ++ 4700 451› 607› 0.0 30 320 59› Very good
2 22 ⁄ M 24 + 7000 973› 16 0.0 24 80 37 Good
3 42 ⁄ M 120 + 7800 266 N.T. 0.6 577 2560› 53› Recurrent
4 32 ⁄ M 24 + 4500 369 23 0.1 53 160 35 Recurrent
5 74 ⁄ F 10 ++ 5800 99 N.T. 0.0 15 160 24 Good
6 22 ⁄ M 6 + 6500 468 186 0.0 161 640 53› Very good
7 55 ⁄ M 12 + 4500 140 226 0.0 59 160 45 Good
8 57 ⁄ M 12 ++ 5900 118 N.T. 0.2 30 80 43 Good
9 66 ⁄ M 3 ++ 8400 168 N.T. N.T. 30 40 57› Good
10 66 ⁄ M 48 + 6200 186 33 0.2 30 80 64› Good
11 69 ⁄ F 48 + 6200 1240› 5115› 0.2 36 N.T. N.T. Very good
12 75 ⁄ M 10 + 8800 625› 600› 0.8 30 160 55› Very good
13 62 ⁄ M 8 + 8000 360 N.T. 0.1 30 40 51› Very good

CH50, total activity of serum complements in the classical pathway (C1–C9), as determined by hemolytic assay of sensitized SRBC (Mayer’s method).
Odontogenic infection: + (moderate), ++ (severe). ASK, anti-streptokinase; ASO, anti-streptolysin O; CRP, C-reactive protein; IgE, immunoglobulin E;
N.T., not tested; WBC, white blood cells.

464  2009 Japanese Dermatological Association


reaction. Figure 1(d,e) shows the nummular eczema-
tous stage of a patient involving a 66-year-old man
with a 16-year history of nummular eczema before
and after dental treatment in our prior report.8 In this
study, we extended our previous observations and
found that some severe nummular eczema cases
seem to be associated with focal infections, such as
odontogenic infection, irrespective of subsequent
prurigo-like changes.
A recent finding revealed the exacerbation of skin
symptoms of atopic dermatitis by odontogenic focal
infections.9 The induction of interleukin-4-producing
CD4 (+) T cells was stimulated by the tooth extraction
in patients with chronic nodular prurigo and ⁄ or num-
mular eczema associated with odontogenic infec-
tion.8 Either bacterial superantigens, Toll-like receptor
or heat shock protein-mediated immune reactions
may be involved in the induction of eczematous skin
reactions.8,10
The present cases suggest that careful exam-
ination may detect latent odontogenic infection in
treatment-resistant nummular eczema with widely-
distributed skin lesions.
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