Effective Removal of Urchin Spines with Erbium :
YAG Laser Ablation :
Report of a Case
Chun-Ping Wu
Tsen-Fang Tsai
In recent years, with the growing popularity of nautical sports, marine medicine becomes increasingly important. The most commonly associated cutaneous diseases are the sun burn and the tanning.
The other aquatic dermatology includes water-induced pruritus, pain, eruptions, and contact dermatitis.
Injuries by jellyfish stings, venomous fish, sponges, and coral are not uncommon. However, sea urchin
sting is relatively rare, and the therapy is often difficult. We report a case of seaurchin-sting successfully
treated with erbium: YAG laser ablation. (Dermatol Sinica 22 : 134-137, 2004)
Key words: Sea urchin, Erbium: YAG laser
(
22 : 134 - 137, 2004 )
INTRODUCTION
In the seas, there are a number of hazards
to human from marine animals. Not only the
vertebrate animals but also the invertebrate animals are dangerous to human. Among the
marine invertebrates, hazards to man may arise
from the effects of protozoans, sponges, coelenteraes, sea worms, echinoderms, as well as other
groups. These effects are due to toxins, injected
venoms, or direct trauma, with superimposed
From the Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
Accepted for publication: November 24, 2003
Reprint requests: Tsen-Fang Tsai, M.D., Department of Dermatology, National Taiwan University Hospital, No. 7, Chung-Shan South
Road, Taipei 100, Taiwan, R.O.C.
TEL: 886-2-23562141 FAX: 886-2-23934177
134
infection, or more complex physical and chemical actions. Some of the injuries are minor,
while others may be severe and even lethal. We
report a case of extensive sea urchin stings
which was effectively removed with erbium:
YAG laser ablation.
CASE REPORT
A 44 - year- old Taiwanese man, while on
vacation in Phuket, Thailand and accidentally
stepped the right foot on the sea urchin on beach
on Feb. 2, 2003. Immediate pain and flu - like
toxic syndrome occurred. The application of
ammonia compresses and freshly - voided urine
were recommended by the local people. He also
pounded the wound with a glass bottle and
attempted to remove the spines mechanically
but in vain. The spines are very fragile and are
very difficult to be extracted entirely, as they are
likely to break off at the surface of skin. The
stinging sensation bothered him when he
stepped on the ground. He went to our outpatient department on Feb. 11, 2003 for persistent
local tenderness and inability to walk well.
Multiple black spines were found in the sole of
right foot. (Fig. 1A).
We used the Continuum Biomedical
Erbium / 2.94 Erbium: YAG laser ( spot size 2.0
mm, 300 mJ, fluence 9.55 J / cm2, repetition rate
4 Hz ) to remove the foreign materials. The
patient was treated under an aseptic condition
without local anaesthesia. The pain during the
treatment was tolerated by the patient. The foreign bodies were destroyed until the black spots
became invisible by the naked eyes, leaving circumscribed crater lesions with tiny pinpoint
bleeding. After operation, an antiseptic wound
dressing was applied with immediate pain relief.
Two 2-mm skin punch biopsies were done and
showed the spines penetrating into the deep dermis grossly. Histological examination revealed
mild perivascular and periadnexal lymphocytic
infiltration. Two weeks after the initial treatment, the wounds were already re - epithelialized. However, there were still some stinging
points when he stepped on the ground. He circled these points with marking pen and another
session of treatment was performed in order to
remove all the residual spines. Two weeks after
the second session, the final session was performed due to the same reason. The wounds
were re - epithelialized without any discomfort
within two weeks after the final treatment and
scars were not found four weeks after the final
treatment. During two months follow - up, no
B
A
Fig. 1A
Fig. 1B
Multiple black spines (white arrows) were found in the sole
of right foot.
The lesions resolved completely without leaving any scar
and grunulomatous reaction.
Dermatol Sinica, June 2004
135
delayed granulomatous, foreign - body reactions
or other complications have been observed (Fig.
1B).
DISCUSSION
Sea urchins are marine invertebrates that
belong to the phylum Echinodermata, class
Echinoidea, characterized by a calcareous skeleton covered by spines and pedicellariae.1, 2 The
mouth consists of a complex arrangement of
muscles and plates surrounding the circular
opening. The anus is located on the upper surface. Depending on the species, movable spines
of various sizes and forms are attached to the
body. These spines often are sharp, pointed and
in some cases even venomous. Their spines consist of calcium carbonate crystals covered by a
layer of epithelium.3 (Fig. 2)
The most common species of sea urchin in
Phuket, Thailand are Echinothrix diadema and
Mespilia globulus. According to the patient's
statement, the sea urchin he stepped on is
Echinothrix diadema ( Fig. 3 ). Its black spines
are long, thin, hollow and very fragile. In
Taiwan, the sea urchins that most commonly
injure people include the family Diadematidae
and Echinometridae. Echinothrix diadem ( Fig.
3 ), Echinothrix calamaris, and Diadema setosum belong to the family Diadematidae.
Echinostrephus aciculatus and Anthocidaris
crassiapina belong to the family Echinometridae.
Injury from sea urchins usually results
from inadvertently coming in contact with the
spines.4 Injuries from sea - urchins result from
penetration of the spines into the dermis or subcutis, leading to pain for several days. Complications of sea urchin stings include local inflammation, infection and delayed granulomatous
foreign - body reactions which always develop
weeks and months later.5, 6 Long - lasting pain
and even loss of function were ever reported.5, 7
Systemic reactions to sea urchin injuries are relatively uncommon but have been reported from
contact with some of the poisonous species.4 Sea
urchin stings may also induce the massive
keloids.8
In order to prevent the long-term complications of the sea urchin stings, therapies may
be indicated. At present, there are no uniformly
accepted successful treatments because the
spines of sea urchin are often difficult to remove
owing to their easily breaking.4 Some sea urchin
spines are quite rough and impossible to pull
out. 4 Anecdotal effective treatment includes
pounding the wound side with a stone for the
purpose of breaking up the spines into smaller
fragments, which are more easily absorbed.9 The
application of ammonia compress or freshlyvoided urine has also been recommended.4 In
this patient, he had tried the previously stated
therapies; however, the result was not satisfacto-
Fig. 2
A spine of the sea urchin, as seen with the scanning electron
microscope ( original magnification x 35 ). The spine has
been broken to reveal the complexity of the internal construction.
136
Fig. 3
Echinothrix diadema.
Dermatol Sinica, June 2004
ry. Other treatment that had been mentioned
includes the application of salicylic-acid paste.
Immersion in hot water (110 ˚F - 115 ˚F) mixed
1 : 1 with vinegar is suggested in the initial
stage.10 The hot water inactivates the toxin and
provides prompt pain relief. Roentgenograms
with soft tissue windows may be needed to
identify and locate retained spines. 10 Wound
infection is common and, if present, should be
treated with antibitiocs such as ciprofloxacin.10
Tetanus prophylaxis should be considered.10 The
spines were ever reported to be safely extruded
by propulsion initiated by the lidocaine tumescence.11 Deeply embedded spines, particularly
when they have resulted in the formation of a
granulomatous lesion, require excision. These
injuries may be quite severe and require extensive surgery to correct.4
Because our patient had failed in the previous treatments and the sole is usually not pone
to scar formation, erbium: YAG laser ablation
was used in this case, as has been reported in
one case.12 The treated lesions left tiny pinpoint
areas of bleeding and the amount of bleeding
was acceptable. After all three treatment sessions, the lesions healed within 2 weeks and no
scar tissues were noted.
With the increasing aquatic activities, sea
urchin stings may be encountered more commonly. Erbium: YAG laser ablation offers an
effective treatment to remove the spines.
Immediate pain relief can be achieved and longterm complication can be prevented.
ACKNOWLEDGEMENT
We greatly thank Kwen-Shen Lee for his
Dermatol Sinica, June 2004
helpful comments and providing the sea urchin
pictures.
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