皮肤性病学总论

1、总论的概要,Basic biology of the skin- structure and function Diagnosis of skin diseases Symptoms Cutaneous signs * Clinical examination Laboratory tests Skin and other body systems Management * How to approach Dermatology? What does it take to be a dermatologist？,*Important sections in this lecture,Refer

2、ences Andrews Diseases of The Skin, Clinical Dermatology, 10th Ed., Odom, James and Verger, W.B. Saunders， 2005 Dermatology, Edited by Bolognia JL, Joriszzo JL, Rapini RP, Mosby 2003 Fitzpatricks Color atlas deviation in temperature (hot, cold); mobility. presence of tenderness, and estimate the dep

3、th of the lesion (i.e., dermal or subcutaneous).,Evaluation of Arrangement, Patterns, and Distribution,Number Single or multiple lesions. Arrangement Grouped: herpetiform, arciform, annular, reticulated (net-shaped), linear, serpiginous (snakelike); Disseminated: scattered discrete lesions. Confluen

4、ce Yes or no. Distribution Extent: isolated (single lesions), localized, regional, generalized, universal; Pattern: symmetric, exposed areas, sites of pressure, intertriginous area, follicular localization, random.,Clinical Signs,Dariers sign a brown macular or a slightly papular lesion of urticaria

5、 pigmentosa (mastocytosis) becomes a palpable wheal after being vigorously rubbed. Auspitzs sign slight scratching or curetting of a scaly lesion reveals punctate bleeding points within the lesion suggests psoriasis, but not specific. Nikolsky phenomenon the epidermis is dislodged from the dermis by

6、 lateral, shearing pressure with a finger, resulting in an erosion. acantholytic disorders staphylococcal scalded skin pemphigus,Syndrome (SSS),Clinical Examinations (1),Dermographism Urticaria、factitious urticaria Muscle strength Dermatomyositis Peripheral nerve： Leprosy Sensation test for enlargem

7、ent of the nerve,Special Techniques Used in Clinical Examination 1,Magnification with hand lens A magnifying glass (hand lens) (7x) or a binocular microscope (5x to 40 x). Woods lamp (360 nm) is valuable in the diagnosis of porphyria. Fluorescent pigments and subtle color differences of melanin pigm

8、entation can be visualized.,Red fluorescence with Woods lamp on psoriatic skin. (a) Heterogeneous red fluorescence within a psoriatic plaque on a leg; (b) standard flash photograph of the same plaque.,Special Techniques Used in Clinical Examination 2,Diascopy Consists of firmly pressing a microscopi

9、c slide or a glass spatula over a skin lesion. Whether the red color of a macule or papule is due to capillary dilatation (erythema) or to extravasation of blood (purpura) that does not blanch. detection of the glassy yellow-brown appearance of papules in sarcoidosis, tuberculosis of the skin, lymph

10、oma,Lupus vulgaris. A hyperkeratotic, crusted, granulomatous plaque (or plaques) on the face or elsewhere is characteristic. An apple jelly color is seen on diascopy (pressure to remove the blood with a glass slide).,Special Techniques Used in Clinical Examination 3,Dermoscopy A hand lens with built

11、-in lighting and a magnification of 10 x to 30 x Noninvasive inspection of deeper layers of the skin (dermal-epidermal junction and beyond). Distinction of benign and malignant growth patterns in pigmented lesions. Digital dermoscopy,Clinical Tests 1,Patch testing To document and validate a diagnosi

12、s of allergic contact sensitization and identify the causative agent. Substances to be tested are applied to the skin in shallow cups (Finn chambers), affixed with a tape and left in place for 24 to 48 h. Contact hypersensitivity will show as a papular vesicular reaction that develops within 48 to 7

13、2 h when the test is read.,Clinical Tests 2,Photopatch testing patch testing + UV irradiation of the test site To document photoallergy Prick testing To determine type I allergies. A drop of a solution containing allergen and the skin is pierced through A wheal within 20 min.,Clinical Tests 3,Acetow

14、hitening To detect of subclinical penile or vulvar warts. 5% acetic acid (white vinegar) is wrapped around the glans penis,the cervix and anus. Warts appear as small white papules.,皮肤疾病的基本病理表现,表皮改变 角化过度 角化不全 角化不良 颗粒层增厚 棘层肥厚 疣状增生 乳头瘤样增生 假上皮瘤样增生 细胞内水肿 细胞外水肿 棘层松解 基底细胞液化变性 微脓肿 Kogoj, Munro, Pautrier,真皮及

15、皮下组织改变 纤维蛋白样变性 嗜碱性变 粘液变性 弹力纤维变性 肉芽肿 渐进性坏死 脂膜炎,Laboratory Tests (1),Microscopic Examination of Scales, Crusts, Serum, and Hair Grams stains and cultures of exudates and of tissue minces bacterial or yeast (Candida albicans) infections. Fungal mycelia and fungal cultures Cells obtained from the base o

16、f vesicles (Tzanck preparation) acantholytic cells in the acantholytic diseases (e.g., pemphigus) Giant epithelial cells and multinucleated giant cells in herpes simplex, herpes zoster, and varicella. Laboratory diagnosis of scabies. intractable generalized pruritus with papules and excoriations cha

17、racteristic locations Identification of the mite, or ova or feces,Biopsy of the Skin,The simplest, most rewarding diagnostic techniques because of the easy accessibility Histopathology and immunopathology electron microscopy Selection of the site early lesions are usually more typical Techniques Use

18、 of a 3- to 4-mm punch, a small tubular knife Specimens for light microscopy should be fixed immediately in buffered neutral formalin. Indicated in: Lesion suspected of being neoplasms; All bullous disorders with immunofluoresence used simultaneously; All dermatologic disorders in which a specific d

19、iagnosis is not possible by clinical examination alone.,皮肤疾病的基本病理表现,表皮改变 角化过度 角化不全 角化不良 颗粒层增厚 棘层肥厚 疣状增生 乳头瘤样增生 假上皮瘤样增生 细胞内水肿 细胞外水肿 棘层松解 基底细胞液化变性 微脓肿 Kogoj, Munro, Pautrier,真皮及皮下组织改变 纤维蛋白样变性 嗜碱性变 粘液变性 弹力纤维变性 肉芽肿 渐进性坏死 脂膜炎,Laboratory Tests (2),Dermatopathology Highly diagnostic tumor, viral Causative

20、organism-pathogens Diagnostic: Bullous, granuloma,病理名词解释要熟记,Laboratory Tests (2),Immunopathology Bullous diseases, SLE, Vasculitis,性病检查,病原体 淋球菌 衣原体 支原体 梅毒螺旋体 毛滴虫检查,血清学检查 RPR TPPA HIV HSV-Ig 醋酸白,Skin and other body systems,The link Skin as the main part of a systemic disease Severe type of adverse dr

21、ug reaction Syphilis T cell lymphoma-mycosis fung Skin as a part of a systemic disease Systemic lupus erythematosus Dermatomyositis Skin sign as a companion/window of internal abnormality Peutz-Jegher syndrome Neurofibromatosis-caf au lait Renal failure,“Skin-deep”? “肤浅”？,Disorders of Psychiatric Et

22、iology,Delusions Dysmorphic syndrome Delusions of parasitosis Compulsive habits Neurotic excoriations Facticious syndromes,Cutaneous findings in systemic diseases,Vascular lesions -leukemia, systemic vasculitis Flushing -carcinoid syndrome Pruitus -Hodgkins disease, myeloma, polycythemia vera, DM, p

23、rimary biliary cirrhosis Eczema Pagets disease, mycosis fungoides Urticaria Hodgkins disease, multiple myeloma Erythema and Edema -Dermatomyositis-cancer,Management/Treatment,General Causative reagents Contact sensitivity Drug Precipitating causes Stress Environment: temperature, moisture Secondary

24、infection Systemic Topical therapy* Physiological therapy Surgery,Systemic Treatment,Antihistomine H1 receptor inhibitors First generation Sedation, anti-cholinergic Toldrin /Chlorpheniramine, Second generation Less/no sedation Clarityne/Loratadine, Zyrtec/Citirizine, H2 receptor inhibitors Cimetidi

25、ne, Ranitidine,Steroid Anti-inflammatory, immune suppressive, Broad applications in dermatology Allergy Drug reactions, contact dermatitis, acute urticaria Autoimmune diseases Vasculitis,Antimicrobial drugs Antibiotics Inhibitors of cell wall synthesis Penicillins, Cephalosporins Protein synthesis i

26、nhibitors Tetracyclines, Aminoglycosides, Macrolides Quinolones Antifungal Superficial Azole (broad)-clotrimazole, miconazole, econazole, bifonazole Potassium iodide Subcutaneous, systemic Azole-fluconazole, itraconazole Antiviral Acyclovir, ribavirin,Retinoids Epithelial differentiation and prolife

27、ration, anti-inflammatory, immunomodulation 1st Generation: all-transretinoic acid, Isotretinoin (oral) 泰尔丝 Acne vulgaris, keratosis palmaris Second generation: etretinate, acitretin 方希 Psoriasis, ichthyosis, keratosis palmaris Third generation: acrotinoid 外用：阿达帕林-达芙文、他扎罗丁 Psoriasis, ichthyosis, ker

28、atosis pilaris, acne vulgaris Immune suppressors and modulators CTX, MTX Cyclosporin A Calcineurin inhibitors-Tacrolimus, pimecrolimus Calcipotriol-vitamine D3 and its analogs Interferon,Topical Therapies (1),Classifications Therapeutic reagents Cleansing Protective Antipruritic Keratoplastics Kerot

29、olytics Antiseptics Causatics Keratolytics Steroids retinoids,常用糖皮质激素外用制剂,极强效： 新适确得霜（0.05卤米松-三氯生）,乳膏 澳能(0.05%卤米松)，乳膏 恩肤霜(0.02%丙酸氯倍他索2%azone) 高效： 肤轻松（国产多为0.025%,属高效，但各药厂制剂质量差异很大）乳膏，软膏 氯氟舒松（0.1%）,乳膏 皮康王霜(0.02%丙酸氯倍他索酮康唑) 中效： 艾洛松乳膏（0.1%康酸莫米松） 奥深 （复方-0.02%氟米松-水杨酸） 派瑞松霜（0.1%去炎松1%益康唑） 复方康纳乐霜（0.1%去炎松制霉素新霉素短

30、杆菌肽） 皮康霜（0.1%去炎松硝酸米康唑新霉素） 皮炎平霜（0.1%地塞米松+薄荷、樟脑） 低效： 醋酸氢化可的松（0.5-2.5%）软膏、乳膏 强的松霜（0.25%）,Topical Therapies (2),Classifications Type of solvents Solution, tincture Powder, lotion Oil, emulsion, ointment Paste Plaster Film Spray,外用治疗 (3),原则 选择正确的外用药种类 选择正确剂型 急性 仅有红斑、丘疹而无渗液-粉剂、洗剂 有糜烂渗出较多时-溶液 有糜烂无渗出时-乳剂、糊剂

31、,外用治疗(4),原则 选择正确的外用药种类 选择正确剂型 亚急性 渗出不多-糊剂、油剂 无糜烂-乳剂、糊剂 慢性 乳剂、软膏、硬膏、酊剂、涂膜剂 封包 单纯瘙痒 乳剂、酊剂,Other Management 1,Physiological therapy Electrocautery, electrolysis Photodynamic UVB Narrow-band UVB UVA Photochemotherapy (PUVA) Laser Hair removal Cryotherapy: liquid nitrogen,Other Management 2,Surgery Biops

32、y Excision Hair transplant Mohrs surgery,Fitzpatricks Color atlas & synopsis of Clinical Dermatology. Edited by K Wolff et al. 5th Ed. McGraw-Hill 2005,Hereditary angioedema,Severe edema of the face during an episode leading to grotesque disfigurement. B. Angioedema will subside within hours. The pa

33、tient had a positive family history and had multiple similar episodes including colicky abdominal pain,遗传性血管性水肿,如何学好皮肤性病学？,学习皮肤性病学的难处 以形态学为主 专业术语多 病种多，不易记 学好皮肤性病学的方法 多看皮疹 新名词，新概念 分门别类：疾病的大类 掌握原则 弄清疾病的本质，不能一概而论 治疗原则,总论 变态反应性炎症 湿疹和皮炎 药物性皮炎 感染 性病：梅毒，淋病，尖锐湿疣，生殖器疱疹 真菌：体癣 病毒：带状疱疹 细菌：毛囊炎 慢性炎症性疾病 银屑病 自身免疫性皮肤病 天疱疮，类天疱疮 SLE，硬皮病 结缔组织病 色素性 白癜风 血管炎 毛发和附属器 斑秃，男性型脱发 痤疮,What Does It Take to be a Dermatologist?,General Good grasp of knowledge of internal medicine Basic surgical skills Basic