皮膚與性病學(xué)-授課教案:第四次課 藥疹、帶狀皰疹、疥瘡

課程名稱

皮膚性病學(xué)

年級(jí)

05本

專業(yè)、層次

臨床醫(yī)學(xué)及專業(yè)方向

授課教師

許飏

職稱

副教授

課型（大、小)

大

學(xué)時(shí)

3

授課題目（章、節(jié))

藥疹、帶狀皰疹、疥瘡

基本教材或主要參考書

陳德宇，主編. 中西醫(yī)結(jié)合皮膚性病學(xué). 北京：中國(guó)中醫(yī)藥出版社. 2004

徐世正主譯. 安德魯斯臨床皮膚病學(xué). 北京：科學(xué)出版社. 2004

教學(xué)目的與要求：

目的：認(rèn)識(shí)和掌握藥疹的定義、病因病機(jī)、診斷和鑒別診斷以及治療和預(yù)防原則。

認(rèn)識(shí)和掌握帶狀皰疹、疥瘡的病因、診斷和鑒別診斷以及治療原則。

要求：掌握引起藥疹的常見藥物種類和臨床表現(xiàn)；

1. 掌握重癥藥疹的治療原則。

2.   掌握帶狀皰疹、疥瘡的臨床表現(xiàn)和診斷、治療原則。

大體內(nèi)容與時(shí)間安排，教學(xué)方法：

內(nèi)容：復(fù)習(xí)、概括總論的知識(shí)要點(diǎn)，比較總論、各論學(xué)習(xí)方法的異同  5分鐘

藥疹的定義、發(fā)病機(jī)理、變態(tài)反應(yīng)性藥疹的特點(diǎn)   25分鐘

藥疹的臨床表現(xiàn)、診斷和鑒別診斷   30分鐘

藥疹的治療原則和預(yù)防    20分鐘

帶狀皰疹的病因病機(jī)、臨床表現(xiàn)和診斷、治療原則    20分鐘

疥瘡的病因病機(jī)、臨床表現(xiàn)和診斷、治療原則  15分鐘

小結(jié)   5分鐘

方法：運(yùn)用啟發(fā)式、討論式等多種教學(xué)方法簡(jiǎn)要復(fù)習(xí)、概括總論的知識(shí)要點(diǎn)，比較總論、各論學(xué)習(xí)方法的異同。恰當(dāng)開展病案式教學(xué)及雙語教學(xué)，以大量圖片、簡(jiǎn)表對(duì)比加深感性認(rèn)識(shí)。布置一些內(nèi)容自學(xué)，彌補(bǔ)教學(xué)學(xué)時(shí)減少的不足。

教學(xué)重點(diǎn)、難點(diǎn)：

重點(diǎn)： 藥疹的定義、病因病機(jī)；

藥疹、帶狀皰疹、疥瘡的臨床表現(xiàn)；

藥疹、帶狀皰疹的診斷；變態(tài)反應(yīng)性藥疹的特點(diǎn)

難點(diǎn)： 藥疹的臨床表現(xiàn)及鑒別診斷、重癥藥疹的治療原則

教研室審閱意見：

教研室主任簽名：

   年   月 日

基本內(nèi)容

教學(xué)手段

課堂設(shè)計(jì)和時(shí)間安排

運(yùn)用啟發(fā)式、討論式等多種教學(xué)方法簡(jiǎn)要復(fù)習(xí)、概括總論的知識(shí)要點(diǎn)，比較總論、各論學(xué)習(xí)方法的異同，起到承前啟后的作用。

Drug eruption

藥疹(drug eruption)亦稱藥物性皮炎(dermatitis medicamentosa)，是藥物通過內(nèi)服、注射、吸入、灌腸、栓劑使用，甚至通過破損皮膚等途徑進(jìn)入人體后，在皮膚粘膜上引起的炎癥性皮疹，嚴(yán)重者尚可累及機(jī)體的其他系統(tǒng)。

由藥物引起的非治療性反應(yīng)，統(tǒng)稱為藥物反應(yīng)，藥疹僅是其中的一種表現(xiàn)形式。

發(fā)病率Frequency:

• In the US: Drug eruptions occur in approximately 2-5% of inpatients（住院病人) and in more than 1% of outpatients（門診病人).

• Internationally: Drug eruptions occur in approximately 2-3% of inpatients.

死亡率Mortality:

Most drug eruptions are mild, self-limited and usually resolve after the offending agent has been discontinued.

Severe and potentially life-threatening eruptions occur in approximately 1 in 1000 hospital patients. Mortality rates for erythema multiforme (EM) major are significantly higher. Stevens-Johnson syndrome (SJS) has a mortality rate below 5%, whereas the rate for TEN approaches 20-30%; most patients die from sepsis.

一、 病因:

1.個(gè)體因素 2.藥物因素

All prescription（處方藥) and over-the-counter（OTC非處方藥)drugs including topical agents, vitamins, and herbal and homeopathic remedies

臨床上易引起藥疹的藥物有：

①  抗生素

② 解熱鎮(zhèn)痛類

③ 鎮(zhèn)靜催眠藥及抗癲癇藥

④ 異種血清制劑及疫苗等

⑤  中藥

二、發(fā)病機(jī)制Pathophysiology:：

1.  免疫性反應(yīng)

immunologically mediated reactions

2.非免疫性反應(yīng)兩大類。

nonimmunologically mediated reactions.

Immunologically mediated reactions

Coombs and Gell proposed 4 types of immunologically mediated reactions, as follows:

• Type I is immunoglobulin E (IgE)–dependent reactions, which result in urticaria, angioedema, and anaphylaxis.
• Type II is cytotoxic reactions, which result in hemolysis and purpura.
• Type III is immune complex reactions, which result in vasculitis, serum sickness, and urticaria.
• Type IV is delayed-type reactions with cell-mediated hypersensitivity, which result in contact dermatitis, exanthematous reactions, and photoallergic reactions.

變態(tài)反應(yīng)性藥疹的特點(diǎn)：

只發(fā)生于少數(shù)過敏體質(zhì)的服藥者

皮疹的輕重與藥理及毒理作用無關(guān)

有一定的潛伏期

皮疹形態(tài)各異

交叉過敏及多價(jià)過敏現(xiàn)象

停止致敏藥物，糖皮質(zhì)激素治療常有效。

三、臨床表現(xiàn)：

Although most drug eruptions are exanthematous, different types 醫(yī)學(xué).全在線gydjdsj.org.cnof drug eruptions exist.

With every drug eruption, it is important to evaluate for certain clinical features that may indicate a severe potentially life-threatening drug reaction, such as TEN or hypersensitivity syndrome. Such features include the following:

• Mucous membrane erosions
• Blisters (Blisters herald a severe drugeruption.)
• Nikolsky sign (epidermis sloughs off withlateral pressure)
• Confluent erythema
• Angioedema and tongue swelling
• Palpable purpura
• Skin necrosis
• Lymphadenopathy
• High fever, dyspnea, or hypotension

藥疹的臨床表現(xiàn)多種多樣

1． 固定型藥疹Fixed drug eruptions

2． 蕁麻疹型藥疹Urticarial

3． 麻疹樣或猩紅熱樣藥疹Morbilliform or exanthematous

4． 濕疹型藥疹

5． 紫癜型藥疹

6． 多形紅斑型藥疹EM - Includes a spectrum of diseases, eg, EM minor and EM major; many categorize SJS (10% of the skin)and TEN(30% or more the total body surface area) as EM major and differentiate them by body-surface involvement

7． 大皰性表皮松解型藥疹

8． 剝脫性皮炎型藥疹Erythroderma

四、診斷及鑒別診斷：

診斷可依據(jù)：

①有明確的服藥史；

②有一定的潛伏期；

③除固定型藥疹外，皮疹多對(duì)稱分布，顏色鮮紅；

④瘙癢明顯；

⑤排除與皮損相似的其它皮膚病及發(fā)疹性傳染病。

鑒別診斷：

①麻疹或猩紅熱相鑒別

②金葡菌性燙傷樣皮膚綜合征相鑒別。

③生殖器皰疹、硬下疳等鑒別。

五、治療：

原則：

①停用一切可疑致敏藥物及結(jié)構(gòu)相似藥物；

②加速致敏藥物的排出；

③對(duì)癥治療已經(jīng)出現(xiàn)的皮損和癥狀；

④注意藥物的交叉過敏或多價(jià)過敏。

⑤預(yù)防藥疹的再次發(fā)生。

重型藥疹  應(yīng)及時(shí)搶救，防止病情加重，減少并發(fā)癥及后遺癥，加強(qiáng)護(hù)理，縮短病程，降低死亡率。原則：

①及早足量使用糖皮質(zhì)激素；

②預(yù)防和治療感染及并發(fā)癥；

③加強(qiáng)支持療法；

④加強(qiáng)護(hù)理及局部治療。

六、預(yù)防：

對(duì)比

案例式教學(xué)

簡(jiǎn)要復(fù)習(xí)變態(tài)反應(yīng)類型及規(guī)律

舉例說明

圖片和病例

結(jié)合病例

舉例說明

圖片對(duì)比

（★－重點(diǎn)，☆－難點(diǎn)，)

5分鐘

★概念

強(qiáng)調(diào)：藥疹的給藥途徑，

突出與接觸性皮炎概念的區(qū)別。

★舉例描述皮損特征，說明藥疹臨床表現(xiàn)的多樣性。指出：臨床上使用頻繁的藥物引發(fā)藥疹的幾率更大。

★強(qiáng)調(diào)：絕大多數(shù)藥疹是通過變態(tài)反應(yīng)機(jī)制發(fā)生的，變態(tài)反應(yīng)性藥疹特點(diǎn)是絕大多數(shù)藥疹的特點(diǎn)，也是重要的診斷依據(jù)。

★強(qiáng)調(diào)：變態(tài)反應(yīng)性藥疹

的潛伏期、多價(jià)過敏現(xiàn)象

是診斷治療的重要方面

25分鐘

★☆結(jié)合圖片和病例形象具體地突出各型藥疹臨床表現(xiàn)的特征。

30分鐘

★結(jié)合變態(tài)反應(yīng)性藥疹的特點(diǎn)容易掌握藥疹的診斷依據(jù)。

★☆強(qiáng)調(diào)與皮損相似的其它皮膚病的鑒別是藥疹的診斷依據(jù)之一。

★☆強(qiáng)調(diào)藥疹是變態(tài)反應(yīng)性疾病、醫(yī)源性疾病，

聯(lián)系大面積燙傷病人治療護(hù)理特點(diǎn)說明重癥藥疹的治療護(hù)理原則。

20分鐘

基本內(nèi)容

教學(xué)手段

課堂設(shè)計(jì)和時(shí)間安排

病毒性皮膚病

病毒可分為脫氧核糖核酸（DNA)病毒和核糖核酸（RNA)病毒兩大類。根據(jù)病毒性皮膚病的不同臨床表現(xiàn)特點(diǎn)，可將其分為3型：

1．新生物型2．皰疹型3．紅斑發(fā)疹型

Shingles (Herpes Zoster)

Shingles (otherwise known as Herpes Zoster) is a painful, blistering rash caused by the chickenpox (varicella) virus, which affects only a limited area of skin, and makes you feel surprisingly tired, run down, and even depressed.

水痘(varicella)和帶狀皰疹（Herpes zoster)是由同一病毒即水痘-帶狀皰疹病毒(varicella- zoster virus, VZV)引起的兩種不同的疾病。水痘是一種以散在分布的水皰為特征、傳染性很強(qiáng)的疾病，多見于兒童。帶狀皰疹以群集小水皰沿神經(jīng)走向單側(cè)分布，伴明顯神經(jīng)痛為特征，多見于成人，中醫(yī)稱為纏腰火丹。

一、病因Causes

You can only get shingles (Herpes Zoster) if you have previously had chickenpox. After having chickenpox the virus lies dormant in the nerves, and shingles occurs when it is revitalised in one particular nerve to the skin, thus explaining the way it affects a clearly demarcated band of skin only.

Usually the cause is a decrease in your body"s natural resistance, which may come through other infections, stress, being generally run down, or occasionally, when the body"s immune defences are affected by certain drugs or other immune deficiencies.

病原體為水痘-帶狀皰疹病毒。具嗜神經(jīng)和皮膚的特性。

三、臨床表現(xiàn)

1.現(xiàn)全身或局部前驅(qū)癥狀1日～4日后，皮膚出現(xiàn)群集的小水皰或丘皰疹。皰液澄清或血皰，沿神經(jīng)走向呈帶狀排列，基底常繞以紅暈。一般不超過軀干中線。

2.多見于肋間神經(jīng)或三叉神經(jīng)第一分支區(qū)，亦可見于腰腹部、四肢及耳部等。

3.神經(jīng)痛是本病的特征之一。

四、診斷及鑒別診斷：

The pattern of the rash, in the form of blisters usually clinches the diagnosis, but a sample of the fluid from the blisters, or of blood can confirm it. It is unlikely that your doctor will need to do any tests.

帶狀皰疹根據(jù)群集小水皰，沿神經(jīng)走向，單側(cè)分布，有明顯的神經(jīng)痛，一般診斷不難。應(yīng)與單純皰疹、膿皰瘡鑒別。

五、治療：

原則：抗病毒、止痛、營(yíng)養(yǎng)神經(jīng)、預(yù)防感染。

補(bǔ)充：

帶狀皰疹后遺神經(jīng)痛，PHN

舉例簡(jiǎn)介

對(duì)比水痘

圖片

結(jié)合病例

舉例說明

（★－重點(diǎn)，☆－難點(diǎn)，)

了解常見的病毒性皮膚病的種類。Herpes zostter 是常見的皰疹型病毒性皮膚病之一。

★對(duì)比說明VZV可引起兩種不同的疾病。取決于患者對(duì)VZV的不同免疫狀態(tài)。強(qiáng)調(diào)Herpes zoster可獲得終身免疫，幾乎沒有傳染性。

★強(qiáng)調(diào)：VZV嗜神經(jīng)和皮膚的特性是帶狀皰疹兩大主要臨床表現(xiàn)的原因。

聯(lián)系中醫(yī)稱帶狀皰疹為纏腰火丹的病名強(qiáng)調(diào)好發(fā)部位。

★☆結(jié)合圖片和病例形象具體地突出帶狀皰疹的特征。

★☆結(jié)合圖片和病例形象具體地突出帶狀皰疹與單純皰疹、膿皰瘡的區(qū)別。

★  聯(lián)系帶狀皰疹的發(fā)病機(jī)理、臨床表現(xiàn)說明其治療原則。

10分鐘

基本內(nèi)容

教學(xué)手段

課堂設(shè)計(jì)和時(shí)間安排

動(dòng)物性皮膚病

疥  瘡Scabies

是由疥螨寄生于人體表皮引起的一種接觸性傳染性皮膚病，可通過握手、同臥及性接觸等密切接觸傳播，易在集體和家庭中流行�！夺t(yī)學(xué)金鑒》稱“蟲疥”。

Scabies is an infestation of the skin with the microscopic mite Sarcoptes scabei. Infestation is common, found worldwide, and affects people of all races and social classes.

Scabies spreads rapidly under crowded conditions where there is frequent skin-to-skin contact between people, such as in hospitals, institutions, child-care facilities, and nursing homes.

一、病因和傳播途徑：

How did I get scabies?

By direct, prolonged, skin-to-skin contact with a person already infested with scabies. Contact must be prolonged (a quick handshake or hug will usually not spread infestation). Infestation is easily spread to sexual partners and household members. Infestation may also occur by sharing clothing, towels, and bedding.

How long will mites live?

Once away from the human body, mites do not survive more than 48-72 hours. When living on a pegydjdsj.org.cn/job/rson, an adult female mite can live up to a month.

二、臨床表現(xiàn)：

How soon after infestation will symptoms begin?

For a person who has never been infested with scabies, symptoms may take 4-6 weeks to begin. For a person who has had scabies, symptoms appear within several days. You do not become immune to an infestation.

1. 丘疹、水皰、隧道、結(jié)節(jié)。

• Pimple-like irritations, burrows or rash of the skin, especially the webbing between the fingers; the skin folds on the wrist, elbow, or knee; the penis, the breast, or shoulder blades.

2. 劇烈瘙癢

• Intense itching, especially at night and over most of the body.

Who is at risk for severe infestation?

People with weakened immune systems and the elderly are at risk for a more severe form of scabies, called Norwegian or crusted scabies.

三、診斷及鑒別診斷： 

How is scabies infestation diagnosed?

Diagnosis is most commonly made by looking at the burrows or rash. A skin scraping may be taken to look for mites, eggs, or mite fecal matter to confirm the diagnosis. If a skin scraping or biopsy is taken and returns negative, it is possible that you may still be infested. Typically, there are fewer than 10 mites on the entire body of an infested person; this makes it easy for an infestation to be missed.

根據(jù)接觸傳染史，好發(fā)部位，夜間劇癢等不難診斷。若找到疥螨即可確診。

鑒別診斷：應(yīng)與癢疹、皮膚瘙癢癥、虱病、丘疹性蕁麻疹、濕疹等鑒別。

四、預(yù)防和治療：

1.隔離消毒。家庭內(nèi)成員或集體生活者應(yīng)同時(shí)治療。

2.治療以外用藥為主，對(duì)瘙癢嚴(yán)重者可輔以鎮(zhèn)靜止癢藥睡前內(nèi)服。

2.并發(fā)化膿性感染時(shí)，應(yīng)同時(shí)采用抗感染藥物治療。

Who should be treated for scabies?

Anyone who is diagnosed with scabies, as well as his or her sexual partners and persons who have close, prolonged contact to the infested person should also be treated. If your health care provider has instructed family members to be treated, everyone should receive treatment at the same time to prevent reinfestation.

How soon after treatment will I feel better?

Itching may continue for 2-3 weeks, and does not mean that you are still infested. Your health care provider my prescribe additional medication to relieve itching if it is severe. No new burrows or rashes should appear 24-48 hours after effective treatment.

小結(jié)：

解釋說明

圖片

結(jié)合病例

舉例說明

解釋說明

（★－重點(diǎn)，☆－難點(diǎn)，)

★結(jié)合疥螨生活史說明疥瘡的傳播和致病特點(diǎn)

★  結(jié)合圖片說明疥瘡的臨床特點(diǎn)

★  強(qiáng)調(diào)疥瘡的外用藥治療方法。

15分鐘

5分鐘

小

結(jié)

藥疹亦稱藥物性皮炎，是藥物通過內(nèi)服、注射、吸入、灌腸、栓劑使用，甚至通過破損皮膚等途徑進(jìn)入人體后，在皮膚粘膜上引起的炎癥性皮疹，嚴(yán)重者尚可累及機(jī)體的其他系統(tǒng)。臨床上易引起藥疹的藥物有：①抗生素②解熱鎮(zhèn)痛類③鎮(zhèn)靜催眠藥及抗癲癇藥  ④異種血清制劑及疫苗等⑤中藥。帶狀皰疹是常見的皰疹型病毒性皮膚病之一。以群集小水皰沿神經(jīng)走向單側(cè)分布，伴明顯神經(jīng)痛為特征。疥瘡是由疥螨引起的接觸性傳染性皮膚病。

本次課所學(xué)醫(yī)學(xué)單詞：drug eruption ，medical dermatitis, Shingles , Herpes zostter，Scabies

復(fù)習(xí)思考題、

作 業(yè)

題

1、變態(tài)反應(yīng)性藥疹的特點(diǎn)？

2、藥疹的臨床表現(xiàn)類型及診斷要點(diǎn)？
3、重癥藥疹的治療原則？
4、帶狀皰疹、疥瘡的臨床特點(diǎn)及治療原則？

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