"Dermatology"
General
Chapter 2 The Structure of the Skin
1. The skin is composed of epidermis, dermis, subcutaneous tissue and appendages , and the epidermis and dermis are connected by a basement membrane band. In addition to various skin appendages such as hair, sebaceous glands, sweat glands and nails, the skin is also rich in blood vessels, lymphatic vessels, nerves, and muscles.
2. The skin is the largest organ in the human body . The skin on the eyelids, vulva, and breasts is the thinnest, and the skin on the palms and toes is the thickest.
3. The epidermis belongs to stratified squamous epithelium in histology, mainly composed of keratinocytes (differentiated from ectoderm), melanocytes , Langerhans cells and Merkel cells . (Melanocytes, Langerhans cells, also known as dendritic cells)
4. More than 80% of epidermal cells are keratinocytes, which are differentiated from ectoderm , and are characterized by the production of keratin during the differentiation process . There are some special connections between keratinocytes and the underlying structures such as desmosomes and hemidesmosomes. According to the differentiation stage and characteristics, it is divided into five layers, from deep to superficial, they are basal layer, spinous layer, granular layer, transparent layer and stratum corneum . (The transparent layer is only seen in the thicker parts of the skin such as palms and soles).
5. Basal layer: Located at the bottom of the epidermis, it is composed of a layer of cuboidal or cylindrical cells. The cytoplasm is basophilic, and mitotic figures are common. (Salient features)
（1） 表皮通过时间或更替时间：正常情况下约30%的基底层细胞处于核分裂期，新生的角质形成细胞有次序地22逐渐向上移动，由基底层移行至颗粒层约需14天，再移行至角质层表面并脱落又需14天，共约28天。（P6）
角质形成细胞分类及特点
6. 棘层：位于基底层上方，由4-8层多角形细胞构成，细胞呈棘刺样形态，表面有许多细小突起，相邻细胞的突起相互连接，形成桥粒。电镜下可见角质小体或Odland小体。（特征）
7. 颗粒层：位于棘层上方，富含透明角质颗粒，由梭形和扁平细胞构成。细胞核和细胞器溶解，胞质可见透明角质颗粒
8. 透明层：位于颗粒层与角质层之间，仅见于掌趾等表皮较厚的部位，由2-3层扁平细胞构成
9. 角质层：角质细胞成熟的最终形态，位于表皮最上层，由5-20层已死亡的扁平细胞构成。细胞正常结构消失，胞质中充满角质蛋白。角质层上部细胞间桥粒消失或形成残体，故易脱落。（没有细胞核，但有丰富的角质蛋白）
（1）角化不全/角化不良——角质层细胞出现细胞核——可形成银屑
（2）角化过度——超过周期角质未脱落——皮肤会变得肥厚
黑素细胞、朗格汉斯细胞、梅克尔细胞特点
10. 黑素细胞：起源于外胚层的神经脊，位于基底层和毛囊
（1）分布：基底层、毛囊、粘膜、眼色素层、暴露部位、乳晕、腋窝、生殖器、会阴部
（2）
（3）作用：遮挡和反射紫外线、保护真皮及深部组织
（4）电镜下胞质内可见特征性黑素小体
（5）1个黑素细胞可通过其树枝状突起向周围10-36个角质细胞形成细胞提供黑素，形成表皮黑素单元
11. 朗格汉斯细胞：起源于骨髓及脾的免疫活性细胞
（1）主要分布于表皮中部及毛囊上皮
（2）作用：免疫识别（吞噬、吞饮、摄取）、抗原呈递等
12. Merkel cells: mostly distributed between the cells of the basal layer, the cells have short finger-like processes, and there are many neuroendocrine granules in the cytoplasm. May have sensory effects not mediated by nerve endings.
13. The basement membrane zone (BMZ) is located between the epidermis and the dermis. Under the electron microscope, the BMZ is composed of four layers: the cell membrane layer, the transparent layer, the compact layer and the subdense layer. The role of BMZ: ① Make the dermis and epidermis tightly connected ② Penetration ③ Barrier effect.
14. Skin appendages, including hair, sebaceous glands, sweat glands and nails, are all differentiated from ectoderm.
15. Hair includes: long hair, short hair, vellus hair, and vellus hair. Hair is composed of keratinized epithelial cells arranged in concentric circles, which can be divided into medulla, cortex and hair cuticle from inside to outside. The hair follicle is located in the dermis and subcutaneous tissue and consists of inner hair root sheath, outer hair root sheath and connective tissue sheath.
16. The growth cycle of hair can be divided into growth period (about 3 years), degenerative period (about 3 weeks) and telogen period (about 3 months) . The hair of each part does not grow or fall off at the same time, and about 80% of all hairs are growing Expect. (P10)
17. The sebaceous gland is a lipid-producing organ that is a vesicular gland consisting of acini and short ducts.
(1) Sebaceous glands are widely distributed and exist in the skin of the whole body except the palms and soles and the flexor sides of fingers and toes. There are more sebaceous glands on the head, face and upper chest and back, which are called seborrhea.
(2) Sebaceous glands also have a growth cycle, and growth and secretion are mainly controlled by androgen levels
18. Sweat glands can be divided into eccrine sweat glands and apocrine sweat glands according to their structure and function.
(1) Small sweat glands: also known as eccrine sweat glands, which are single tubular glands, composed of a secretory part and a ductal part
①Distribution: In addition to red lips, tympanic membrane, nail bed, nipples, inner foreskin, glans, labia minora, and clitoris, it spreads all over the body, with more palms, soles, armpits, and forehead, and less on the back.
② eccrine sweat glands are controlled by the sympathetic nervous system.
③ Innervated by sympathetic nerves, the neurotransmitter is acetylcholine
④ Physiological functions: regulate body temperature; moisturize and protect; antibacterial effect
(2) Apocrine sweat glands, once called apocrine glands, are large tubular glands consisting of a secretory part and a ductal part
① Mainly distributed in armpits, areola, umbilicus, perianal, foreskin, mons pubis and labia minora.
② Secretion is mainly affected by sex hormones
③ Innervated by sympathetic nerves, the neurotransmitter is norepinephrine
19. Nail is the hard cuticle covering the extension surface of the finger (toe), which is composed of multiple layers of compact keratinocytes.
11. Skin functions: barrier, absorption, sensation, secretion and excretion, temperature regulation, substance metabolism, immunity, etc.
12.皮肤的吸收功能可受多种因素的影响：①皮肤的结构和部位②角质层的水合程度③被吸收物质的理化性质④外界环境因素
第四章 皮肤性病的临床表现及诊断
1.原发性皮损： 最早出现的皮损
1) 斑疹和斑片：斑疹为皮肤黏膜的局限性颜色改变，直径≦1cm，与周围皮肤平齐，无隆起或凹陷，大小可不一，形状可不规则，边界可清楚或模糊。直径>1cm时，称为斑片。
2) 斑块：为丘疹扩大或较多丘疹融合而成，直径大于1cm的隆起性扁平皮损，中央可有凹陷。见于银屑病等。
3) 丘疹：为局限性、实质性、直径小于1cm的表浅隆起性皮损，形态介于斑疹与丘疹之间的稍隆起皮损称为斑丘诊；丘疹顶部有小水疱时称丘疱疹；丘疹顶部有小脓疱时称丘脓疱疹。
4) 风团：为真皮浅层水肿引起的暂时性、隆起性皮损。皮损可呈红色或苍白色，周围常有红晕，一般大小不一，形态不规则。皮损发生快，此起彼伏，一般经数小时消退，消退后不留痕迹，常伴有剧痒。见于荨麻疹。
5) 水疱和大疱：水疱为局限性、隆起性、内含液体的腔隙性皮损，直径一般小于1cm，大于1cm者称大疱，内容物含血液者称血疱。
6) 脓疱：为局限性、隆起性、内含脓液的腔隙性皮损，可由细菌或非感染性炎症引起。脓疱的疱液可浑浊、稀薄或黏稠，皮损周围常有红晕。水疱继发感染后形成的脓疱为继发性皮损。
7) 结节：为局限性、实质性、深在性皮损，呈圆形或椭圆形，可隆起于皮面，亦可不隆起，需触诊方可查出，触之有一定硬度或浸润感。可由真皮或皮下组织的炎性浸润、代谢产物沉积或肿瘤引起。
8) 囊肿：为含有液体或黏稠物及细胞成分的囊性皮损。一般位于真皮或更深位置，可隆起于皮面或仅可触及。外观呈圆形或椭圆形，触之有囊性感，大小不等。
2. 继发性皮损，是由原发性皮损自然演变而来，或因搔抓、治疗不当引起。包括糜烂、溃疡、鳞屑、浸渍、裂隙、瘢痕、萎缩、痂、抓痕、苔藓样变。
（1）糜烂：局限性表皮或粘膜上皮或全部缺损形成的红色湿润创面。常由水疱、脓疱破裂或浸渍处表皮脱落所致。因损害较表浅，愈后一般不留瘢痕。
(2) Ulcers: Wounds formed by localized skin or mucosal defects, which may reach to the dermis or deeper. It can be caused by infection, injury, tumor, vasculitis, etc. Because of the damage to the basal layer cells, the healing is slow and scarring can be left after healing.
(3) Scale: It is the accumulation of keratin visible to the naked eye. It is caused by excessive formation of epidermal cells or disturbance of normal keratinization process. The scales vary in size, shape, and thickness, and can be chaff-like (such as pityriasis versicolor), oyster-like (such as psoriasis), or large flakes (such as exfoliative dermatitis)
(4) Dipping: The stratum corneum of the skin absorbs more water, resulting in whitening and softening of the epidermis. It is common in parts that have been immersed in water for a long time or are in a wet state. After rubbing, the epidermis is easy to fall off and the erosive surface is exposed, which is prone to secondary infection.
(5) Fissures: linear skin fissures that can reach deep into the dermis, also known as chapped skin. It is often caused by skin inflammation, thickening of the stratum corneum, or skin dryness, resulting in decreased skin elasticity, increased fragility, and stretching.
(6) Scar: After the dermis and subcutaneous tissue are damaged or damaged, it is formed by the hyperplasia and repair of new connective tissue, which can be divided into hyperplastic and atrophic.
(7) Atrophy: degenerative lesions (thinning) of the skin, caused by the reduction of cells and tissue components. Can occur in the epidermis, dermis and subcutaneous tissue.
(8) Scab: It is formed by mixing and coagulating the liquid (serum, pus, blood) on the surface of the skin lesion with exfoliated tissue or drugs (appendages).
(9) Scratch marks: linear or point-like exfoliative defects of the superficial layer of the epidermis or dermis. Often caused by mechanical trauma, such as scratching, laceration, or friction. There may be exudation, blood scab or desquamation on the surface of the skin lesion. If the injury is deep, it may also leave a scar after healing.
(10) Lichenification: localized roughness and thickening of the skin caused by repeated scratching and constant friction. It is manifested as steep and raised skin, deepened skin grooves, clear boundaries of skin lesions, and often accompanied by severe itching.
Chapter Five Auxiliary Examination Methods for Skin and Venereal Diseases
Chapter VII Prevention and Treatment of Skin and Venereal Diseases
1. Dosage forms of drugs for external use: (P50)
1) Solution: It is an aqueous solution of the drug. It has cleansing and astringent effects, and is mainly used for cold wet compresses (it can relieve congestion and edema and remove secretions and scabs, etc.), and is mainly used for acute dermatitis and eczema diseases.
2) Tincture and spirit: alcohol solution or infusion of medicine, tincture is alcohol solution of non-volatile medicine, spirit is alcohol solution of volatile medicine. It has the functions of disinfection, antipruritic and degreasing.
3) Powder: It has the functions of drying, protection and heat dissipation. It is mainly used for acute dermatitis skin lesions without erosion and exudation, especially for intertriginous areas.
4) Lotion: Also known as oscillator, it is a mixture of powder (30%-50%) and water, and the two are incompatible with each other. It has antipruritic, cooling, drying and protective effects.
5) Oil: Dissolve or mix medicine with vegetable oil. It has cleaning, protecting and lubricating effects, and is mainly used for subacute dermatitis and eczema.
6) Emulsion: It is a formulation formed by emulsifying oil and water. There are two types, one is water-in-oil (W/O), the oil is the continuous phase and has a slightly greasy feeling, and it is mainly used for dry skin or winter in the cold season; the other is oil-in-water (O /W), water is the continuous phase, also known as cream, because water is the continuous phase, it is easy to wash off, suitable for oily skin. Both water-soluble and fat-soluble drugs can be formulated into emulsions, which have protective and moisturizing effects and good permeability. They are mainly used for severe acute and chronic dermatitis.
7) Ointment: It is a dosage form with vaseline, single ointment (vegetable oil plus beeswax) or animal fat as the base. It has the function of protecting the wound surface and preventing dryness and cracking. Ointment has better permeability than emulsion. Adding different drugs can exert different therapeutic effects. It is mainly used for chronic eczema, chronic lichen simplex and other diseases. Since ointment can prevent water evaporation, it is not conducive to heat dissipation Therefore, it is not suitable for acute dermatitis, exudative period of eczema, etc.
8) Paste: It is an ointment containing 25%-50% solid powder ingredients. The effect is similar to ointment, because it contains more powder, so it has certain water absorption and astringent effects, and it is mostly used for subacute dermatitis and eczema with mild exudation, etc. Paste is not suitable for hair parts.
9) Hard plaster: A semi-solid matrix composed of fatty acid salts, rubber, resin, etc. is attached to the mounting material (such as cloth, paper material or perforated plastic film). The plaster can be firmly adhered to the skin surface and has a long-lasting effect, which can prevent water loss, soften the skin and enhance drug penetration.
10) Film coating agent: It is made by dissolving drugs and film-forming materials in volatile solvents. After external use, the solvent evaporates quickly and forms a uniform film on the skin. It is often used to treat chronic dermatitis, and can also be used for occupational disease protection.
11) Gel: It is a drug for external use made up of polymer compounds and organic solvents. After external use, the gel can form a thin layer, which is cool and lubricating, non-irritating, and can be used for acute and chronic dermatitis.
12) Aerosol: Also known as spray, it is made by mixing medicine, polymer film-forming material and liquefied gas. After spraying, the drug is evenly distributed on the skin surface, which can be used to treat acute and chronic dermatitis or infectious skin diseases.
13) Others: Dimethyl sulfoxide (DMSO) can dissolve a variety of water-soluble and fat-soluble drugs, also known as a universal solvent. The DMSO dosage form of drugs often has good transdermal absorption and good curative effect for external use. 1%—5% Azone solution also has good transdermal absorption and is non-irritating.
★★★2. Therapeutic principles of topical drugs:
I. Correctly choose the type of external drug
应根据皮肤病的病因与发病机制等进行选择，如细菌性皮肤病宜选用抗菌药物，真菌性皮肤病可选抗真菌药物，超敏反应性疾病选择糖皮质激素或抗组胺药，瘙痒者选用止痒剂，角化不全者选用角质促成剂，角化过度者选用角质剥脱剂等。
II. 正确选用外用药物的剂型
应根据皮肤病的皮损特点进行选择，原则为
①急性皮炎仅有红斑、丘疹而无渗液时可选用粉剂或洗剂，炎症较重，糜烂、渗出较多时宜用溶液湿敷，有糜烂但渗出不多时则用糊剂
②亚急性皮炎渗出不多者宜用糊剂或油剂，如无糜烂宜用乳剂或糊剂
③慢性皮炎可选用乳剂、软膏、硬膏、酊剂、涂膜剂等
④单纯瘙痒无皮损者可选用乳剂、酊剂等。
III.详细向患者解释用法和注意事项
应当针对患者的个体情况如年龄、性别、既往用药反应等向患者详细解释使用方法、使用时间、部位、次数和可能出现的不良反应及处理方法等
3、系统药物治疗：常包括抗组胺药、糖皮质激素、抗细菌药物、抗病毒药物、抗真菌药物、维A酸类药物及免疫抑制剂
（1）抗组胺药：竞争抑制组胺受体
Ⅰ、抗组胺药：可以对抗组胺引起的毛细血管扩张、血管通透性增高、平滑肌收缩、呼吸道分泌增加、血压下降等效应。适用于荨麻疹、药疹、接触性皮炎、湿疹等
ü 第一代
药物易透过血脑屏障，导致嗜睡、乏力、困倦、头晕、注意力不集中，部分药物的抗胆碱作用可导致黏膜干燥、排尿困难、瞳孔散大。高空作业、精细工作者和驾驶员禁用或慎用，青光眼和前列腺肥大者也需慎用。
ü 第二代
药物不不易透过血脑屏障，无明显或轻度嗜睡作用，困倦程度有个体差异，同时抗胆碱作用较小。
Ⅱ、抗组胺药：可抑制胃酸分泌，也有一定程度的抑制血管扩张和抗雄性激素作用。不良反应有头痛、眩晕，长期应用可引起血清转氨酶升高、阳痿和精子减少等，孕妇及哺乳期妇女慎用。在皮肤科主要用于慢性荨麻疹、皮肤划痕症等。
（2）糖皮质激素：具有抗炎、免疫抑制、抗细胞毒、抗休克、抗增生、抗过敏、抗核分裂等多种作用。
Ⅰ. Indications:
①Allergic skin disease
② Autoimmune diseases
③Some serious infectious skin diseases
④ Connective tissue disease
⑤ Bullous skin disease
⑥ allergic skin disease
⑦Acute dermatitis
⑧Severe drug eruption
(3) Antibiotics
① Penicillins
② Cephalosporins and carbapenem antibiotics
③ Aminoglycosides
④ Glycopeptides
⑤ Tetracyclines
⑥ Macrolides
⑦ Quinolones
⑧ Sulphonamides
⑨ Anti-tuberculosis drugs
⑩ Anti-leprosy drugs
⑪ Others: metronidazole, clindamycin ..
(4) Antiviral drugs
① Nucleoside antiviral drugs
② Foscarnet
③ Vidarabine
(5) Antifungal drugs
① Acrylamines
② Polyene drugs
③ Flucytosine
④ Azole
⑤ Griseofulvin
⑥ Iodine
(6) Vitamin A acid drugs
(7) Immunosuppressant
(8) Other
Hydroxychloroquine: It can reduce skin sensitivity to ultraviolet light, stabilize lysosomal membranes, inhibit neutrophil chemotaxis, phagocytosis and immune activity. Mainly used for lupus erythematosus, light eruption multiforme, lichen planus, etc. Adverse reactions include gastrointestinal reactions, leukopenia, drug eruption, corneal pigmentation spots, retinal macular damage, liver damage, etc.
monograph
Chapter VIII Viral Skin Diseases
1. Herpes simplex: caused by herpes simplex virus (HSV) , clinically characterized by clustered vesicles, self-limited, but prone to recurrence.
(1) HSV can be divided into type I and type II
(2) The primary infection of HSV-I occurs in children and spreads through kissing or public utensils, mainly causing skin and mucous membranes other than genitals, brain infection (above the waist), mouth, and eyes.
(3) The initial infection of HSV-II is mainly seen in young people or adults, and it is transmitted through close sexual contact, mainly causing infection in the genital area or newborns (below the waist)
(4) Clinical features:
① Occurs at the junction of skin and mucous membrane
② Occurs when the immune system is weakened due to overwork, fever, etc.
③ Erythema, clustered vesicles
④ Self-healing after 1-2 weeks, easy to relapse
(5) Clinical manifestations: The incubation period of primary infection is 2-12 days, with an average of 6 days, and some patients may have no symptoms of primary infection.
1) Initial onset: Relatively wide range of skin lesions, obvious subjective symptoms, slightly longer course of disease
① Herpetic gingivostomatitis
② Neonatal herpes simplex: 70% of patients are caused by HSV-2, mostly infected through the birth canal. Generally, the onset occurs 5-7 days after birth, manifested as blisters and erosions on the skin, oral mucosa, and conjunctiva. In severe cases, it may be accompanied by fever, dyspnea, jaundice, hepatosplenomegaly, and disturbance of consciousness. It can be divided into skin-eye-oral localized type, central nervous system type and disseminated type, and the latter two types are dangerous.
③ Herpetic eczema
④ Vaccination herpes
2) Recurrent type: after the primary infection subsides in some patients, recurrence occurs at the same site
3) Genital herpes
(6) Laboratory examination:
1) Virus culture is the gold standard for identifying HSV infection
2) Immunofluorescence detection of viral antigen in blister fluid and PCR detection of HSV-DNA are helpful for confirming the diagnosis
3) Serum HSV-IgM antibody detection is helpful for auxiliary diagnosis
(7) Diagnosis and differential diagnosis:
1) Diagnosis can be made based on the characteristics of clustered blisters, frequent occurrence at the junction of skin and mucous membranes, and easy recurrence.
2) The disease should be differentiated from herpes zoster, impetigo, hand, foot and mouth disease, etc.
(8) Prevention and treatment
1) Treatment principles: shorten the course of the disease, prevent secondary bacterial infection, reduce the chance of recurrence and transmission
2) Local treatment: wet compress for erosion patients
antiviral ointment for non-erosion
Antibacterial ointment for co-infected patients
3) Systemic treatment: antiviral treatment - acyclovir, immune enhancer (systemic drug treatment)
① Initial hair: Acyclovir, valacyclovir or famciclovir can be used, and the course of treatment is 7-10 days
② Relapsing type: Intermittent therapy is used, and the treatment is started within 24 hours before the appearance of prodrome or skin lesions. The drug is the same as that of the initial type, and the course of treatment is generally 5 days.
③Frequent relapse type (more than 6 relapses in one year): In order to reduce the number of relapses, continuous suppression therapy can be used, generally taking acyclovir orally for 6-12 months.
2. Chickenpox and herpes zoster: caused by varicella-zoster virus (VZV) , characterized by clusters of small blisters along the distribution of unilateral peripheral nerves, often accompanied by obvious neuralgia. The primary infection manifests itself as chickenpox, and the reactivation of the virus dormant in nerve cells causes shingles.
(1) Etiology and pathogenesis
1) VZV has weak resistance to the in vitro environment and quickly loses its activity in the dry scab
2) Human is the only host of VZV
3) When the body's immunity is weakened, the latent virus is activated and blisters are formed
4) After the herpes zoster is cured, a longer-lasting immunity can be obtained, and generally there will be no recurrence
(2) Clinical manifestations
Shingles
1) Caused by VZV
2) Occurs when the resistance is extremely reduced
3) Clinical features: hyperesthesia, neuralgia and other systemic symptoms before eruption
4) Occurs more frequently in the intercostal nerve and the first branch of the trigeminal nerve
5) Erythema distributed in bands and clustered small blisters
6) Not exceeding the midline of the body
7) The course of the disease is 2-3 weeks, and life-long immunity will be obtained after the cure
8) Obvious neuralgia, which may develop into postherpetic neuralgia
9) Ramsay-Hunt syndrome: facial paralysis, ear pain, herpes in the external auditory canal
10) 顿挫型带状疱疹：仅有神经痛、丘疹性损害而不形成水疱
水痘
1）VZV引起，儿童、青少年多发
2）有全身中毒症状
3）皮损分布以躯干为多，四肢较少，呈向心性分布
4）口腔黏膜可发疹
5）皮损为绿豆大小红斑、丘疹、丘疱疹
6）并发症：水痘继发感染
水痘性肺炎
脑炎
爆发性紫癜
带状疱疹的特殊表现
1）眼带状疱疹：
2）耳带状疱疹：系病毒侵犯面神经及听神经所致，表现为耳道或鼓膜疱疹。膝状神经节受累同时侵犯面神经的运动和感觉神经纤维时，可出现面瘫、耳痛及外耳道疱疹三联征，称为Ramsay－Hunt综合征。
3）播散性带状疱疹：
带状疱疹相关性疼痛（ZAP）：带状疱疹在发疹前、发疹时以及皮损痊愈后均可伴有神经痛，统称ZAP。带状疱疹皮损痊愈后神经痛持续存在者，称为带状疱疹后神经痛
(3) 诊断和鉴别诊断
根据水痘个带状疱疹的典型临床表现可作出诊断。疱底刮取物涂片找到多核巨细胞和核内包涵体有助于诊断，必要时可用于PCR检测VZV DNA和病毒培养确诊
1）水痘需与丘疹性荨麻疹、痒疹鉴别
2）带状疱疹早期应与心绞痛、肋间神经痛、胸膜炎、胆囊炎、阑尾炎、坐骨神经痛、尿路结石、偏头痛等进行鉴别，发疹后需要与单纯疱疹、脓疱疮等进行鉴别。
3）带状疱疹临床表现（诊断要点）：簇集的水疱，基底红，簇与簇之间有正常皮肤，单侧分布，带状排列，伴有神经痛。
(4) 预防和治疗
治疗原则：抗病毒、止痛、消炎、缩短病程、预防继发感染
1）带状疱疹
① 全身治疗：抗病毒药：早期、足量——阿昔洛韦、泛昔洛韦
糖皮质激素：消炎
镇静止痛药——吲哚美辛
免疫调节剂
② 局部治疗：外用药与单纯疱疹同
2）水痘
① 有自限性
② 全身治疗：阿昔洛韦、丙种球蛋白、抗组胺药
③ 局部治疗：与单纯疱疹同
④ 预防：注意隔离
3. 疣是由人类乳头瘤病毒（HPV）感染皮肤黏膜所引起的良性赘生物，临床上常见有寻常疣、扁平疣、跖疣和尖锐湿疣。寻常疣俗称“刺瘊”“瘊子”，有传染性（故切忌抓），自限性。
（1）同形反应：（扁平疣）搔抓后皮损可呈串珠状排列，即自体接种反应或称Koebner现象。
（2）治疗：
1) 全身治疗：
① 抗病毒药——阿昔洛韦、泛昔洛韦等
② 免疫增强剂——α-干扰素、IL-2、转移因子
2) 局部治疗：
① 物理治疗——液氮冷冻、电离子烧灼
② 外涂药——5-FU霜、肽丁胺软膏、咪喹莫特霜
第十一章 细菌性皮肤病
1、脓疱疮：是由凝固酶阳性金黄色葡萄球菌和（或）乙型溶血性链球菌引起的一种急性皮肤化脓性炎症。
（1）病因：以凝固酶阳性金黄色葡萄球菌为主，其次是乙型溶血性链球菌，或两者混合感染。
（2）临床特征：多见于2-8岁儿童
皮肤屏障破坏后易发
好发于面部、四肢等暴露部位
有四种临床类型
（3）临床表现：
1）寻常型脓疱疮：也称接触传染性脓疱疮
① 由凝固酶阳性金黄色葡萄球菌和乙型溶血性链球菌引起
② 传染性强，可在小范围儿童中流行
③ 皮损：点状红斑、丘疹→薄壁脓疱，易破→糜烂面→脓液干涸→灰黄色或黄褐色厚痂
④ 可自身接种使皮损蔓延全身
⑤ 自觉瘙痒
⑥ 重者可高热39-40℃，伴淋巴结炎，败血症、急性肾功衰等
2）深脓疱疮：又称臁疮
① 由乙型溶血性链球菌引起
② 好发于下肢
③ 皮损：初为炎性水疱、脓疱→破后溃疡形成→向深部发展→深溃疡→预后留有瘢痕
④ 自觉疼痛
⑤ 溃疡附近淋巴结肿大
3）大疱性脓疱疮
① 由金黄色葡萄球菌引起
② 好发于儿童的面部、四肢、躯干
③ 夏季多发病
④ 皮损：米粒大水疱脓疱→1-2天形成大疱，脓性分泌物沉于疱底呈半月形→疱破→干涸结痂或痂下积脓并向周围蔓延→环形脓疱
⑤ 有明显瘙痒，但无全身症状
4）新生儿脓疱疮：是发生于新生儿的大疱性脓疱疮
① 由凝固酶阳性金黄色葡萄球菌引起
② 是大疱型脓疱疮的异型
③ 传染性强
④ 皮损：初为豌豆至蚕豆大水疱，脓疱→红色糜烂面
⑤ 好发于面部、胸部、背部、四肢
⑥ 患儿中毒症状重，甚至危及生命
5）葡萄球菌性烫伤样皮肤综合征（SSSS）：
① 由凝固酶阳性、噬菌体Ⅱ组71型金黄色葡萄球菌所产生的表皮剥脱毒素导致，
② 多累及5岁内婴幼儿，少数成年人
③ 特征性表现：大片红斑基础上出现松弛性水疱，尼氏征阳性
④ 皮损：初为红斑→蔓延全身→红斑基础上出现松弛性水疱，尼氏征阳性，呈烫伤样，触痛明显→手足皮肤呈手套、袜套样剥落，口周呈放射状皲裂→5-7天皮损暗红、干燥、脱屑→1-2周痊愈
⑤ 起病突然且有高热
⑥ 血常规示WBC↑、N↑，脓液培养为金黄色葡萄球菌，血培养阴性
（4）实验室检查：WBC↑、N↑，脓液中可分 离出金黄色葡萄球菌或链球菌，必要时可做菌型鉴定和药敏试验
（5）诊断和鉴别诊断
① 寻常型脓疱疮有时需与丘疹性荨麻疹、水痘等进行鉴别
② SSSS应与非金黄色葡萄球菌所致的中毒性表皮坏死松解症进行鉴别
（6）预防和治疗
① 卫生宣教
② 局部治疗：以消炎、杀菌、清洁、收敛、去痂为原则
脓疱破者用杀菌剂液湿敷
干燥后用百多邦、红霉素软膏外用
③ 全身治疗：根据药敏试验选用抗生素（半合成青霉素或红霉素等）
④ 中医中药
2、毛囊炎、疖和痈
毛囊炎、疖和痈是一组累及毛囊及其周围组织的细菌感染性皮肤病
（1）病因和发病机制
由凝固酶阳性金黄色葡萄球菌感染引起，也可由真菌性毛囊炎继发细菌感染所致
（2）临床表现
1）毛囊炎
① 毛囊口化脓性感染
② 急、慢性
③ 表浅型和深型
④ 常见病因：细菌、真菌、螺旋体、寄生虫、化学性因素、物理性因素
⑤ 机体抵抗力低下，患瘙痒性皮肤病及慢性消耗性疾病为诱因
细菌性毛囊炎：
⑥ 毛囊浅部或深部的细菌感染
⑦ 多为凝固酶阳性金黄色葡萄球菌感染
⑧ 好发于皮脂溢出丰富部位
⑨ 毛囊性炎性丘疹——脓疱
⑩ 中心毛囊贯穿、周围炎性红晕
⑪ 分批发生、互不融合
⑫ 有微痛和瘙痒感
⑬ 经久不愈且反复发作者为慢性毛囊炎
⑭ 浅部毛囊炎仅为毛囊性小丘疹，预后不留瘢痕
⑮ 深部毛囊炎损害较深，遗留瘢痕
⑯ 枕项部有瘢痕硬结者称为项部硬结性毛囊炎
⑰ 头皮发生脓肿，脓腔贯通，预后留有萎缩性瘢痕者称穿凿性脓肿性毛囊炎
⑱ 须部皮疹数多经久不愈者称为须疮
2）疖与疖病：
① 急性化脓性毛囊及毛囊周围感染称疖
② 反复发生多处者称疖病
③ 病原菌主要为金黄色葡萄球菌，其次为白色葡萄球菌
④ 贫血、慢性肾炎、营养不良、糖尿病、长期使用皮脂类固醇激素以及免疫缺陷易发生
⑤ 好发于头面、颈项、背、臀部
⑥ 单发或多发
⑦ 重症患者可有不同程度的毒血症、脓毒血症、败血症
疖的临床特点：
⑧ 多发于中青年男性
⑨ 毛囊炎性丘疹——红色质硬结节
⑩ 结节化脓坏死、脓栓及坏死组织
⑪ 有疼痛及压痛
⑫ 肿胀消退、1-2周内结痂痊愈
⑬ 发热、头痛、不适，脓毒血症或败血症
⑭ 面部疖易引起海绵窦血栓性静脉炎和脑脓肿等颅内感染
3）痈：由两个及两个以上的疖融合而成，可深达皮下组织。可伴局部淋巴结肿大和全身中毒症状，亦可并发败血症
（3）实验室检查
取脓液直接涂片做革兰染色后镜检，可留取标本做细菌培养鉴定及药敏试验
（4）诊断和鉴别诊断
本病根据病史和临床表现，皮损处革兰染色和细菌培养可支持诊断
与破溃的表皮或毛发囊肿、化脓性汗腺炎相鉴别
（5）预防和治疗
1）毛囊炎、疖的治疗
① 全身用磺胺类药或抗生素
② 顽固性反复发作的疖病可注射自家菌苗或多价葡萄球菌菌苗，每周1-2次，由0.1ml逐渐增至1.0ml
③ 注射丙种球蛋白
④ 局部用20%鱼石脂软膏、2%碘酊、5%新霉素软膏、莫匹罗星（百多邦）、聚维酮碘溶液（艾利克）外涂
⑤ 如已化脓，应切开排脓引流
⑥ 严禁挤捏和早期切开
3、丹毒和蜂窝织炎
①丹毒和蜂窝织炎是一组累及皮肤深部组织的细菌感染性皮肤病
②溶血性链球菌感染
③皮肤及皮下组织内淋巴管及其软组织急性炎症
④中医称为流火
⑤皮肤破损后细菌侵入
⑥足癣及下肢皮肤外伤可诱发小腿丹毒
⑦鼻腔、咽、耳等处损伤可诱发面部丹毒
⑧营养不良、酗酒、糖尿病、肾炎等易患
临床特点：
（1）前驱症状（畏寒、发热、头痛、恶心、呕吐）
（2）境界明显的鲜红色水肿性斑片
（3）表面紧张发亮，有灼热感
（4）皮损中心区可出现大小水疱
（5）疼痛及压痛明显
（6）邻近淋巴结肿大
（7）可继发肾炎及败血症
（8）反复发作称复发型丹毒
（9）小腿慢性淋巴水肿称象皮肿
治疗：
（1）休息、病灶处理、支持疗法
（2）首选青霉素肌注或红霉素等
（3）局部涂15%-20%鱼石脂软膏
（4）50%硫酸镁溶液热湿敷
(5) For those with blisters, use 0.5% neomycin solution to heat and wet compress after taking out the blister fluid
(6) Wet compress with 0.5% povidone solution (Eric)
(7) Recurrent erysipelas can be treated with ultraviolet radiation
Chapter 12 Fungal Skin Diseases
1. The basic forms of fungi are single-celled individuals (spores) and multicellular filaments (hyphae).
2. According to the different depths of fungal invasion of tissues, pathogenic fungi are clinically divided into superficial fungi and deep fungi. Superficial fungi mainly refer to dermatophytes, and their common feature is keratinophilicity, which invades the skin and hair of humans and animals , deck, the infection that causes is collectively referred to as dermatophytosis, ringworm for short. Most of the deep fungi are conditional pathogens, and they often invade the immunocompromised.
3. Tinea capitis is a dermatophyte infection that affects the hair and scalp.
(1) According to the different pathogenic bacteria and clinical manifestations, tinea capitis can be divided into four types: yellow tinea, white tinea, black dot tinea, and purulent tinea.
(2) Tinea capitis is mainly transmitted through direct or indirect contact with patients or animals, as well as items contaminated by bacteria.
(3) Identification of yellow tinea, white tinea, black dot tinea, and purulent tinea
| Yellow tinea |
Ringworm |
Ringworm |
Pyorrhea |
|
| Pathogenic fungi |
Trichophyton schlenii |
Microsporum canis, Microsporum ferruginosa |
Trichophyton violaceum, Trichophyton trichophyton |
Microsporum canis, Microsporum ferruginosa, Microsporum gypsumiformis |
| Infected people |
Mainly seen in children, but can also occur in adults and adolescents |
Children are often violated, and preschool children are more common |
Can occur in both children and adults |
more common in children |
| clinical features |
①Mainly occurs in childhood, ②Erythematous papules, small herpes, ③Formation of characteristic yellow tinea scab after drying, ④Permanent alopecia |
①It is more common in children, ②Oval-shaped white scaly spots (mother spot) at first, and then small scaly spots (child spots) arranged in a satellite shape, ③The diseased hair is dry and easy to break, and the residual root is 2-4mm (high broken hair) , ④ There are bacterial sheaths, ⑤ New hair can grow after healing |
①Children and adults can be affected, ②The diseased hairs in the gray-white scaly patches have just emerged from the scalp and are broken (lower broken hairs), and there are many residual roots of the diseased hairs in the pores of the skin lesions, which are in the form of black spots. , ④ permanent hair loss and punctate atrophic scars after healing |
①It is more common in children, ②It develops from white tinea and black dot tinea, ③follicular papule→follicular pustule→abscess, ④Leaves scar after healing, forming permanent alopecia |
| direct microscopic examination of fungi |
Mycelium and joint spores parallel to the long axis of hair can be seen in the lesion, and the scab of yellow tinea is full of chlamydospores and staghorn hyphae |
There are piles of round microspores outside the outbreak |
Round megaspores arranged in a chain can be seen within the concomitant |
|
| Wood Light Inspection |
dark green fluorescence |
bright green fluorescence |
no fluorescence |
(4) Treatment:
①Adopt griseofulvin comprehensive therapy—take medicine, haircut, shampoo, apply medicine, and disinfect 5 measures at the same time
② Medication - griseofulvin
③ Haircut - shave once/week x 8W
④ 洗头——硫磺香皂1次/天×8W
⑤ 搽药——5-10%硫磺软膏 1%联苯咔唑软膏2次/天×8W
⑥ 消毒——理发工具消毒，病发焚烧，患儿生活用品煮沸消毒
(5) 预防：
① 早发现早治疗
② 患儿隔离
③ 患儿生活用品严格消毒
④ 家庭动物管理和治疗
4. 体癣指发生于除头皮、毛发、掌跖和甲以外其他部位的皮肤癣菌感染；股癣指腹股沟、会阴、肛周和臀部的皮肤癣菌感染，属于发生在特殊部位的体癣。
² 治疗和预防同手足癣
5. 手癣指皮肤癣菌侵犯指间、手掌、掌侧平滑皮肤引起的感染；足癣则主要累及足趾间、足跖、足跟和足侧缘。手足癣可分为三型：水疱鳞屑型、角化过度型、浸渍糜烂型。
(1) 病因：红色毛癣菌（90%）
(2) 传染途径：直接和间接途径
(3) 临床表现：
1) 手癣：
① 大多从足癣传染而来
② 常为单侧
③ 角化型和水疱型
④ 自觉瘙痒
⑤ 可多年不愈
2) 足癣：
① 多见于成人
② 鳞屑水疱型 角化过度型 浸渍糜烂型
③ 常以一型为主兼有其他类型
(4) 治疗：
1) 局部治疗：
① 浸渍糜烂型：渗出多者湿敷，渗出少者抗真菌软膏（达克宁霜、兰美抒）
② 角化过度型：复方苯甲酸软膏 5%水杨酸软膏
③ 鳞屑水疱型：复方苯甲酸酊
2) 全身治疗：
① 伊曲康唑
② 特比奈芬
③ 瘙痒者抗组胺药
(5) 预防：
① 注意个人卫生
② 衣着宽松透气
③ 生活用品分开
6. 由各种真菌引起的甲板或甲下组织感染统称甲真菌病，甲癣特指由皮肤癣菌所致的甲感染。
(1) 病因：红毛癣菌、石膏样毛癣菌等
(2) 临床表现：白色浅表型
远端甲下型
近端侧缘甲下型
全甲营养不良型
(3) 治疗：
1) 局部治疗：30%冰醋酸 5%阿莫洛芬搽剂 40%尿素霜
2) 全身治疗：
伊曲康唑间歇冲击疗法：
0.2bid×1周休3周
指甲真菌病2-3个疗程
趾真菌病3-4个疗程
特比奈芬：0.25qd
第十四章 皮炎和湿疹
1. 接触性皮炎是指人体接触某种外源物质后，在皮肤或粘膜接触部位上因强烈刺激或过敏而发生的一种急性或慢性炎症反应。
2. 接触性皮炎的发病机制可分为原发刺激性和接触性致敏物。
Ø Irritant contact dermatitis: The contact substance itself has a strong irritant (such as strong acid, strong alkali), and anyone who comes into contact with the substance can develop the disease. Common features of this type of contact dermatitis are:
①Anyone can get sick after contact with it;
②No definite incubation period;
③Skin lesions are mostly limited to direct contact parts, with a clear boundary;
④Skin lesions can subside after cessation of contact
Ø Allergic contact dermatitis: a typical type IV hypersensitivity reaction,
Common features of this type of contact dermatitis are:
①Only a few people have seizures
② There is a certain incubation period, no reaction occurs after the first exposure, and the onset occurs after 1 to 2 weeks of exposure to the same allergen;
③ Skin lesions tend to be extensive and symmetrically distributed;
④ easy to relapse;
⑤ Positive skin patch test (patch test is to prepare an infusion, solution, ointment or original substance of appropriate concentration according to the nature of the test substance as a reagent, stick it on the skin in an appropriate way, and observe whether the body is sensitive to it after a certain period of time. It produces a hypersensitivity reaction.
3. Clinical manifestations of contact dermatitis: ① Morphology of skin lesions: Relatively single shape, erythema, papules, blisters, necrosis, ulcers
②Skin lesion site: limited to the contact site, with a clear boundary
a The contact object is gas dust, then the skin lesions are diffusely distributed on the exposed parts of the body
b Scratching can bring pathogenic substances to distant parts to produce similar skin lesions
c When the body is in a highly sensitive state, the contact material can be absorbed by the body and cause the rash to spread all over the body
③Subjective symptoms: itching, burning, swelling pain
④ course of disease: self-limiting
⑤Duration 1-2 weeks
⑥ long-term repeated exposure, proliferation, lichenification
4. Diagnosis:
① Contact history
② Clinical manifestations
③ Patch test
5. Treatment:
Principle: Find the cause, quickly break away from the contact object, and actively treat the symptoms
(1) External therapy: treat according to the treatment principles of acute, subacute and chronic dermatitis
① Acute stage: mainly wet compress, 3% boric acid, 0.1% Ravenul; only redness and swelling without exudation can choose lotion or powder
② Subacute phase: tars, corticosteroid emulsions, pastes
③ Chronic phase: coal tar, corticosteroid ointment or cream
(2) Internal therapy:
① Antihistamines: chlorpheniramine, ketotifen, astemizole, Keminon, Xiantemin, etc.
② Calcium: Intramuscular injection of vitamin Gel calcium; intravenous injection of 10% calcium gluconate 10ml; oral administration of calcium gluconate, etc.
③ Hormone: acute phase: prednisone 30-40mg/day
Severe cases: dexamethasone 10mg/day, amber hydrocortisone 200-300mg/day, intravenous infusion
6. After hypersensitivity contact dermatitis is cured, re-contact with allergens should be avoided as much as possible to avoid recurrence.
7. 湿疹是由多种内、外因素引起的真皮浅层及表皮炎症，临床上急性期皮损以丘疱疹为主，有渗出倾向，慢性期以苔藓样变为主，病情易反复发作。发病机理为Ⅳ型变态反应。
(1) 非传染性
(2) 变态反应性
(3) 炎症性
(4) 皮疹形态多样
(5) 自觉瘙痒
(6) 易复发
8. 湿疹的临床表现：
(1) 急性湿疹：
① 皮损形态：多形性：红斑、丘疹、丘疱疹、水疱、糜烂、渗出、结痂
② 皮损部位：任何部位,好发于手、足、面等皮肤暴露部位，多对称分布
③ 自觉症状：巨痒和灼热感
④ 渗出明显
⑤ 夜晚加重
(2) 亚急性湿疹：皮疹以小丘疹、鳞屑和结痂为主，瘙痒剧烈，也可有轻度浸润
① 红斑、水疱、渗出、瘙痒减轻
② 糜烂逐渐愈合
③ 鳞屑及结痂明显
(3) 慢性湿疹：
① 由急性及亚急性期迁延
② 皮肤苔藓样变
③ 色素沉着或色素减退
④ 病情反复
⑤ 自觉瘙痒
9. 常见慢性湿疹类型
手湿疹——多由接触物引起
足湿疹——可由足癣诱发
乳房湿疹：多见于哺乳期女性，可单侧或对侧发病。若为老年人，要做病检，以排除湿疹样癌（Paget病）
外阴及肛门湿疹
小腿湿疹——多继发于小腿静脉曲张
10. 急性湿疹与急性接触性皮炎的鉴别：
| 急性湿疹 |
急性接触性皮炎 |
|
| 病因 |
复杂，多属内因、不易查清 |
多属外因 |
| 好发部位 |
任何部位 |
主要在接触部位 |
| 皮损特点 |
多形性、对称、无大疱及坏死，炎症较轻 |
形态单一、可有大疱及坏死，炎性较重 |
| 皮损境界 |
不清楚 |
清楚 |
| 自觉表现 |
瘙痒，一般不痛 |
瘙痒，灼热及疼痛 |
| 病程 |
较长，易复发 |
较短，去除病因后迅速消退，不接触不复发 |
| 斑贴试验 |
常阴性 |
多阳性 |
11. 治疗
(1) 去除病因：食物
理化刺激物
消除慢性病灶
治疗全身性疾病
(2) 内用疗法：原则：消炎、止痒
① 抗组胺药：扑尔敏、酮替芬、息斯敏、克敏能
② 钙剂：维丁胶钙、葡萄糖酸钙、益钙灵、钙尔奇、普鲁卡因封闭
③ 激素：应严格控制使用
④ 中医中药：小柴胡汤、六味地黄丸等
(3) 局部用药：原则：清洁、止痒、抗菌消炎、收敛及角质促成剂
① 急性期：湿敷为主，3%硼酸、0.1%雷佛奴尔；仅有红肿而无渗出者可选用洗剂或粉剂
② 亚急期：焦油类、皮质类固醇乳剂、糊剂
③ 慢性期：煤焦油类、皮质类固醇软膏或霜剂
第十五章 荨麻疹类皮肤病（详见书）
1. 荨麻疹：俗称“风疹块”,是由于皮肤、黏膜小血管反应性扩张及通透性增加而产生的一种局限性水肿反应。临床上表现为大小不等的风团伴瘙痒，有时可伴有腹痛、腹泻和气促等症状。
2. 荨麻疹特点：
①皮损形态 风团，可融合成片，风团此起彼伏，消退后不留痕迹。
②皮损部位 任何部位，严重者可累及胃肠道、呼吸道粘膜,甚至发生过敏性休克。
③自觉症状 瘙痒
3. 临床表现：
Ⅰ、急性荨麻疹：
① 水肿性红斑、风团
② 持续数分钟至数小时
③ 消退不留痕迹
④ 局部或全身
⑤ 可伴发呼吸道、胃肠道、心血管系统症状
Ⅱ、慢性荨麻疹：大多病因不明，皮损反复发作超过6周以上。全身症状一般较轻，风团时多时少，反复发生，常达数月或数年之久。
4. 诱导性荨麻疹
(1) 皮肤划痕症：亦称人工荨麻疹
① 表现为用手搔抓或用钝器划过皮肤后，沿划痕出现条状隆起
② 伴瘙痒或不伴瘙痒
③ 暂时性的红色条状隆起，不久后可自行消退
皮肤划痕试验：在荨麻疹患者皮肤表面用钝器以适当压力划过，可出现以下三联反应，称为皮肤划痕试验阳性：
①划后3~15秒，在划过处出现红色线条，可能由真皮肥大细胞释放组胺引起毛细血管扩张所致
②15~45秒后，在红色线条两侧出现红晕，此为神经轴索反应引起的小动脉扩张所致，麻风皮损处不发生这反应
③划后1~3分钟，划过处出现隆起、苍白色风团状线条，可能是组胺、激肽等引起水肿所致。
(2) 冷接触性荨麻疹：
(3) 日光性荨麻疹
(4) 延迟压力性荨麻疹
(5) 热接触性荨麻疹胆碱能性荨麻疹
5. 诊断：①皮肤反复出现，来去迅速的风团 ②剧痒 ③风团退后不留痕迹
6. 鉴别诊断：①丘疹性荨麻疹（虫咬性皮炎）
②Urticarial vasculitis: The damage is often accompanied by pain, the damage lasts for more than 24 hours, and it is fixed, and post-inflammatory purpura or pigmentation remains after healing.
7. Treatment:
(1) Remove the cause
(2) Internal medicine
① Antihistamines
② Hormone, epinephrine: anaphylactic shock, severe condition
③ Infection control
④ Calcium, Vitamin C
⑤ other
(3) Topical treatment: antipruritic
8. Angioedema: Also known as giant urticaria, it is a localized edema that occurs in subcutaneous loose tissue or mucous membrane.
Chapter 16 Drug Eruption (see book for details)
1. Drug eruption: also known as drug-induced dermatitis, is an inflammatory reaction of the skin and mucous membranes caused by drugs entering the human body through various channels. In severe cases, other systems of the body can still be affected.
2. Drug factors that are likely to cause drug eruption: ⑴antibiotics, ⑵antipyretic and analgesic drugs, ⑶sedative hypnotics and antiepileptic drugs, ⑷heterogeneous serum preparations and vaccines, ⑤various biological agents
3. The characteristics of allergic drug eruption:
① There is a certain incubation period, the onset occurs within 4-20 days after the first medication, and within a few minutes to 24 hours after the second medication;
②It only occurs in a small number of people with allergies, and most people do not get sick;
③ There is no correlation between the severity of the disease and the pharmacology, toxicological effects, and dosage of the drug. In a state of hypersensitivity, even a very small dose of the drug can induce severe drug eruption;
④Complicated clinical manifestations and various forms of skin lesions;
⑤Cross-allergies can occur in hypersensitivity state (meaning that after the body is sensitized by a certain drug, an allergic reaction can also occur if the drug has a similar chemical structure or a common chemical group with the drug) and polyvalent allergy ( Refers to when an individual is in a state of hypersensitivity, he is allergic to multiple drugs with no similar chemical structure at the same time);
⑥ Stop the use of sensitizing drugs and get better, and the treatment with glucocorticoids is effective.
4. Clinical manifestations of fixed erythema drug eruption:
① Often caused by sulfonamides, antipyretic analgesics, barbiturates and tetracyclines
②Skin lesions are mostly found at the junction of oral cavity and genital skin-mucosa
③Round or quasi-circular, edematous dark purple macule, 1-4cm in diameter, usually 1, occasionally can be counted, with clear boundary, surrounded by blush, and blisters or bullae may appear in severe cases
④ Gray and dark hyperpigmentation spots remain after fading.
5. Scarlet fever-type drug eruption and measles-type drug eruption: they are the most common types of drug eruption. The skin lesions are similar to measles and scarlet fever, but with obvious itching and mild systemic symptoms.
6. Key points for the diagnosis of drug eruption: ①. Clear medication history
②, there is a certain incubation period
③. The rash occurs suddenly, and the distribution is more symmetrical, and soon spreads all over the body
④ There is a certain relationship between the shape of the skin lesion and the drug
⑤. Exclude other skin diseases and eruptive infectious diseases with similar skin lesions
⑥, drug allergy test
7. Treatment principles for drug eruption: (1) Stop using all suspected sensitizing drugs and drugs with similar structures
⑵促进体内致病药物排出
⑶应用抗过敏药和解毒药
⑷预防和控制继发感染
⑸支持疗法
7. 治疗：
(1) 停用可以药物
(2) 局部处理
(3) 系统处理
① 抗组胺药
② 钙剂
③ 皮脂激素
④ 支持疗法
⑤ 抗感染
8. 重症药疹治疗原则：
① 停用一切可疑药物
② 及时足量使用糖皮质激素，待病情好转后减量
③ 预防和治疗感染及并发症
④ 加强护理及支持疗法
⑤ 中医中药治疗
第十九章 红斑丘疹鳞屑性皮肤病
1. 可急性发作，有渗出倾向 银屑病：俗称“牛皮癣”，是一种慢性复发性炎症性皮肤病，特征性损害为红色丘疹或斑块上覆有多层银白色鳞屑。
① 常见、易复发、慢性炎性皮肤病
② 皮肤出现鳞屑性红斑、丘疹和斑块（寻常型）
③ 或大量无菌性脓疱（脓疱型）
④ 或具有关节炎（关节性病）
⑤ 或绝大部分皮肤弥漫性潮红脱屑（红皮型）
病因：
2. 根据银屑病的临床特征，可分为寻常型（99%以上）、关节病型、脓疱型及红皮病型。
3. ★寻常型银屑病的临床表现：
(1) 基本皮损：红斑、丘疹，表面覆盖多层银白色鳞屑
(2) 皮损特征——滴蜡现象：
——薄膜现象
——点状出血现象（Auspitz征）
(3) 自觉症状：不同程度的瘙痒
(4) 季节性：冬季重，夏季轻
4. 寻常型银屑病根据病情特点可分为三期：
Ⅰ、进行期：不断出现新的皮损或原有皮损逐渐增大，常有同形反应（即Koebner现象，指外观正常的皮肤在各种刮伤、抓伤、针刺等伤及真皮的刺激后，发生与原发皮疹相同皮损的现象）。另：扁平庞也有同形反应
Ⅱ、静止期：皮损稳定，无新皮损出现，炎症较轻，鳞屑较多，
Ⅲ、退行期：皮损缩小或变平，炎症基本消退，遗留色素减退或色素沉着斑。 5. 急性点滴状银屑病：又称发疹性银屑病，常见于青年，发病前常有咽喉部的链球菌感染病史。起病急，皮疹迅速发展，数日内可泛发全身，呈点滴状，皮损为0.3~0.5cm大小丘疹、斑丘疹，色泽潮红，覆以少许鳞屑，痒感程度不等。
5. 关节病型银屑病：
男性多见
常于寻常型银屑病基础上发病
非对成性外周小关节炎、关节症状与皮肤症状同轻同重
6. 红皮病型银屑病：全身皮肤弥漫性潮红、浸润肿胀并伴有大量糠状鳞屑
7. 脓疱型银屑病：分为泛发性和局限性
8. 诊断和鉴别诊断
根据典型临床表现进行诊断和分型
鉴别
① 溢脂性皮炎：
② 头癣：
③ 二期梅毒：
④ 扁平苔癣：
⑤ 慢性湿疹：
9. 银屑病的治疗★★★
(1) 原则：
① 慎用可导致严重毒副作用反应的药物
② 进行期患者的外用治疗应温和
③ 局限性银屑病应以局部治疗为主
④ 治疗方案因人因时而异
(2) 目的：控制症状、提高患者的生活质量
(3) 外用药物疗法（局部）：
Ø 角质促成剂
① 机理：改善局部微循环
抑制RNA合成
减少有丝分裂
② 常用药物：5%-12%松馏油软膏
0.1%-5%蒽林软膏
1/8000-1/20000芥子气软膏
③ 注意事项：从低浓度到高浓度
面部及粘膜处禁用
Ø 钙泊三醇
① 机理：维生素
衍生物
调节角朊细胞的分化
② 药物：大力士软膏
③ 注意事项：面部、、皱褶及黏膜处禁用
Ø 皮质类固醇
① 机理：使真皮血管收缩
抗细胞有丝分裂
② 常用药物：乐肤液
③ 注意事项：头皮、暴露部位顽固皮损，小面积使用
局部皮肤萎缩
毛细血管扩张
停药后反跳
(4) 全身疗法：
⑤ 抗生素：急性点滴性、脓疱型
⑥ 维A酸（依曲替酯）
⑦ 免疫抑制剂（MTX）
⑧ 环保菌素A
⑨ 皮质类固醇：不宜用于寻常型
第二十一章 大疱性皮肤病
第二十一章 大疱性皮肤病
1. 天疱疮：是一组由表皮细胞松解引起的自身免疫性慢性大疱性皮肤病。好发于中年人，组织病理为表皮内水疱，血清中和表皮细胞存在IgG型的抗桥粒芯糖蛋白抗体（天疱疮抗体）。
(1) 较严重皮肤黏膜疾病
(2) 与自身免疫有关
(3) 好发于中年以上
(4) 出现极易破裂的水疱
2. 天疱疮一般可分为五型：寻常型、增殖型、落叶型、红斑、疱疹样。
3. 寻常型天疱疮的临床表现：
①最常见、最重的类型，多累及青壮年，儿童罕见。好发于胸、腹部、四肢近端、口腔黏膜，约60%患者初发损害在口腔黏膜。
②皮损特点：浆液性水疱
疱壁薄而松弛易破
尼氏征阳性
糜烂面不易愈合
③病程迁延反复，长期不愈
④全身表现：发热、组织液丢失、水电解质平衡紊乱、消耗
⑤自觉症状：疼痛
⑥本型预后在天疱疮中最差（死亡原因：Ⅰ长期、大剂量应用糖皮质激素等免疫抑制剂后引起的感染等并发症及多脏器衰竭；Ⅱ病情持续发展导致大量体液丢失、低蛋白血症、恶病质）
4. 落叶型天疱疮：多累及中老年人，好发于头面及胸背上部，口腔黏膜受累少。疱壁更薄，更易破裂，在表浅糜烂面上覆有黄褐色、油腻性、疏松的剥脱表皮、痂和鳞屑，如落叶状，痂下分泌物被细菌分解可产生臭味。
5. 增殖型天疱疮是寻常型天疱疮的“亚型”，多累及青壮年，好发于脂溢部位（腋窝、乳房下、外阴等），皮损破溃后在糜烂面上形成乳头状的肉芽增殖。红斑型天疱疮是落叶型天疱疮的“亚型”，皮损更多见红斑鳞屑性损害，伴有角化过度。
6. 尼氏征：即棘层松解征，是某些皮肤病发生棘层松解（如天疱疮）时的触诊表现，可有四种阳性表现：
①手指推压水疱一侧，水疱沿推压方向移动；
②手指轻压疱顶，疱液向四周移动；
③稍用力在外观正常皮肤上推擦，表皮即剥离；
④牵扯已破损的水疱壁时，可见水疱周边的外观正常皮肤一同剥离。
7. 天疱疮基本病理变化为棘层松解、表皮内裂隙和水疱，疱液中有核深染的棘层松解细胞，直接免疫病理显示表皮细胞间有IgG或C3呈网状沉积；间接免疫荧光检查血清中有针对桥粒成分的天疱疮抗体，其滴度与疾病的严重程度和活动性相平行。
8. 大疱性类天疱疮（BP）是一种好发于中老年人的自身免疫性表皮下大疱病。
9. 大疱性类天疱疮诊断要点：
①多见于中老人（60-70岁），好发于胸腹部和四肢近端、口腔，红斑、丘疹或正常皮肤上出现紧张性大疱（1-5cm），疱壁厚，不易破裂，尼氏征阴性，糜烂面容易愈合
②黏膜损害少而轻微
③组织病理变化为表皮下水疱，免疫病理显示基底膜带有IgG和（或）C3呈线状沉积
④盐裂皮肤间接免疫荧光检查检出结合至表皮侧的IgG型基底膜带自身抗体。
⑤自觉症状：剧烈瘙痒
12. 天疱疮的治疗
(1) 支持疗法：高蛋白高维生素
全身衰竭者输血
(2) 皮质类固醇激素：首选
根据皮损面积给予30-80mg/d
(3) 免疫抑制剂：硫唑嘌呤1-2mg/kg/d
甲氨蝶呤10-25mg/kg/d
(4) 血浆置换
(5) 局部治疗：1:8000高锰酸钾
13. 大疱性类天疱疮治疗基本原则同天疱疮治疗
14. 天疱疮和大疱性类天疱疮的鉴别对比：
| 天疱疮 |
大疱性天疱疮 |
疱疹样皮炎 |
|
| 好发年龄 |
中年 |
老年 |
青年 |
| 好发部位 |
全身 |
全身 |
四肢、躯干伸侧 |
| 水疱位置 |
表皮内 |
表皮下 |
表皮下 |
| 水疱及内容 |
松弛易破、难治愈、疱液清或浑，少有血性 |
紧张难破、易自愈，疱液清或浑，少有血性 |
多形性，簇集或环状张力性水疱为主 |
| 尼氏征 |
阳性 |
阴性 |
阴性 |
| 直接免疫荧光 |
表皮细胞间IgG和 网状沉积 |
基底膜带有IgG和 呈线状沉积 |
真皮乳头顶端颗粒状IgA沉积 |
| 间接免疫荧光 |
血清中有天疱疮抗体 |
血清中有抗基底膜带IgG抗体 |
|
| 糖皮质激素治疗 |
有效但所需剂量较大 |
有效且需剂量略小 |
|
| 瘙痒 |
- |
+ |
++ |
第二十四章 皮肤附属器疾病
1. 寻常痤疮：是一种累及毛囊皮脂腺的慢性炎症性疾病。以粉刺、丘疹、脓疱、结节、囊肿及瘢痕为其特征，常伴皮脂溢出，多发生于青春期男女。
2. 痤疮的发病主要与雄激素水平增加（遗传）、皮脂分泌增加、毛囊漏斗部角化过度、痤疮丙酸杆菌感染、等四大原因相关。
3. 痤疮的临床表现：
①好发年龄 15~30岁青年男女 (诊断要点)
②皮损特点 开放性粉刺(黑头粉刺)及闭合性粉刺(白头粉刺)、炎性丘疹、结节、囊肿、瘢痕
③好发部位 面部、上胸背部
④自觉症状 无自觉症状 ，炎症显著时有疼痛和触痛
⑤常伴皮脂溢出
4. 痤疮病情分类：
Ⅰ度（轻）：黑头粉刺散发或多发 或散发炎性丘疹
Ⅱ度（中等）：Ⅰ度加浅在性脓疱 炎性丘疹多，限于面部
Ⅲ度（重）：Ⅱ度加深在性炎性皮疹 发于面、颈及胸背部
Ⅳ度（极重）：Ⅲ度加囊肿 易形成瘢痕，发于上半身
5.痤疮治疗原则：
(1) 纠正毛囊内的异常角化——溶解角质
(2) 降低皮脂腺的活性——去脂
(3) 减少毛囊内的菌群——杀菌
(4) 抗炎及预防继发感染——抗炎
(5) 调节激素水平
6.痤疮治疗
（1）内服药物：
① 抗生素类：美满霉素、四环素、红霉素
② 维甲酸类：异维A酸、维胺酯
③ Sex hormones: Dyne-35 (cyproterone acetate and ethinyl estradiol), only for women, spironolactone
(2) Drugs for external use:
① Antibiotics: erythromycin tincture or gel, fusidic acid cream
② Retinoids: naphthoic acid derivatives (Duffin), vitamin A acid ointment (Bangli Acne King)
③ Traditional Chinese Medicine: Guibaiyao Film
④ Dissolving keratin: benzoyl peroxide
⑤ Degreasing: Sulfur lotion, Zaile lotion, selenium sulfide, etc.
(3) Matters needing attention:
① Boring acne treated with antibiotics may be secondary to Pityrosporum folliculitis
② Microscopic examination and culture of fungi
③ Stop using antibiotics
④ switch to antifungal drug treatment
（4）
① Early treatment to reduce scars
② Mild: topical medication + diet control
③ Mild to moderate: topical medication + antibiotics
④ Moderate to severe: topical medication + antibiotics + retinoic acid
⑤ Phototherapy: red and blue light therapy, photodynamic therapy
⑥ Auxiliary treatment: acne squeezer, chemical peeling agent, traditional Chinese medicine fire needle
Chapter 29 Sexually Transmitted Diseases
1. Sexually transmitted diseases (STDs) refer to a group of infectious diseases that are mainly transmitted through sexual contact, similar sexual behavior and indirect contact. Lesions can not only occur in the urogenital organs, but also invade the lymph nodes belonging to the urogenital organs, and even invade important tissues and organs of the whole body through hematogenous spread.
2. The surveillance diseases of sexually transmitted diseases stipulated in my country include: gonorrhea, syphilis, genital chlamydial infection, condyloma acuminatum, genital herpes, chancroid, AIDS and several other diseases.
3. Transmission route:
① Sexual behavior route: Homosexual and heterosexual intercourse is the main mode of transmission
②Indirect contact route
③Blood and blood products route
④Vertical pathway for mother and child
⑤Iatrogenic route
⑥ Organ transplantation and artificial insemination
⑦Other ways
4. STDs do not only occur in the genital area; diseases that do not occur in the genital area are STDs.
5. Prevention and treatment of STDs:
(1) Improve legal protection
(2) Emphasis on publicity and education
(3) Standardize epidemic reporting
(4) Strengthen behavioral intervention
(5) Avoid cross-infection, alcoholism or fatigue, and the spouse and sexual partner receive treatment at the same time
6. Syphilis is a chronic infectious disease caused by Treponema pallidum (TP), mainly through sexual contact, mother-to-child transmission and blood transmission.
(1) Chronic sexually transmitted diseases caused by Treponema pallidum
(2) In the early stage, it mainly invades the skin and mucous membranes
(3) Multiple organs involved in late stage (heart and central nervous system, etc.)
(4) It can also be in an asymptomatic latent state for many years
7. Pathogens
(1) Treponema pallidum - a small, slender spiral-shaped microorganism
(2) Anaerobic - not easy to survive in vitro
(3) Dryness, sunlight, soapy water, and common disinfectants (carbocarbonic acid, alcohol, bromogeramine) are all likely to cause death
(4) 50℃半小时丧失感染力
(5) 100℃立即死亡
(6) 潮湿环境内可存活数小时
8. 梅毒的传播途径：性接触传染；垂直传播；其他途径（血液传播、接吻等）
9. 发病机制：
微小创伤——淋巴——血——全身
(1) 早期：螺旋体数量多，分布广
机体破坏不重，但传染性强
(2) 晚期：螺旋体数量少，局限，肉芽肿性
组织破坏性大，但传染性小
10. 梅毒的临床分型与分期
11. 梅毒的临床表现：
获得性梅毒：
Ⅰ、一期梅毒：主要表现为硬下疳和硬化性淋巴结炎
⑴硬下疳：由TP在侵入部位引起的无痛性炎症反应，好发于外生殖器。 特点：多单发，触之具有软骨样硬度，无痛性；内含大量TP，传染性极强，不治3~4周可自行消退；治疗者在1~2周后消退
⑵硬化性淋巴结炎：发生于硬下疳出现1~2周后。常累及单侧腹股沟或患处附近淋巴结，呈质地较硬的隆起，表面无红肿破溃，一般不痛。消退常需数月。淋巴结穿刺检查可见大量TP。
Ⅱ、二期梅毒：一期梅毒未经治疗或治疗不彻底，TP由淋巴系统进入血液循环形成菌血症播散全身，引起皮肤黏膜及系统性损害。
梅毒螺旋体——血液循环——全身播散性感染
⑴皮肤黏膜损害：万能的模仿者
①梅毒疹：主要有斑疹性梅毒疹、丘疹性梅毒疹、扁平湿疣、其他...
二期梅毒皮损共同特点：
a皮疹泛发对称，多呈古铜色，好发于掌跖
b皮损和分泌物中有大量TP，传染性强
c多无自觉症状
d不经治疗持续数周可消退，破坏性小
②扁平湿疣：发生于肛门等皱褶部位的扁平或分叶状的疣状损害
③梅毒性脱发
④黏膜损害
⑵骨关节损害 骨膜炎（最常见）、骨炎、骨髓炎等
⑶眼损害 虹膜炎、脉络膜炎、视网膜炎、视神经炎、角膜炎等
⑷神经损害 无症状神经梅毒、梅毒性脑膜炎、脑血管梅毒
⑸多发性硬化性淋巴结炎
⑹内脏梅毒
Ⅲ、三期梅毒：早期梅毒未经治疗或治疗不充分，经过3~4年，40%患者发生。
三期梅毒共同特点：①损害数目少，分布不对称，破坏性大，愈后留有萎缩性瘢痕，面部皮损毁容②自觉症状很轻，客观症状严重③损害内TP少，传染性弱或无传染性④梅毒血清阳性率低
⑴皮肤黏膜损害：①结节性梅毒疹
②梅毒性树胶肿（梅毒瘤），是三期梅毒的标志，破坏性最强的皮损，好发于小腿。
内脏大多在感染梅毒后15-20年出现症状
⑵骨梅毒 长骨骨膜炎
⑶眼梅毒
⑷心血管梅毒：最重要（主动脉炎、主动脉关闭不全、主动脉瘤等）
⑸神经梅毒
（6）肝
(1) 先天性梅毒：患梅毒的母亲妊娠期内通过胎盘血液传染给胎儿，又称胎传梅毒
(2) 主要发生在妊娠4个月后
(3) 患胎传梅毒的妇女一般不再对其子女有传染性，只有极少数传染给其子女者，称为第三代梅毒，甚为罕见
特点：①不发生硬下疳
②早期病变较后天梅毒重
③骨骼及感觉器官受累多而心血管受累少
Ⅰ、早期先天梅毒 全身症状：皮肤干皱，呈老人貌
皮肤黏膜损害：皮损与二期获得性梅毒相似，口周及肛周形成皲裂，愈后遗留放射性瘢痕，具有特征性
梅毒性鼻炎
骨梅毒
Ⅱ、晚期先天梅毒
标志性损害：
①哈钦森齿：门齿游离缘呈半月形缺损，表面宽基底窄，牙齿排列稀疏不齐
②桑椹齿：第一臼齿较小，其牙尖较低，且向中偏斜，形如桑椹
③胸锁关节增厚：胸骨与锁骨连接处发生骨疣所致
④角膜基质炎
⑤神经性耳聋
哈钦森三联征：哈钦森齿、神经性耳聋和间质性角膜炎合称
Ⅲ、先天潜伏梅毒 无临床症状，仅梅毒血清反应阳性，并脑脊液检查正常
12. 潜伏梅毒：凡有梅毒感染史，无临床表现或临床表现已消失，除梅毒血清学阳性外，无任何阳性体征，并且脑脊液检查正常者。
不治疗的后果：出现临床症状
终身潜伏状态
产出先天梅毒儿
自然痊愈
13. TP antigen serum test: TPPA is the antibody of TP, once infected, it exists for life, but it has no protective effect on the body.
14. Treatment principles for syphilis: early, sufficient, and regular treatment to avoid tertiary syphilis, sexual partners should be checked and treated at the same time, regular follow-up should be done after treatment, generally for at least 3 years.
15. Conventional treatment: penicillin is the first choice
Long-acting formulations: procaine penicillin/benzathine penicillin
Macrolides/tetracyclines