皮膚性病學(xué)總論壓縮版2012

1、皮膚性病學(xué)總論壓縮版2012 皮膚性病學(xué)的定義和范疇 研究皮膚、附屬器及相關(guān)疾病的學(xué)科 皮膚性病學(xué)的發(fā)展史 歷史悠久但長期發(fā)展緩慢，近年來突飛猛進(jìn) 皮膚性病學(xué)的學(xué)科特點(diǎn)強(qiáng)調(diào)皮損和組織病理形態(tài)學(xué)改變，直觀性強(qiáng) 學(xué)習(xí)方法 重視感性認(rèn)知過程，注重臨床實(shí)踐和積累見習(xí)教學(xué) PBL教學(xué)法，病案討論 第一章 皮膚性病學(xué)導(dǎo)論皮膚性病學(xué)發(fā)展現(xiàn)狀從單純形態(tài)學(xué)向分子免疫學(xué)、分子生物學(xué)、皮膚遺傳學(xué)等方向縱深發(fā)展分出皮膚美容、皮膚外科等邊緣分支學(xué)科我校皮膚性病學(xué)概況 始建于上世紀(jì) 50 年代初，擁有多名國內(nèi)知名專家 擁有變應(yīng)性皮病、真菌、美容、病理、性病等亞專業(yè) 西南地區(qū)皮膚科疑難重癥的診治中心之一 醫(yī)教研水平位于國內(nèi)

2、同行前列 博士學(xué)位授予點(diǎn) 化妝品皮膚病診斷機(jī)構(gòu) 人體最大器官 約占體重的 16 成人皮膚總面積約 1.5 m2 皮膚厚度約 4 mm第二章 皮膚的結(jié)構(gòu)remember! 皮膚的構(gòu)成：表皮 真皮 皮下組織 附屬器 皮膚附屬器：毛發(fā) 毛囊 指(趾)甲 皮脂腺 小汗腺 大汗腺皮膚的結(jié)構(gòu)來源：復(fù)層鱗狀上皮組成：角質(zhì)形成細(xì)胞 keratinocyte 黑素細(xì)胞 melanocyte 朗格漢斯細(xì)胞 Langerhans cell麥克爾細(xì)胞 Merkel cell表皮 Epidermis 來源外胚層 分布 表皮主要構(gòu)成細(xì)胞占表皮細(xì)胞80以上 分層 根據(jù)分化階段和特點(diǎn)分為5層 基底層 棘層 顆粒層 透明層 角

3、質(zhì)層角質(zhì)形成細(xì)胞 keratinocyte正常的角化由基底層移行至顆粒層表面約14天由顆粒層移行至角質(zhì)層表面約14天正常表皮更替時(shí)間約為28天角質(zhì)形成細(xì)胞正常細(xì)胞周期remember! 來源外胚層神經(jīng)嵴 分布 廣泛 基底層、毛囊、粘膜、視網(wǎng)膜較多 作用 遮擋和反射光線 保護(hù)深部組織黑素細(xì)胞 Melanocyte思考題：黑素細(xì)胞的數(shù)量與人種和膚色有關(guān)，對(duì)嗎？ 來源 骨髓及脾 分布基底層以上的表皮及毛囊上皮 性質(zhì) 免疫活性細(xì)胞，有多種表面標(biāo)記 作用吞噬 吞飲 攝取 抗原呈遞等朗格漢斯細(xì)胞 Langerhans cell思考題：HE染色的組織切片中能看到 Langerhans cell嗎？ 形態(tài) 具

4、有短指狀突的細(xì)胞 分布基底層細(xì)胞之間 作用形成Merkel cell軸索復(fù)合物，能 感受觸覺麥克爾細(xì)胞 Merkel cell角質(zhì)形成細(xì)胞間及其與真皮間的連接 橋粒 角質(zhì)形成細(xì)胞間連接的主要結(jié)構(gòu) 半橋粒 連接基底層和基底膜帶 基底膜帶 basement membrane zone BMZ 連接表皮和真皮remember!組成 膠原纖維 網(wǎng)狀纖維 彈力纖維 細(xì)胞 基質(zhì)真皮 Dermis 分層 乳頭層 網(wǎng)狀層 毛發(fā) 毛囊 皮脂腺 汗腺 指（趾）甲 皮膚附屬器毛發(fā)生長周期生長期 3y退行期 3w休止期 3m正常人每日可脫落100根頭發(fā)皮脂溢出部位面部“T”形區(qū)胸背上部remember! 屏障功能 吸

5、收功能 感覺功能 分泌排泄 體溫調(diào)節(jié) 代謝功能 免疫功能第三章 皮膚的功能（自學(xué)）思考題1.皮膚如何防護(hù)光線？2.比較不同部位皮膚的吸收差異。3.what is the meaning ofskin immune system?臨床表現(xiàn) 自覺癥狀（主觀感覺） 他覺癥狀（皮疹）重點(diǎn)掌握診斷內(nèi)科診斷學(xué)專科查體第四章 皮膚性病的臨床表現(xiàn)及診斷皮損 skin lesion原發(fā)皮損 primary lesion由皮病組織病理變化直接產(chǎn)生，對(duì)診斷意義重大。繼發(fā)皮損 secondary lesion由原發(fā)皮損演變而來，對(duì)診斷意義較小。注意：兩者有時(shí)不能截然分開原發(fā)損害斑疹 macule斑片 patch丘疹

6、papule斑塊 plaque風(fēng)團(tuán) wheal水皰 vesicle大皰 bulla膿皰 pustule結(jié)節(jié) nodular囊腫 cyst糜爛 erosion潰瘍 ulcer鱗屑 scale浸漬 maceration裂隙 fissure瘢痕 scar萎縮 atrophy痂 crust抓痕 excoration苔蘚樣變 lichenification繼發(fā)損害remember!斑疹 Macule局限性皮膚粘膜顏色改變，不隆起、不凹陷，直徑小于1cm斑片Patch直徑大于1cm的斑疹稱斑片色素缺失斑丘疹(Papule)限局性、隆起性、實(shí)質(zhì)性損害，直徑小于1cmPapulePlaque斑塊斑塊為丘疹增大

7、或融合而成的扁平、隆起性損害結(jié)節(jié) Nodule限局性、實(shí)質(zhì)性損害，深度可達(dá)真皮或皮下組織風(fēng)團(tuán) Wheal真皮淺層水腫所致的暫時(shí)性、限局性隆起性損害水皰和大皰 Vesicle and bulla直徑小于1cm稱水皰、大于1cm稱大皰膿皰 Pustule Pustule is a circumscribed elevated lesion which contains pus in the epidermis or dermis. It frequently form in sweat glands or hair follicles. Abscess is usually in the derm

8、is or subcutis. .囊腫 cyst內(nèi)含液體、粘性物質(zhì)和細(xì)胞成分的限局性囊性損害浸漬 maceration皮膚角質(zhì)層含水量增多，導(dǎo)致的表皮強(qiáng)度減弱表皮或粘膜上部的缺損，露出紅色糜爛面，愈后不留瘢痕糜爛 erosion 潰瘍 Ulcer皮膚或粘膜深達(dá)真皮或皮下組織的缺損，愈后會(huì)留有瘢痕 裂隙 Fissure系皮膚的線條狀裂口瘢痕 Scar 真皮或真皮以下組織的缺損或破壞經(jīng)新生結(jié)締組織修復(fù)而成萎縮 Atrophy退行性的皮膚變薄，可發(fā)生于表皮、真皮及皮下組織鱗屑Scale脫落或即將脫落的角質(zhì)層由皮損表面的漿液、膿液、血液及脫落組織等干燥、凝固而成的附屬物痂 Crust抓痕 excori

9、ation線狀或點(diǎn)狀表皮缺損，由搔抓所致，可深達(dá)真皮淺層。因搔抓或摩擦所致的皮膚浸潤肥厚皮溝加深及皮嵴突起苔蘚樣變 Lichenification原發(fā)損害斑疹 macule斑片 patch丘疹 papule斑塊 plaque風(fēng)團(tuán) wheal水皰 vesicle大皰 bulla膿皰 pustule結(jié)節(jié) nodular囊腫 cyst糜爛 erosion潰瘍 ulcer鱗屑 scale浸漬 maceration裂隙 fissure瘢痕 scar萎縮 atrophy痂 crust抓痕 excoration苔蘚樣變 lichenification繼發(fā)損害remember!重點(diǎn)掌握表皮基本病理變化第五章

10、皮膚組織病理學(xué) 皮膚組織病理對(duì)皮膚病的診斷有重要價(jià)值，是皮膚病診斷中最常用的輔助檢查手段之一。角化過度 Hyperkeratosis角質(zhì)層過度增厚，見于尋常疣等棘層肥厚（Acanthosis）: increase in keratinocyte population of prickle cell layer with thickening of the epidermis.角化不全 Parakeratosis角質(zhì)層中有細(xì)胞核殘留，見于銀屑病等Spongiosis (Intercellular Edema): Widening of the interspaces between kerati

11、nocytes due to edema fluid without detachment of cells from each other. Intracellular EdemaBallooning DegenerationSuch as herpes zoster Reticular degenerationSuch as herpes simplex棘層松解 Acantholysis 表皮細(xì)胞失去粘連，見于天皰瘡Munro微膿腫(Munros microabscess)見于尋常型銀屑病等中性粒細(xì)胞集聚課堂內(nèi)未講授的其他基本皮膚病理改變請(qǐng)同學(xué)們結(jié)合教材圖片自學(xué)什么叫微膿腫，常見的微膿腫有

12、哪些，出現(xiàn)在哪些疾病中？思考題 病理檢查 真菌檢查 變應(yīng)原檢測 濾過紫外線檢測 性病檢測 螨和陰虱檢查 分子生物學(xué)技術(shù)第六章 皮膚性病常用實(shí)驗(yàn)室檢查（見習(xí)講授）思考題什么叫斑貼試驗(yàn)，它有哪些適應(yīng)癥？ 皮膚劃痕征（Dermatographism） is a sharply localized edema or wheal with a surrounding erythematous flare occurring within seconds to minutes after the skin has been stroked. 斑貼試驗(yàn) Patch Test Patch test is us

13、ed to detect hypersensitivity to a substance that is in contact with the skin so that the allergen may be determined and corrective measures taken. A suspected allergen is applied to the intact uninflamed skin on a small surgical pad or in an aluminum chamber. Removed the pad in 48 hrs or earlier.Ev

14、aluation( Erythema, papules, vesicles): day 2, day 4, day 5, day 7 內(nèi)用藥物療法 外用藥物療法 重點(diǎn)掌握 物理治療 外科治療第七章 皮膚性病治療學(xué)機(jī)理：競爭性抑制組胺受體分類：H1受體阻斷劑 H2受體阻斷劑第一代抗組胺藥：賽庚啶 等第二代抗組胺藥：氯雷他定 等抗組胺藥物內(nèi)用藥物（一）糖皮質(zhì)激素的藥理作用 抗炎、抗過敏、免疫抑制劑、抗核分裂、抗毒在皮膚性病科的適應(yīng)癥主要有1、結(jié)締組織病 2、大皰性皮膚病3、變態(tài)反應(yīng)性皮膚病 糖皮質(zhì)激素糖皮質(zhì)激素有哪些副作用？思考題內(nèi)用藥物（二）唑類（咪康唑、氟康唑、伊曲康唑）灰黃霉素（1520mg

15、/kg/d）頭癬首選抗真菌藥物丙烯胺類：特比奈芬（蘭美抒）內(nèi)用藥物（三）無環(huán)鳥苷類：皰疹病毒首選藥病毒唑（利巴韋林）：流感病毒、皰疹病毒干擾素：廣譜輔助抗病毒作用抗病毒藥物內(nèi)用藥物（四）外用藥物療法 Topical Application and Dosing (1)Attention:Medication should be gently massaged into the skin in one thin layer.One gram of cream covers 1010cmApplied once or twice per day usually. Extra-pharmacothe

16、rapyTopical Application and Dosing (2)Medication penetration vs skin anatomic site (Mucous membraneeyelidsface torsoextremitiespalms and soles)Skin breakdown allows increased drug penetration.Dressing or body suits increase drug absorption. Extra-pharmacotherapyTopical DrugsBasic Points:Two main fac

17、tors: drug and vehicle (base)Vehicle assistant in both drug delivery and therapeutic propertiesAdequate concentration Adequate formulationExtra-pharmacotherapy按藥物劑型分為皮膚外用藥分類油劑乳劑軟膏糊劑硬膏涂膜劑噴劑凝膠溶液酊劑粉劑振蕩劑溶液 SolutionsSolution involves the dissolution of two or more substances into homogenous clarity. The

18、vehicle (base) may be aqueous, hydroalcoholic, or nonaqueous (alcohol, oils, or propylene glycol) .(3% Boracic acid)酊劑 Tinctures Tincture is a hydroalcoholic solution with a concentration of alcohol of approximately 50%. (iodine)vs 醑劑 Spiritus粉劑 Powders Powders absorb moisture and decrease friction.

19、 Because they adhere poorly to the skin, their use is limited to cosmetic and hygienic purposes. talcum powder, starch 振蕩劑 （洗劑） Lotions Lotions (Suspensions) is a two-phase system consisting of a finely divided, insoluble drug dispersed into a liquid in a concentration of up to 20%.mint calamine lot

20、ion乳劑 Emulsions Emulsions are twophase systems involving one or more immiscible liquids dispersed in another with the assistance of emulsifying agent. Water-in-oil emulsions contain less than 25% water, with oil being the dispersion medium. Oil-in-water emulsions (Creams，霜?jiǎng)? contain greater than 31%

21、 water. In fact, the aqueous phase may comprise up to 80% of the formulation. zinc oxide軟膏 Ointments Ointments are semisolid preparations that spread easily. They can be protective, hydrating and lubricating. The bases are hydrocarbon bases and absorption bases.糊劑 Pastes Pastes are simply the incorp

22、oration of high concentrations of powders (up to 50%) into an ointment such as a hydrocarbon base or a water-in-oil emulsion. The powder must be insoluble in the ointment. zinc oxide凝膠 Gels Gels are semi-solid preparations containing high-molecular-weight polymers, such as carboxypolymethylene or me

23、thylcellulose, and can be regarded as thicken aqueous lotion. 硬膏 Plasters Plasters ( Adhesive plaster, Adhesive tape ) are kinds of adhesive, whose surface painted with natural rubber and zinc oxide as main raw materials, with weaving-cloth back lining. It is used in dressing wounds. 角質(zhì)松解劑油劑 Oils Oi

24、ls can be obtained from numerous vegetable sources by pressing or by solvent extraction. These are slippery or viscous liquid or liquefiable substance not miscible with water. 氣霧劑 Aerosols 氣霧劑：系將藥物和拋射劑裝入高壓容器中，掀動(dòng)閥門時(shí)，藥物借助壓縮氣體或液化氣體的壓力以霧狀噴出。溶液酊劑粉劑洗劑油劑霜?jiǎng)┤閯┸浉鄽忪F劑糊劑洗劑醑劑氣霧劑霜?jiǎng)┌此幬镄再|(zhì)分為皮膚外用藥分類抗真菌劑 抗細(xì)菌劑 抗病毒劑 殺蟲劑角質(zhì)促成劑 角質(zhì)松解劑 收斂劑 遮光劑清潔劑 保護(hù)劑 止癢劑 清潔劑 Clearing agent Clearing agent is the substance used to clear the exudation, scale or crust of the sk