真菌性皮肤病-.ppt

TINEA PEDIS(Ringworm of the Feet)Tinea pedis is common.Trichophyton mentagrophytes infections typically begin in the 3rd and 4th interdigital spaces and later involve the plantar surface of the arch.Toe web lesions often are macerated and have scaling borders;they may be vesicular.Acute flare-ups,with many vesicles and bullae,are common during warm weather 1Infected toenails become thickened and distorted.T.rubrum produces scaling and thickening of the soles,often extending just beyond the plantar surface.Itching,pain,inflammation,or vesiculation may be slight or severe.2Tinea pedis may be complicated by secondary bacterial infection,cellulitis,or lymphangitis,which may recur.Tinea pedis may be confused with maceration(from hyperhidrosis and occlusive footgear),contact dermatitis,eczema,or psoriasis.3浸渍糜烂型4角化过度型5水疱鳞屑型6水疱型手癣继发细菌感染角化过度型手癣7炎症反应明显者8Itraconazole and terbinafine are the most effective treatments for mycologically proven tinea pedis but may have little immediate effect on an acute inflammatory infection,which is a cell-mediated immune reaction.Either drug may be used to treat chronic infections and prevent acute exacerbations.Interdigital infections can be successfully treated with topical agents.9Systemic treatment for infected nails(onychomycosis)may require therapy for many months and is especially difficult if the toenails are involved.Because of the keratophilic characteristics of these newer drugs,itraconazole 200 mg/day for 1 mo or pulse therapy with 200 mg bid 1 wk/mo for 1 to 2 mo often cures uncomplicated tinea pedis.Concomitant topical antifungal use may reduce recurrences.10Cure with topical treatment is difficult,but control may be obtained with long-term therapy.Recurrence is common after therapy is discontinued.11手癣和足癣手癣（tinea manus）、足癣（tinea pedis）是皮肤癣菌侵犯掌跖、指（趾）间表皮，引起的浅部真菌感染性疾病。手癣相当于中医的“鹅掌风”和“脚湿气”致病菌为红色毛癣菌、絮状表皮癣菌、石膏样毛癣菌、白色念球菌等。多数则由公用足盆、拖鞋、水池浇足等相互传染而得，尤以穿胶鞋、球鞋、塑料鞋者最易发生。12【临床表现】（一）水疱鳞屑型：是指（趾）或掌跖及足缘发生的厚壁性深在水疱，伴剧烈瘙痒，水疱可相互融合，破后成环状，可累及掌部，易致脓疱、蜂窝织炎、丹毒等继发感染。（二）浸渍糜烂型：是指（趾）间由于潮湿加上真菌感染而形成，表现为浸渍、糜烂和渗出，有异臭，瘙痒难忍，常因搔抓摩擦易继发细菌感染。（三）角化过度型：手掌或侧缘呈不规则形红斑鳞屑性皮损，界限清楚，或不清楚，上被层状鳞屑，外侧波及全掌，皮肤干燥粗糙，易致皲裂，冬天尤甚，易累及指甲。13【实验室检查】真菌镜检阳性。【诊断与鉴别诊断】手足癣的诊断根据临床表现，结合真菌检查并不困难，但在水疱型手足癣时，有时难与掌跖脓疱病鉴别，有时亦应与汗疱疹作鉴别。在鳞屑角化型时，则应与慢性皲裂性湿疹相鉴别。14治疗 内服口服伊曲康唑、特比萘芬和氟康唑等。外用擦烂型可先扑枯矾粉或脚癣粉，如渗出明显者可用3硼酸溶液或18000高锰酸钾湿敷。水疱型或鳞屑型可外用咪康唑霜、克霉唑 霜、复方苯甲酸搽剂、复方雷锁辛搽剂。角化增厚型可用复方苯甲酸软膏、咪康唑霜或10%冰醋酸浸泡。有皲裂者，可加用20%尿素脂。皮损消退后继续搽药至少2周，手部因经常水洗，特别是洗手之后要加搽软膏或霜剂。15【预防】（一）应注意个人卫生。浴室中最好不用公用拖鞋，洗澡应携带个人毛巾及浴巾。（二）要积极治疗手足癣，以免接触传染他人。（三）袜子要煮沸消毒，皮鞋及不能水煮沸消毒的用具，可用5%福尔马林倒在草纸上，与皮鞋或其他用具一起用纸包裹消毒。16TINEA UNGUIUM(Ringworm of the Nails)This form of onychomycosis is usually caused by Trichophyton.Infections of the fingernails are less common than those of the toenails.The nails thicken and become lusterless,and debris accumulates under the free edge.The nail plate becomes thickened and separated,and the nail may be destroyed.17Differentiating a Trichophyton infection from psoriasis is particularly important because drug therapy for tinea unguium is specific,and long-term treatment is required.1819202122When griseofulvin is used to treat onychomycosis,long-term cure is achieved in 20%of cases.Therefore,systemic treatment with oral itraconazole or oral terbinafine is probably the treatment of choice.Itraconazole 200 mg po bid 1 wk/mo for 4 mo or terbinafine 250 mg/day achieves a high cure rate for fingernail and toenail infections.23 For onychomycosis of fingernails,the duration of terbinafine treatment is 6 wk,and for toenails,12 wk.It is not necessary to treat until all abnormal nail is gone because these drugs remain bound to the nail plate and continue to be effective after oral administration has ceased.Topical treatments for nail infections are rarely effective,except for the superficial white type,in which infection occurs on the nail surface only.24甲癣和甲真菌病甲癣（tinea unguium）指皮肤癣菌引起的甲板或甲下组织感染，若由念珠菌引起，称甲念球菌病或归入甲真菌病。由其他真菌如青霉、曲霉、帚霉等引起的甲感染称甲真菌病（onychomyosis）。本病相当于中医的灰指（趾）甲。25【病因】甲癣的病原菌主要是红色毛癣菌（约65%）和石膏样毛癣菌（约17%）。其他有紫色毛癣菌、黄癣菌、絮状表皮癣菌等。甲癣常来源于手足癣的直接蔓延，甲单独感染者常与甲板外伤有关。26临床表现（一）甲下型皮损常自甲板两侧或末端开始，多先有轻度甲沟炎，逐渐侵犯甲板而发生沟纹、凹点、混浊、增厚、脆裂、变形、淡灰白色或污秽褐色。（二）浅表型初起甲板表面发生小点状混浊区，逐渐扩大增多，而成不规则的云片状混浊，局限一处亦可波及整个甲板及其他甲，但常对称，亦可长年不发展。真菌检查、培养阳性。27【诊断及鉴别诊断】甲变色、无光泽、增厚或变薄、破损，从一甲逐渐蔓延到其他甲应疑及甲癣，真菌检查阳性可确诊。应与下列疾病鉴别：全身疾病的甲表现多同时累及多数或全部甲。局限性皮肤病如手部湿疹、甲沟炎、扁平苔藓引起的甲改变，甲板多仍有光泽，依据真菌检查结果不难鉴别。甲癣和甲真菌病的鉴别需做真菌培养。甲念球菌病则多有职业因素并伴指趾间糜烂和甲沟炎，甲板高低不平仍有光泽，真菌培养多为白念珠菌。28【治疗】剥甲疗法选用40%尿素软膏、12%乳酸、6%水杨酸软膏，将病甲封包，34天后取开，甲剥落或部分剥落后，再选用5%碘酊、10%冰醋酸外用或浸泡，如此反复，直到治愈。刮甲疗法每日用温水将甲泡软后，用锋利小刀轻刮病甲，直至甲床，再涂10%冰醋酸、5%碘酊。29 手术拔甲疗法用外科手术拔除病甲，在手术中清理病甲甲床，不损伤甲母，创面愈合外涂碘酊等抗真菌剂。口服药物疗法氟康唑，每日50mg或每周150mg顿服，连续个月。伊曲康唑200mg，每日2次，每月服1周，指甲癣连续2-3个月，趾甲癣连续3-4个月。特比萘芬：0.25/日，指甲癣4周，趾甲癣6周30防治甲癣，必须积极治疗其他常见的癣病，尤其是手足癣的治疗。甲癣是浅部真菌病中最顽固的一种，因此治疗必须彻底。31