Professional Documents
Culture Documents
I HC Y KHOA H NI
in thoi : 0973.910.357
THNG TIN
NG H :
Tc gi xin chn thnh cm n mi s ng h v mt ti chnh gip cho Bch Khoa Y Hc c pht
trin tt hn v ngy cng hu ch hn.
Mi tm lng ng h cho vic xy dng mt website dnh cho vic ph bin ti liu hc tp v ging dy
Y Khoa ca cc c nhn v Doanh nghip xin gi v :
S ti khon : 5111-00000-84877
CNH BO :
TI LIU NY CH MANG TNH CHT THAM KHO nhm mc ch nng cao hiu bit v Y khoa.
Tuyt i khng c t p dng cc thng tin trong ebook ny chn on v t iu tr bnh, nht
l vi nhng ngi khng thuc nghnh Y . Tc gi ebook ny khng chu bt c trch nhim g lin quan
n vic s dng thng tin trong cun sch p dng vo thc tin ca bn c. y l ti liu su
tm t nhiu tc gi khc nhau, nhiu cun sch khc nhau, cha c kim chng , v th mi thng tin
trong cun sch ny u ch mang tnh cht tng i . Cun sch ny c phn pht min ph vi mc
ch s dng phi thng mi, bt c hnh vi no lin quan n vic mua bn, trao i, chnh sa, in n
cun sch ny vo bt c thi im no u l bt hp l . Ni dung cun ebook ny c th c thay
i v b sung bt c lc no m khng cn thng bo trc.
GII THIU
B sch ny c cung cp n tay bn , hon ton da trn tinh thn t nguyn ca bn. Khng c bt
kz s thng lng, mua chuc, mi gi hay lin kt no gia bn v tc gi b sch ny.
Mc ch ca b sch phc v cng tc hc tp cho cc bn sinh vin Y khoa l chnh, ngoi ra nu
bn l nhng i tng ang lm vic trong nghnh Y cng c th s dng b sch nh l ti liu tham
kho thm .
Mi thng tin trong b sch u ch c tnh chnh xc tng i, thng tin cha c kim chng bi
bt c c quan Php lut, Nh xut bn hay bt c c quan c trch nhim lin quan no . V vy, hy
lun cn trng trc khi bn chp nhn mt thng tin no c cung cp trong b sch ny.
Tt c cc thng tin trong b sch ny c su tm, tuyn chn, phin dch v sp xp theo trnh t
nht nh . Mi bi vit d ngn hay di, d hay d d cng u l cng sc ca chnh tc gi bi vit
. L nh Sng ch l ngi su tm v phin dch, ni mt cch khc, ngi gip chuyn ti nhng
thng tin m cc tc gi bi vit cung cp, n tay cc bn .
B sch ny l ti liu su tm v dch bi mt sinh vin Y khoa ch khng phi l mt gio s tin s
hay mt chuyn gia Y hc dy dn kinh nghim,do c th c rt nhiu li v khim khuyt khng
lng trc , ch quan hay khch quan, cc ti liu b tr c th cha hp l , nn bn cnh vic thn
trng trc khi thu nhn thng tin , bn cng cn c k phn mc lc b sch v phn hng dn s
dng b sch s dng b sch ny mt cch thun tin nht.
Tc gi b sch in t ny khng chu bt c trch nhim no lin quan n vic s dng sai mc ch ,
gy hu qu khng tt v sc khe, vt cht, uy tn ca bn v bnh nhn ca bn .
Khng c chuyn mn , khng phi l nhn vin y t , bn khng c ph p t s dng nhng thng tin
c trong b sch ny chn on v iu tr. T trc ti ny, cc thy thuc IU TR BNH NHN
ch khng phi l IU TR BNH. Mi ngi bnh l mt thc th c lp hon ton khc nhau, do
vic b nguyn xi tt c mi thng tin trong b sch ny vo thc tin s l mt sai lm ln . Tc gi s
khng chu bt c trch nhim g do s bt cn ny gy ra.
Mi l thuyt u ch l mu xm, mt cun sch hay vn cun sch cng ch l l thuyt, ch c thc t
cuc sng mi l cun sch hon ho nht, bn khng phi l c gi m l din vin chnh. V
Bch Khoa Y Hc cng ch l mt ht thc nh, vic s dng n xo nu hay nhn ging l hon ton
ty thuc vo bn c. V ngi to ra ht thc ny s vui mng v c truyn thm ng lc tip
tc c gng nu bit rng chnh nh bn m bit bao ngi khng cn phi xp hng ch cu tr.
Mi ng gp lin quan n b sch xin gi v cho tc gi theo a ch trn. Rt mong nhn c phn
hi t cc bn c gi cc phin bn sau c tt hn.
Knh chc bn c, gia quyn v ton th ngi Vit Nam lun c sng trong khe mnh, cuc sng
ngy cng m no hnh phc.
ABOUT
DONATE
The author would like to thank all the financially support to help the Medical Encyclopedia are
developing better and more-and-more useful.
All broken hearted support for building a website for the dissemination of learning materials and
teaching Medicine of individuals and enterprises should be sent to:
Bank name: BANK FOR INVESTMENT AND DEVELOPMENT OF VIETNAM
Bank Account Name: Le Dinh Sang
Account Number: 5111-00000-84877
DISCLAMER :
The information provided on My ebooks is intended for your general knowledge only. It is not a
substitute for professional medical advice or treatment for specific medical conditions. You should not
use this information to diagnose or treat a health problem or disease without consulting with a qualified
health professional. Please contact your health care provider with any questions or concerns you may
have regarding your condition.
Medical Encyclopedia 2010 and any support from L nh Sng are provided 'AS IS' and without
warranty, express or implied. L Sng specifically disclaims any implied warranties of merchantability
and fitness for a particular purpose. In no event will be liable for any damages, including but not limited
to any lost or any damages, whether resulting from impaired or lost money, health or honnour or any
other cause, or for any other claim by the reader. Use it at Your risks !
YOU ARE RESTRICTED TO adapt, reproduce, modify, translate, publish, create derivative works from,
distribute, and display such materials throughout the world in any media now known or hereafter
developed with or without acknowledgment to you in Authors ebooks.
FOREWORD
These ebooks are Le Dinh Sangs collection, compilation and synthesis with the aim of providing a useful
source of reference-material to medical students, and all who wish to learn, research, investigate to
medical information.
Just a set of open-knowledge, based on community resources, non-profit purposes, not associated with
commercial purposes under any kind, so before you use this books you must agree to the following
conditions. If you disagree, you should not continue to use the book:
This book is to provide to you, completely based on your volunteer spirit. Without any negotiation,
bribery, invite or link between you and the author of this book.
The main purpose of these books are support for studying for medical students, in addition to others if
you are working in health sector can also use the book as a reference.
All information in the book are only relative accuracy, the information is not verified by any law agency,
publisher or any other agency concerned. So always be careful before you accept a certain information
be provided in these books.
All information in this book are collected, selected, translated and arranged in a certain order. Each
artical whether short or long, or whether or unfinished work are also the author of that article. L nh
Sng was only a collectors in other words, a person to help convey the information that the authors
have provided, to your hand. Remember the author of the articles, if as in this book is clearly the
release of this information you must specify the author of articles or units that publish articles.
This book is the material collected and translated by a medical student rather than a professor Doctor
experienced, so there may be many errors and defects unpredictable, subjective or not offices,
documents can be arranged not reasonable, so besides carefull before reading information, you should
also read carefully the contents of the material and the policy, manual for use of this book .
The author of this e-book does not bear any responsibility regarding the use of improper purposes, get
bad results in health, wealth, prestige ... of you and your patients.
7. Not a professional, not a health worker, you are not allowed to use the information contained in this
book for diagnosis and treatment. Ever, the physician treating patients rather than treatment. Each
person is an independent entity and completely different, so applying all information in this book into
practice will be a big mistake. The author will not bear any responsibility to this negligence caused.
8. As is the community material, these books could be developed or not are not only based on their
strength and perseverance of the author of this book , the contribution, suggestions, additional
adjustment of the reader is great motivation for this book keep developed. Because a goal of becoming
a medical reference books in accordance with general requirements and the practical situation in the
health sector in particular and life.
9. The contents of this book, may only correct in a certain time in the past and the present or in the near
future. In this era of scientific and technological revolution as sweeping as fast now, no one knew before
is whether the knowledge that you have obtained can be applied in future or not. To answer this
question, only yourself, have to always update-YOURSELF-for latest information in all areas of life,
including the medical field. No one can, of course this book can not, do it for you.
10. Strictly forbidden to use this book in any bad purpose, not be allowed to commercialize this product
under any mean and any time by any media . The author of this book is not the inventor of the book-
articles, but has made a lot of effort, time, and money to create it, for the advanced of the community.
You must take full responsibility for any misuse purposes and does not comply with the contents of this
book yet.
11. All theories are just gray, a thousand books or a book are only theory, the only facts of life are the
most perfect book, in which you are not an audience but are the main actor. This Book just a small grain,
using it to cook or fry breeding is completely depend on you. And the person who created this grain will
begin more excited and motivated to keep trying if you know that thanks that so many people no longer
have to queue to wait for relief.
12. All comments related to the books should be sent to the me at the address above. We hope to
receive feedbacks from you to make the later version better.
13. We wish you, your family and Vietnamese people has always been healthy, happy and have a
prosperous life.
MC LC
THNG TIN
GII THIU
ABOUT
MC LC
1. M HC DA
2. I CNG BNH DA V HOA LIU
3. KHM BNH DA LIU
4. BNH DA NGH NGHIP
5. VIM DA C
6. VIM DA M
7. VIM DA PHNG DO KIN KHOANG
8. SI MO G
9. XM DA
10. X CNG B ( SCLRODERMIE )
11. ZONA
12. THUC BI NGOI DA
13. THUC IU TR BNH NM
14. TRNG C
15. U MM LY
16. UNG TH T BO GAI
17. UNG TH T BO Y
18. VY NN
19. VY NN (PSORIASIS)
20. VY NN MN M LNG BN TAY CHN
21. VY NN MN M TON THN
22. VY PHN HNG GIBERT
23. VIM B THN KINH
24. MN TRNG C
25. NM LANG BEN
26. NM MNG
27. NM TC
28. PHNG CHNG BNH NM
29. PEMPHIGIOD BNG NC
30. PEMPHIGUS
31. RNG TC
32. SN NGA DO CN TRNG
33. T A
34. TN THNG C BN
35. CC BNH NM DA
36. XT NGHIM CHN ON NM GY BNH
37. CHNG MT (ROSACEA)
38. SC PHN V
39. ECZEMA
40. GH ( SCABIES, GALE)
41. HT CM ( VERRUCAE)
42. HI CHNG LYELL
43. HI CHNG STEVEN JOHNSON
44. LAO DA
45. LUPT BAN H THNG
46. LUPT BAN MN TNH
47. LI LNG ( HAIRY TONGUE)
48. BNH NM ASPERGILLOSIS
49. BNH NM BLASTOMYCOSIS NAM M
50. BNH NM CRYPTOCOCCOSIS
51. BNH NM PENICILLIOSIS
52. BNH NM SPOROTRICHOSIS
53. BNH NM BLASTOMYCES BC M
54. BNH NM MYCETOMA ( MADURAMYCOSIS)
55. BNH PAGET
56. BNH PHONG
57. BNH RAYNAUD
58. BNH THAN (ANTHRAX)
59. BNH GII LEO ( HERPES ZOSTER)
60. CC BNH NM CANDIDAS
61. U TRNG SN LN DI DA
62. BAN MY AY V PH MCH
63. BAN M AY
64. BCH BIN
65. BNH BOWEN
66. BNH DUHRING BROCQ
67. BNH CHM
68. BNH GIANG MAI
69. BNH LU
70. BNH LYME
71. BAN NHIM SC C NH TI PHT
72. VIM NIU O DO CHLAMYDIA TRACHOMATIS
73. BNH MN RP (ECPET)
74. BNH TIU THNG B PHNG NC BM SINH
75. TNG QUAN BNH LY TRUYN QUA NG TNH DC
76. BNH NM ACTINOMYCOSIS
77. Y HC C TRUYN IU TR BNH NGOI DA
78. PHNG TRNH BNH STD V NHIM HVI/AIDS
79. PHC IU TR THEO HI CHNG CC BNH LTQTD
80. THUC BI CORTICOID IU TR BNH NGOI DA
NI DUNG
1. M HC DA
Trn cc lt ct m hc ca da bnh thng, ranh gii gia thng b v trung b khng bng
y). Chng c bo tng bt mu kim nh, nhn hnh bu dc hay di cha nhiu cht
nhim sc. Cc t bo ny nm st nhau v dnh vi nhau bng cc cu ni bo tng. Trong
mt s t bo thng thy hnh nhn chia.
Mng y khng bt mu thuc nhum thng thng. Khi s dng thuc nhum acid schiff,
b.
1.2. Lp gai(Stratum spinosum)
hng. Cc t bo ny cha cht eleidin, hnh thnh do ho lng cc ht sng trong cha nhiu
nhm disulfit.
Lp sng trn cng, cc t bo tr nn dt hon ton, mng bo tng dy, nhn bin mt.
Trong bo tng ch cn ton nhng si sng. Mi t bo bin thnh mt l sng mng, chng
chng cht ln nhau, nhng t bo mt trn cng lun lun b bong ri ra.
1.6. Sc t ca thng b:
Sc t da thuc nhm hc t, c tc dng bo v c th trnh tc hi ca tia cc tm.
+ Ngoi cc thnh phn trn trung b cn c nhng ng mch, tnh mch, bch mch ( h
3. H b .(cn gi l m di da.Subcutaneous)
c nhiu ngn cch bi nhng vch ni lin vi trung b, trong mi c mch mu, thn kinh,
t bo m, t bo trn, t bo sng.
4. Phn ph ca da.
4.1. Thn kinh da c chia lm 2 loi : c v bc myelin ( thn kinh no tu) v thn kinh
khng c v myelin ( thn kinh giao cm ). C mch mu, thn kinh, t bo m, t bo trn, t
bo sng.
C 5 loi tiu th :
- Tiu th Water Pacini c nhiu lng ngn tay cho bit cm gic s m.
4.3. Tuyn b : nm cnh bao lng v thng vi nang lng bng ng tit. Mi tuyn b c nhiu
4.4. Nang lng l phn lm su xung ca thng b cha si lng v tip cn vi tuyn b.
Nang lng ri rc khp da tr lng bn tay v lng bn chn. Mi nang lng c 3 phn : ming
nang lng thng vi mt da, c nang- phn ny b li v bao lng l phn di nht n su
xung h b.
2.5.Mng:
nhng l sng m khng c lp ht. Chn b ca r mng c nhiu mao mch. Chn b ca
thn mng l mt m x, t mao mch, nhiu si collagen, si chun song song vi mt mng,
mt s si c hng vung gc dnh cht vo mng xng nn chn b vng thn mng rt
khi lnh v khi b bnh . Bnh hoa liu l mn hc cc bnh ly truyn qua quan h tnh dc
do vi khun, virut, nm, k sinh vt gy ra. Mn hc v bnh da v hoa liu gi chung l mn
hc bnh da liu (dermato- venereology).
Ngy nay, chuyn ngnh da liu pht trin t trung ng n a phng, cp c bnh
da v hoa liu,trong ch trng trc mt l mt s bnh da ph bin v bnh phong, bnh
hoa liu . .
- Qua cc thng k ca cc bc s chuyn ngnh Vin Da liu Trung ng, Thi nguyn,
Vnh Phc, Hi phng, thnh ph H Ch Minh trn 10- 25% dn s. cc bnh vin a khoa t
l bnh nhn nm iu tr bnh da liu chim 1,25% - 2% trong tng s bnh nhn.
hin cng tc thanh ton phong tng vng, thanh ton phong trong ton quc, cho n nay
50/63 tnh thnh t c ch tiu- s lng bnh nhn phong nh hn 1/10.000 dn). Ch
tiu mi (2015) ca ngnh phn u l s lng bnh nhn phong 1< 50.000 dn s ...). y l
mt thch thc, mt mc tiu rt kh khn i hi nh nc phi u t nhiu tin ca, cn b
chuyn ngnh phi c nhiu tm huyt mi c th thc hin c. Theo cc chuyn gia nhiu
kinh nghim v bnh phong, Vit Nam phi phn u t 80 - 100 nm na con s bnh nhn
phong ton quc mi c th t < 2 con s. Bnh ly truyn qua ng tnh dc mc tiu l cn
gim st c bnh, c bit l bnh lu, giang mai v nhim HIV/AIDS. Gn y vn k th
ho v hin i ho, cc sn phn cng nghip ngy cng nhiu... l cc tc nhn trc tip gy
ra nhiu bnh ngh nghip, trong c bnh da.
+ Trong Qun i.
thanh nin c sc kho vo phc v, cho nn nhng bnh nh phong, bnh ly truyn qua
ng tnh dc chim mt t l rt nh so vi tnh hnh chung ca x hi, v d ti Qun y Vin
1-2 bnh nhn phong vo iu tr. Nhng lu hn l nhng bnh nhn nhim HIV/AIDS ( khi
tuyn qun t l phn ng HIV (+) l 4%o thanh nin khm tuyn, nhng thanh nin ny
khng tiu chun vo qun i).C hnh nh lm sng ca bnh rt a dng... thy thuc
cha c nhiu kinh nghim, ch quan, nn c nhiu bnh nhn khng c pht hin sm dn
n vic d phng ly lan cho thy thuc..., chm sc bnh nhn c nhiu khim khuyt m ta
cn phi khc phc. Cc bnh ngoi da trong qun i ch yu vn l cc bnh nm, vim da
m, bnh da d ng v bnh gh ( gn ging nh trong thi gian chin tranh chng M), nhng
c phn hi khc: hin nay do iu kin n ca b i tt hn, nc dng c sch hn v
th hnh nh lm sng bnh khng in hnh, t bin chng... khin cho vic chn on d b
st.
2. Cn nguyn bnh:
Nhn chung bnh da liu bao gi cng c 2 yu t tc ng pht sinh v pht trin bnh :
yu t ni gii v yu t ngoi gii.
+ Yu t ni gii:
- Di truyn
- Gia nh .
- Bnh to keo
+ Yu t ngoi gii:
Do cc tc nhn vi khun, virus, k sinh trng, nm, thc vt, phn hoa, lng th thc n l tc
3. Tc hi:
+ Tc hi n bn thn ngi bnh: v th cht au, nga kh chu c khi lm bin dng thn
th, n l mt cc hnh trng din cho bnh nhn. V tm l, cc bnh nh phong, trng c,
bnh hoa liu c nh hng rt nng n. Mt s bnh c th gy t vong hoc nh hng ln
ti sc kho ngi bnh nh nhim c da d ng thuc, bnh luput ...
+Bc l cc vng da cn khm :gii thch cho bnh nhn r khi cn ci qun o, bc l vng da
cn khm (nht l i vi ph n).
b c th, ca cc c quan ni tng nh tim mch, tiu ho, gan, thn, ni tit c nh hng
2. Cc bc tin hnh.
+ Quan st theo trnh t: u, mt, c, chi trn, bn tay, ngn tay, k ngn tay, lng bn tay,
mng tay, ngc, vai, nch, bng, lng, mng, vng sinh dc - hu mn, hai chn, bn
chn, mng chn.
Tnh cht, c im ca v tr: c v tr c bit khng (bnh gh thng gp tn thng vng
k ngn tay, ngn c tay, b trc nch, quanh rn,b phn sinh dc....). Nhiu bnh thng
hay xut hin mt s v tr (v tr hay gp, v tr a thch) v d nh bnh nm hc lo thng
2 np bn, k mng, quanh tht lng ; bnh l da du thng mt, da vng c, vng lin b,
Bnh nhn nhiu khi khng thy, khng bit ht cc tn thng mnh c,mt khc tn thng
cc v tr khc nhau nhng li b sung chn on cho nhau (tn thng nm mng, nm bn
chn thng km nm mng bn).
+ V kch thc, hnh dng: tn thng c kch thc mt vi mm, mt vi cm, hnh trn, bu
dc, hnh a cung, hnh nhn...
+ Cch sp xp, b tr: ri rc, l t, ring r, thnh m, cm, mng, thnh vt, thnh hnh
vng,hnh vn vo, rn ln.
+ n dng hay a dng: trn cc vng da ch thy mt loi tn thng nh nhau (n dng)
hay c nhiu loi tn thng khc nhau (a dng) . V d:trong bnh vy nn tn thng c
tnh cht n dng,d to hay nh l cc sn,m mng ,cm,ph vy trng,cn trong bnh
vim da dng ec-pt Duhring- Brocq, tn thng c tnh cht a dng: mn nc, bng nc,
+Cn hnh dung c qu trnh pht sinh, pht trin, din bin ca tn thng.
Khi khm nhiu khi cn phi dng mt s thao tc th thut (ni phn sau) gip bc l c
im ca tn thng mt cch y hn.
2.3. Hi v tin s:
+ Bt u bng triu chng g (cn khu gi, hng dn cho bnh nhn), cm gic ti ch v
tnh trng ton thn lc ra sao?. Sau din bin ra sao.
+ Trong tin s bn thn c bnh g lin quan khng? B bnh ln u hay ti pht nhiu ln.
+ Chn on quyt nh khi c xt nghim vi khun hc, min dch hc, m bnh hc da.
2.5. Lm cc xt nghim cn thit v vi khun hc, xt nghim nm, huyt thanh hc, min
dch hc, m bnh hc da hoc nu cn khm thm cc chuyn khoa khc b sung cho
3.1. Mt s thao tc th thut gip cho chn on, lm trc tip trn tn thng.
+ n knh: phn bit ban v ban xut huyt di da, pht hin lupome, phn bit u
gin mch v m xut huyt (petechies).
+ Chc dch bng kim v trng phn bit sn v mn nc, p giy thuc l pht hin
mn nc v hoc git m trong da du.
+ Co theo phng php Brocq pht hin du hiu vt nn,du hiu v hnh,du hiu git
sng mu (du hiu Auspitz) trong chn on vy nn.
+ Mit mnh ln da cnh phng nc bng ngn tay tm du hiu Nikolsky trong chn on
bnh pemphigut.
+ Soi n wood: lc tia t ngoi qua mt knh oxyd nikel, s c lung nh sng vi bc sng
3650 A. nh sng ny gip cho chn on mt s tn thng ngoi da, bng cch lm cho
cht hu c bt mu hunh quang khc nhau (gip cho chn on nm tc, lang ben, ..).
3.2. Mt s xt nghim vi sinh vt:.soi cy khun v lm khng sinh .ly bnh phm mn
,bng nc,mn m,vt let,dch m niu o.......
+ Co vy, ly m, lng, tc, mng, cht nhy...lm xt nghim nm candida,soi trc tip v
nui cy.
+ Ly dch trn sng giang mai, trong hch, tm xon khun giang mai trn knh hin vi nn
en.
Tim truyn chut lang trong chn on lao- gy bnh thc nghim i vi phong -
3.4. Cc xt nghim sinh ho chn on chc phn (ni tit, men, sinh t, vi cht). Xt nghim
min dch, xt nghim t bo LE (lupus erythemathosus), yu t khng th khng nhn ANF
(antinuclear factor)...
3.5. Cc th ng da: rch da, p da,tim trong da (i vi cht gy d ng, tubeculin, KN nm,
lepromine...).
Thng phi tip xc trc tip cht gy bnh v mi trng lao ng mt thi gian tng
i di.
Khi cho ngh vic th thy bnh gim r, khi tr li lm vic bnh li vng ln.
Loi tr cht kch thch khng phi ngh nghip, xem cng nhn c dng m phm
khng,cng nhn c dng cht dit cn trng khng , ch nhng trng hp mn cm c tnh
cht ngh ngip v sinh hot.
Xem c nhiu ngi cng iu kin c b bnh ging nhau khng, cc vt tip xc
c lm thay i mu sc, ng cht tip xc , vt nt, xc,, vt chai (do ngh nghip) xem
mng tay c thay i khng, ni tip xc c gin mch, cc so trn da do yu t ngh nghip
gy nn ?
6 - Phng php xt nghim v thm d chc nng trong bnh da ngh nghip.
- Cng nhn tip xc vi ho cht , nh lng ho cht trong mu, trong nc tiu.
+ Chn v tr : vng sau lng dc 2 bn ct sng gia 2 xng b vai hoc pha trong
cng tay ,cnh tay pha ngoi,t ming gc tm dung dch d nguyn nghi ng,sau t 1
c kt qu : * n thun ()
* v ph ti ch (+)
* + sn ph (++)
* + sn ph + mn nc (+++)
+ Phng php nh git c dng rng ri khi cht tip xc l nhng ho cht.
cm, ri nh git dung dch ho cht ho tan trong ru 60 hoc trong aceton vi nng ph
thuc cht lm th nghim 1- 2 %. Khi nh git 1 thi gian, ru v aceton s bc hi cn
li ho cht tc ng ln da v gy phn ng.
Ngnh cng nghip ho cht l ngnh quan trng l c s pht trin cng nng
nghip ,cng nhn lm trong cc ngnh cng nghip khc nhau u c th mc bnh da. Cc
ho cht tc ng trn da c th gy kch thch, c th gy d ng .
BDNN xy ra cng nhn ngnh thu tinh, cao su, cht do.
Clo Trng c.
H 2SO4 lot da
Bnh da do kch thch ca ho cht thng xy ra cho a s cng nhn lm vic trc
tip vi ho cht v trong iu kin lm vic ging nhau ( orthoergiqne) .Cc bnh da do d
ng ca ho cht ch xy ra trn 1 s ngi c c a thch hp ho cht khi ngm vo da +
Protein ca c th tr thnh d nguyn gy d ng thng tn xa vng tip xc.
xut hin cc mn nc, mn nc v ra chy nc vng, bnh nhn rt nga v cng nga
phi gi nhiu nga li cng tng ln c th b bi nhim vi khun.
-Vi Nitrat bn rung khi tip xc xut hin cc sn mu vng da cam quanh cc nang lng v
- Cc loi thuc tr su cng c th hay gy tai bin da ngoi cc biu hin lm sng
Triu chng khi u l nhng ban ni tip xc, nu ngng th thi cn khng ngng th
dn n da ton thn, nt da v chy nc vng.Ton trng st cao nu khng iu tr kp
- Lm sng : Trn da vng ngm nc (li) l nhng sn mu ring r bng u inh ghim
- pht hin lm th nghim test p trn da vi cc dung dch xem nh thnh phn ch yu
ca xi mng nh l Potassium bichromate 0,5% ho tan trong nc ;Nickel sulfat 2% ho tan
trong nc , Cobalt clorua 2% ho tan trong nc.
c kt qu sau 24 h.
- Lm sng: Khi tip xc vi cht kim ca xi mng thng xuyn vim da biu hin da kh nt
tu ho.
triu chng khc nhau : Vim da, xm da nhim c, vim nang lng, qu sng.
Mt s nguyn tc cn ch :
- Vim da do cht Dinitrochlorobenzol ( ho tan trong du) p bng dung dch nc.
- Vim da do Crom ho tr 6 p bng dung dch Natri hyposulfit c tc dng chuyn phn t
crm 6 sang crom 3 trung ho cht .
-Khi tuyn cng nhn cn ch khm sc kho nhng ngi c tin s d ng hen,m
ay, chm... khng tuyn vo ni c ho cht hoc lm vic trong mi trng lao ng nng
.Nhng ngi b "trng c ngi tr", da m khng lm vic vi du m.
- Cn khm nh k pht hin bnh da c k hoch iu tr d phng .
- Tng cng bin php v sinh lao ng: qun o lao ng, phi c ring ,phi c nc
Thuc bo v da:
V d : Kaolin 20g
Lanoline 20 g
Nc 40 ml
Hoc :
Casein 19 g 7
Glycerine 19,7
Amoniac 1,9
Acide boric 5g
Oxyt km 5g
Bt Talc 15g
Du thc vt 75g
h Brocq lm mm da .
H Brocq gm : Oxyt km 30 g
Lanoline 30 g
Vaseline 40 g
T l : 3 : 3 : 4 .
5. VIM DA C
( Dermatomyosite)
i cng :
- L bnh c thng tn ch yu da v c.
- C 2 gii u b nh nhau.
Thng pht ra sau 1 bnh nhim khun ton thn hoc khu tr nh vng hm mt.
1-1. Hnh th cp :Thng bt u triu chng ca ton thn bng st,s mi thng
xy ra sau nhim trng ti ch hoc n gii sau khi bt u bng triu chng: au, yu c
, mt mi ton thn hoc xut hin hng ban c ph v nga.
Cc hin tng trn c th pht cng 1 lc, nhanh trong vng vi ngy hoc chm hn
Vnh tai thng c hoi t nh rt au, hoi t xut hin c th gp trn cc thng tn
mt cm gic ging bnh phong .
cc khp, bnh ko di trong vi ngy n vi tun , thnh thong kh nim mc ming . Vim
ming v cc Amidal vim .
- au cc c theo nhiu trnh , au tng ln khi bp vo cc c . Mt s ng tc nh
d tay ln cao khng th lm c , trc tin l cc c b vai b thng tn sau n cc c
c thn mnh v cc chi gy tr ngi khi c ng, lc ca cc c gim st, cc c chng mt
rng th s pht sinh nut kh do thng tn cc c thc qun, c honh, c rut, c tim , c
nhn cu mt v ri lon cc c tht.
- Cc hch bch huyt sng to. Lch sng to ,gan khng to.
- Bnh nhn st nh, st tng trong bnh vng, ra m hi nhiu ,ngi gy st, huyt
p h. Vss thng tng , nc tiu c tr niu, Prtin niu,Protein mu thp, nhng M globulin
ngc li trong cc bnh to keo khc khng tng cao.
hp cc c b can xi ho mnh .
1- 2. Th kinh din
Bnh tin trin nhiu nm tr thnh kinh din hoc bnh t pht ra l kinh din.
- Tn thng da: bnh pht ra u tin mt, c, mt dui cc chi sau lan ra c thn mnh. Tn
thng l nhng hng ban kt hp vi bong vy dn mch hnh mng li xut hin cc sn
3 - Tin trin .
- Thi gian ko di 2-4 nm, bt u cp tnh qua t vng bnh dn dn bin thnh kinh din.
- Tin trin nng bnh nhn c th t vong. Nhng bnh nhn trn 40 tui thng b t vong do
vim phi, lit h hp. Cht l do vim c tim v nhim khun huyt, rt t khi bnh lnh hon
ton, thng li di chng teo c ,gim hoc mt hn phn x gn dn n teo v thm da.
4 - T chc bnh hc
- Thy thng b teo lp gai c khi dy, gia thng b v trung b trong trng hp cp tnh c
th thy 1 lp khe phn cch , trung b ph thng cc dy chun b ph. Thm nhim xung
quanh mch mu gm t bo lm ba ln ln vi t chc bo , tng bo (Plasmocyte) v
nhng n bo t khi thy t bo x non.
5 - iu tr
Ban u tim tnh mch vi liu tn cng. Sau cho ung. Nu dng ko di c tc dng ph
ca corticoid. au c kh phn bit vi t vng bnh.
- Sinh t cc loi.
- Cc thuc c ch min dch. Dng trong nhng trng hp bnh khng corticoid.
+ Methotrexate 2,5 mg dng liu hng tun / ln 25 - 50 mg tim tnh mch, ng ung 7, 5
mg - 30 mg / ung lm 3 ln cch 12 gi ung 1 ln v ung trong 1 tun.
+ Cyclosporine :
Dng 2,5 - 7,5 mg / ngy th c th ci thin hoc b corticoid i vi nhng bnh nhn ph
thuc vo corticoid.
- iu tr triu chng.
Trong t vng bnh ngh ngi l chnh gii hn vn ng ,khi bnh gim r tp vn
ng cc khp dn dn, t t.
iu tr vi ho xng: vi ho thng tin trin nhanh trong t vng bnh dng colchicine :
1- 2 mg / kg / ngy dng bng ng ung.
I - i cng
Bnh thng trn da c nhiu tp khun, phn ln l t cu v lin cu, nhiu nht l nhng
Trong nhng iu kin thun li nh c th suy yu, v sinh km, nga gi, sy xt da. tp
khun trn da tng sinh, tng c t gy nn bnh ngoi da gi chung l vim da m.
Ngi ta thng phn thnh vim b m do t cu v vim b m lin cu, nhng t khi hai loi
cu khun hot ng ring r m phn nhiu cng phi hp gy bnh.
Trong b i thng gp nhng ngi cng tc lao ng, chin u cng thng, hay b chn
thng xy st trn da, v sinh thiu st, dinh dng km. Vim b m cn l tn thng th
pht ca nhiu bnh ngoi da gy nga nh gh Eczema, sn cc
II- Vim b m do t cu :
T cu thng gy tn thng vim nang lng, biu hin bng nhng mn m n khp vi l
- iu tr cng gin n : chm cn It 1-3%, dung dch xanh methylen 1%. Bi m chloroxid
1%,kem silver,m bactroban, m fucidin
- Do t cu vng c c t cao.
- Ban u ch l mn m quanh l chn lng, nhng nhim khun ngy cng su lm cho t
chc quanh nang lng nhim cm. Vim lan rng v su hn thnh nhiu mn m ri rc hoc
cm li thnh m , cng cm g g nn ra m.
- Vim nang lng su vng cm, mp, gy, ria tc,u. gi l Sicosis, tin trin dai dng hay
ti pht.
- iu tr :
Ti ch bng dung dch st trng ( cn It 1-3% xanh methylen 1%) m khng sinh Penixilin,
Chloroxid 1%, oxyd vng thu ngn 10%.m bactroban,m fucidin.
- Tin trin ; Ban u ni thnh u , au, quanh chn lng,nn cng cm (Giai on 1): Dn
dn u mm c triu chng ba ng lm m,to ngi.( Giai on 2): Khong ngy th 8-10 nht
mm nhn, v m nn ra mt ngi c sau lnh so ( Giai on 3).
inh nht vng quanh ming gi l "inh ru" rt nguy him, c th gy tc tnh mch, nhim
trng huyt khng nn chch nn sm.
"Hu bi "(carbuncle) cn gi l inh hng sen, l mt cm inh nht gp vng gy gia hai
b vai, xng cng. Do t cu vng c tnh cao, gy vim lan su rng n chn b v h b
lm hoi t c mt vng . Thng gp ngi gi, ngi suy yu . Ton thn bnh nhn yu
mt, st cao c triu chng nhm khun nhim c nng . ti ch b sng n, tm c nhiu
m, nhiu ngi, l ch nh t ong. C th dn ti nhim khun huyt, , mng v xng cng
gy hoi t hoc lot c khi chm vo mch mu to lm chy mu t.
Nht by l nhiu inh nht mc lin tip t ny n t khc, dai dng hng thng. Thng
gp ngi suy nhc lao tm lao lc, hoc i ng.
- iu tr :
i vi inh nht ; khng nn nn chch sm. Khi mi ni sng , cng : chm cn I t 3-5%
hoc bi ichthyol tinh cht, c iu kin chy sng ngn. Khi nht v m nn ht ngi ra,
chm thuc mu hoc bi m khng sinh, ton thn cho ung hoc tim mt t khng sinh.
i vi inh ru : tuyt i trnh chch nn bi cn iod 3%. Kp thi tim ung thuc khng sinh
liu cao,phi hp khng sinh, kt hp sinh t C, thuc gim au, chy sng ngn.
i vi hu bi : iu tr sm bng khng sinh liu cao,phi hp khng sinh, sinh t, thuc nng
cao th trng . Khi m tn thng mm thay bng hng ngy,khng chch rng tho m
4 - Nht g (hidradenitis):
- Do vim nang lng, km theo vim tuyn hi tuyn b vng nch thnh ti m su chn b
v h b.
- iu tr : , bi thuc mu ,m khng sinh,tim ung khng sinh . Nu cn gii quyt bng phu
thut nh chch nn cc vim x ha.
Trn thc t trong bnh chc , t cu v lin cu thng phi hp vi nhau. Tr em hay b hn
ngi ln.
- Bnh bt u bng mt phng nc nh, lng nhng hnh trn , xung quanh c qung
vim . Nc ban u trong dn dn thnh m c giai on phng nc v phng m rt
ngn. Chng bao lu ng vy tit vng kiu mt ong . Di lp vy l mt lp cht , nng ,
khng cm , v tn thng trong bnh chc rt nng.
Chc ri rc ton thn, c th km theo st bin chng vim cu thn cp, n cng chn, mi
- iu tr:
Chc c phng m cha v : dng kim st trng chc m ra, cho m thm vo bng,
khng m chy lan ra vng da ln cn . Sau chm cc loi thuc mu nh dung dch
milian xanh methylen 1%,dd eosin 2% hoc m khng sinh. nh m chlorocid 1% kem
- Phng bnh : nh tr cn phng trnh ly lan khng dng chung chn khn mt vi ngi c
bnh.
- Thng gp chc lot bnh nhn thiu dinh dng thiu v sinh c th yu km ,c bnh
i ng hoc nghin ru.
- iu tr :
Ra vt lot bng dung dch thuc tm 1/4000, hoc dung dch rivanol 1%. Chm dung dch
Nitrat bc 0,25- 0,50%. Sau bi m khng sinh.Ton thn cho ung tim tng t
khng sinh.
3/ Hm k ( intertrigo)
- iu tr :
Ra bng nc thuc tm 1/4000, chm dung dch yarish , nitrat bc 0,25%. Bi thuc mu, h
4- Chc mp(perlech):
- iu tr : Chm dung dch yarish, Nitrat bc 0,25% thuc mu, m khng sinh neomyxin, m
biomyxin 3%, m chlorocid 1% m fucidin,m bactroban .
Trc kia bnh ny hay gp v t vong cao ngay c khi nm vin. Hin nay tr s sinh,
ngi gi hoc cc bnh nhn c km cc bnh khc ... th cng nng.
Vi khun xm nhp trc tip hoc qua ng mu c bit khi c cc chn thng cc m,
s mn cm chung tng ln, hoc khi bnh nhn thiu dng, nghin ru hoc h d globulin
. Lm sng .
bng. m vim qung mu ti kch thc vi cm n hng chc cm, hi cao hn mt da,
n, cm, ranh gii r, c b con trch g cao. au t nhin hay bp vo th au. cc vng t
chc lng lo c khi to ph n mnh ( mi mt, sinh dc ) hoc ban c gii hn r v c th
sau mt nhim trng ngoi da nh ( lot su qung, lot ung th, hoc chn thng do d vt
lm nh hng ti s ton vn ca da ). Mc ph thay i tu tng vng. Bn cnh tn
thng b nhim sc, sng v bong vy.
Triu chng ton thn thng nng nhng ngi c sc khng yu. Ton trng st cao li
b, hch lymph khu tr sng au. C th thy bin chng vim ni tm mc, khp , mng no,
-. iu tr .
1. i c ng :
kin nht, kin cong t... u nh c ru nhn hoc hnh bu dc cong v pha trc .
d i. Paedrus chy v bay rt nhanh, khi chy cong t ln nh t b cp. Cn trng sng bng
- Paedrus sng quanh lng, quanh cc v tr ng qun , trong cc ng rc tri lnh bnh
trn mt rung, mt sng. T cc v tr chng c th bay vo trong nh, phng lm vic nht
l khi trong phng c nh sng, gy nn bnh vim da tip xc cho nhng ngi va chm
vo n.
Pavan chit xut t cn trng mt cht gi l Pederin. Cht ny khi bi ln da chut bch
gy phn ng vim mch, bi ln da ngi gy vim da phng nc.
2. Hnh nh lm sng :
sng.
V tr tn th ng ch yu phn h, mt, c hai cng tay, 1/2 trn thn mnh. Nhng cng c
tr ng hp thy c vng kn nh nch, quanh tht l ng, bn, i.
c hnh mt vt g ( l vt mit ca cc ngn tay bnh nhn). 100 % c cm gic nng bng
ti ch. Ton trng bnh nhn c cm gic ngy ngy st kh chu mt mi c th ni hch
vng t ng ng. Mt s tr ng hp ph n hai mi mt. Hoc c tn th ng vim da ( ph
n nh ) cc vng da kn khc do bnh nhn gi, mit nhng c t ca cn trng vo vng
da . Sau mt vi ngy c th c nhim khun th pht gy phng m, c vy tit.
Chn on phn bit vi vim da do cc cn nguyn khc ( ho cht, sn, cy c...), hoc giai
on u ca bnh zna.
3. iu tr v d phng.
iu tr ti ch : dng cc dung dch du da : kem km,h nc, dung dch Yarit bi ngy 2- 3
ln. Dng cc dung dch st khun, m khng sinh khi c nhim khun.
Ton thn dng thuc khng histamin tng hp, hoc thuc khng sinh khi c nhim khun.
D phng :
- Khi ra mt, tm git cn git sch khn mt hoc gi qun o tr c khi mc trnh st
mit cn trng ln da.
1. i cng :
1.1. Mm bnh.
1.3. ng ly truyn:
Ch yu ly truyn qua ng tnh dc, cn c th ly truyn qua tip xc. Tr s sinh
c th b ly bnh t ng i m mc bnh trong lc sinh .
2. Triu chng lm sng.
+ V tr tn th ng: n ng th ng quy u, rnh qui u, vng hm, bao qui u,
- U mm ly.
- Liken phng.
- N vi.
4. iu tr.
- Phu thut lnh bng ni t lng.
- t in.
- Bi cc cht nh : axit Trichloraxetic 80- 90%.
Nha Podophyllin 10- 25%..
bnh.
+ Tt c ph n u nn lm xt nghim knh pht dch c t cung hng nm pht
hin c nhim HPV v pht hin sm ung th.
1.i cng.
Melanin l mt cht protein phc hp, mu en, do cc cht axit amin trong ch yu l
tyrosin chuyn thnh.
Theo Bruno Bloch ( 1916- 1921) Tyrosin hoc mt cht gn ging sinh ra mt cht to sc
khng mu phn lp c trn cc thc vt l cht Di-oxy-phnyl- alanine m Bloch gi l
Dopa. Di nh hng ca men Dopa-oxy-dase cht Dopa c oxy ho tr thnh Melanine.
Nhng ngi cho ti nay cha phn lp c Dopa cng nh Dopa. Oxydase... Nhng vi
cht Dopa mt cht ho hc tng hp c, c th gip pht hin kh nng to sc t ca
mt s t bo bng" phn ng Dopa".
mt s cht trung gian chuyn thnh melanin giai oan ny cng vn c vai tr ca Tyrosinaza
Cuprotein kch thch Tyrosinaza to iu kin cho hnh thnh melanine. Vai tr ca cc nhm
SH c ch Tyrosinaza v hm qu trnh to thnh melanin. Nh vy Cu l kch thch v lu
Tyrosin
Di nh hng ca Tyrosinaza.
C mt xy.
Dopa
C mt xy.
Melanin:
Cc vt xm da u tin ngy cng lan rng, lin kt li thnh mt xm da lan to, ton thn,
xen k mt s vng da mu nht hn ( lng bn tay, mi mt) hoc mt s m xm mu hn.
c, huyt p h, biu hin tiu ho , au tht lng, gy st, nhiu ri lon chuyn ho khc...
Bnh Addison l do tn thng v tuyn thng thn , hay gp nht l do lao c 2 bn , thoi
ho b u, giang mai, ung th 2 bn, teo, x...
- Xm da ngi lang thang : ngi ngho, i, suy kit, c bnh chy, rn dai dng,,, c th
- Xm da nhim c.
Cht Asen ( nht l Asen khong vt): trong iu tr, n ung, ngh nghip do nhim c... ko
- Xm da th pht :
da, rc da, liken phng, sn nga mn tnh, nga mn tnh, liken ho, c th li di chng
xm da.
vo loi ny.
3.3.Nm m thng xut hin trong lc c mang ( mt n ngi c mang) sau khi , c kinh
3.4. Lina fusca: cn goi l " cung nu trn" l mt xm da vng trn, chy t thi dng ny
sang bn kia, dc theo ria tc, chiu rng khong 1 cm nh l mt hnh cnh cung, m hai u
thi dng thng v rng hn, i khi hnh cnh cung t r hn v t on.
Thng km theo tn thng vim hoc u no, hoc thn kinh trung ng ( vim no, giang
mai thn kinh, u no...).
3.5. Xm da Riehl : cn gi l " xm da chin tranh" do Riehl t t 1917,sau trong chin
tranh th gii ln th II cng cn gp. Trong cc nc khng c chin tranh bnh ny him gp
hn.
Thng xut hin sau mt bui ra nng vi triu chng ban nga ca " chy nng" sau
nhanh chng thm mu. Nhiu t nga , rc da,c lin qua ti ra nng hoc khng li
tip din, lm cho da ngy cng xm li,c trng hp ngay t u xm da, ngy cng lan
rng, khng c lin quan g ti nh nng, khng qua giai on ban . Nhng phn ln trng
Ban u ch l nhng vt, nhng im xm da rt nh, nhng sau lan rng nhanh, lm cho
Thng b bnh thng nhng i khi vng c hnh mng li da hi teo kiu vim da bin
dng (Poikilodermic). Trn cc vng xm mu c, c th thy cc sn dt nh, bng, dng
liken. Trong nim mc ming cng c th c cc vt trng dng liken. Bnh ko di hng nm,
tng v ma h d ti pht nhng tin lng lnh tnh ch nh hng v thm m. Nguyn sinh
Vai tr ca nh sng. Do tc dng trc tip hoc do cm ng nhng porphyrin rt t khi cao.
Ri lon ding dng thi chin: ( n thc phm cht lng xu,thiu viatmin C,PP, B) nhng
nng thn nhiu ngi dinh dng tt vn b bnh.
Ri lon tiu ho, thiu nng gan...
Lin quan gia xm da Riehl v liken phng, c trng hp ly ken phng tin trin di dng
mt xm da Riehl.
- Ch dinh dng.
- Thuc an thn.
- Vitamin C,PP.
- Chiu radio vng gy tc ng trn giao cm c 100r- 150r tng liu 600- 650r, 6 t 2 ngy 1
ln.
3.6. Vim da nhn to nhim sc: xm da, vim da nhim c Hofmann Habermann.
xut ca Anthracine kiu Acridine). Hp thu qua mi, ming, cc cht trn cng c th gy cm
ng.
M bng (Brillantin) chi tc, cht kem, phn thoa mt, cht nhum tc (Paraphesnylne,
- Bnh da nhim sc quanh ming ca Brocq: sng nhim sc quanh ming. Do Brocq t t
th t nhin khi.
Hin nay hnh nh lm sng c khc thi k Brocq t, bnh thng bt u bng mt da, rc
vy nh ranh gii kh r, c tnh cht mt sng trn da u. Sau dn dn xut hin xm
da, rc vy nh , ng nh tn gi: sng nhim sc quanh ming.
rm da hoc xm da Riehl.
4. Xm da khu tr.
h: mt, c, ngc, lng bn tay, mt ngoi cng tay v cnh tay... phn kn (vai) him hn v
tha hn. Tn nhang l nhng vt nh bng u inh ghim, ht vng, i khi san st mu vng
m, nu xm, ranh gii r, hoc hi nham nh, phng nhn khng c vy da, khng bao gi
Tp 2 : sn
Tp 3 : ng mch ch .
Tp 4 : mng c bn .
II- X cng b :
Hin t ng lng ng can xi, vin on (Raynaud's) gin mao mch li ti hay cn gi x
cng vin on lan to.
Ch a bit nguyn nhn, ch a r c tn thng mao mch, v sao c ri lon v min dch
: ti sao c mt cn bng tng hp ho ging collagene, hay c ri lon to keo chc nng .
Hin nay ng i ta i su vo cc vn sau :
hc nhn thy c s thiu ht v cht v l ng. Cht c ch Proteaza ( men phn hu Protein )
t sinh ra h qu s hot ho yu t huyt thanh c t bo i vi cc t bo ni m ca
mao mch.
mch.
- Ri lon v min dch : Cc ri lon min dch pht hin trong x cng b h thng ch a
Ngoi ra cn thy xut hin cc khng th khng nhn ADN , ARN, khng th khng
bao c, lng ng Ig, lng ng b th v cht fibrinogene vng tip ni th ng b trung b v
thnh mch mu mao mch.
cc enzym tch ra, cc cht ny kim sot ng c li nguyn bo si, s tch ni trn khng
bnh thng dn n s hnh thnh cc si ngho Aminopeptt cui chui vi s kim sot
ng c km hiu qu.
Ngoi ra cn c 1 s yu t khc nh :
3- Lm sng :
- Tn th ng da :
Khi pht do lnh, bt u bng kch pht c lit . Mt hoc nhiu ngn tay tn th ng
trng c, lnh hu nh v cm, gii hn trn ca co mch r nt cc u ca ngn tay hay
Lm xt nghim soi mao mch ca mng cn thit cho vic chn on. Thy c cc
vnh mao mch th a ca mch mu to ra, thoi ho. Cc du hiu ny khng ph thuc vo
mc tn th ng da. Lm c xt nghim ny phi chp ng mch v sinh thit. Hi
chng Raynaud' c tng t c khi rm r c khi lng l tu tng ng i .
Tp 2 ( x vin on )
th ng mt,thn mnh ch a b . 58 %
Tp 3 ( x lan to )
21 %
Hu qu :
Tp 1: - Tn ph
Tp 2, 3:
- Trong cc th tin trin chm x cng ngn tay, chn rt pht trin. Khi s x
- Trong th tin trin nhanh v nng, x cng pht trin rt mnh, x cng b
vng vai nh o gip da lm mt v,da bng tr nn cng cng nh da trng, hin t ng xc
p cc chi d i, lm mt , mi , lm hp mm chung quanh mm c du hiu nan hoa xe
p d chn on. C ri lon mu sc da ch m, ch nht ( nhm vi bch bin ).
- Tn th ng cc c quan khc :
cht.
15 -30 % bnh nhn x cng b c tn th ng thn nh, Pr niu va, cao huyt p,
i khi nng Nitr / mu kn o cn kim tra bng Ure mu.
th nng dn n kch pht tin trin tc th thnh cp tnh v do nh hng ca yu
t no nh dng corticoid ton thn, do c cha .
+ Tn th ng tim :
+ Tiu ho :
+ Tn th ng khc :
ng bnh tin trin trong nhiu thp nin . Nguyn nhn 1/2 do tn th ng thn ( tp 2 v 3
) t gp tp 1. Cn nguyn nhn t vong l do tim, phi, d dy, rut.
- Tn th ng thn tr em t hn ng i ln.
Tiu chun ph : - X cng ngn thay chn hoc lot hoc so mp ngn tay chn.
- X phi 2 nn .
Nu khng c tiu chun chnh cn 2/3 tiu chun ph ( nh ng phi c x cng ngn tay
chn ).
Chn on khc :
1- Hi chng Raynaud' .
2- Acrosclrose ( x vin on ).
7- iu tr :
- Kt qu iu tr rt d dt.
- iu tr th :
+ Dng cc thuc chng vim : Prednisolon liu 1 mg/ kg / ngy v gim liu khi c tin
+ C th dng M Interferol.
+ Vt l tr liu : tm ngm n c m .
Trn b mt tn th ng khng c lng, khng tit m hi, tit cht b gim, cm gic
cng gim. Khi khi x cng b mng li mu xm cc mc khc nhau, sm mu ko
Ch tn th ng da u ch tn th ng dn n rng tc ( so khng c tc ).
2- Th x cng b gii:
- chi :
+ Hay gp ng i tr.
+ C tn hi cn c d i tn th ng da.
+ i khi c tn th ng x ng : li x ng ( mlorhostose).
+ Hi chng Leri dy x ng theo chiu di, ch 1 u x ng v c tng sinh mng x
ng .
- Mt, da u: th hnh vt dao chm ( Coup de sabre ) l in hnh nht nu xut hin
trn biu hin mt gii , cnh chnh gia rng 2-3 cm pha da u c tc th ng ln vo mt t
v gy tri tc so. Pha d i lan xung qu cung mt lm lm cung mt lan xung m ti
tn mi, li v hm c th b x teo.
3- Mt s th khc :
4- iu tr :
- Corticoide ton thn liu 0,5 mg / kg / ngy ( Prednisolon ) dng ko di trong 3 thng
nn dng sm .
11. ZONA
Dch t hc
Virt Varicella Zoster gy ra hai th bnh ring bit. Nhim khun tin pht gy bnh thy u,
mt bnh rt hay ly nhng thng lnh tnh, xy ra thnh dch nhng tr cm th. S ti hot
sau ny ca virt Varicella Zoster tim n trong cc hch r lng to nn mt pht ban ngoi da
khu tr gi l zona (gii n). Cc p ng min dch qua trung gian t bo chuyn bit cho virt
Trn 90% ngi ln Hoa K c chng c huyt thanh ca vic nhim virt Varicella Zoster v
u c nguy c b zona (Choo PW, et al. 1995). S mc mi hng nm ca zona vo khong
1,5 3 trng hp/1.000 ngi (Donahue JG, 1995; Ragozzino MW, et al. 1982). T l mc mi
2 trng hp/1.000 ngi ng ngha vi trn 500.000 trng hp mi hng nm ti nc M.
Tui i tng l yu t nguy c ch cht ca bnh zona, s trng hp mc mi ca zona
nhng ngi trn 75 tui vt qu con s 10 trng hp/1.000 ngi-nm. Nguy c mc zona
trong sut cuc sng c tnh l 10 20% (Ragozzino MW, et al. 1982).
Mt yu t nguy c khc c xc nh r ca bnh zona l tnh trng min dch qua trung
gian t bo b thay i. Nhng bnh nhn (BN) c cc bnh l v u tn sinh (c bit cc ung
th tng sinh t chc lymph), nhng ngi ang dng thuc c ch min dch (gm c
corticosteroid), v nhng ngi nhn ghp c quan l nhng thnh phn c nguy c tng cao b
mc zona. Tuy nhin, vic tm kim mt bnh l ung th tim n nhng ngi b ngoi c v
vi 2/1000 ngi nm nhm HIV (-) i chng (Buchbinder SP, et al. 1992). V zona c th
xy ra nhng ngi b nhim HIV khng triu chng, xt nghim huyt thanh c th thch
Bnh s t nhin
Trong thi k tin triu ca zona, BN b nhc u, s nh sng v kh , nhng him khi c st.
Bnh khi u vi cc cm gic da bt thng khu tr, bao qut t nga hoc au nhi n au
d di, c trc cc tn thng da t mt n nm ngy, cn au vi cc cng khc nhau
xy ra hu nh tt c BN b zona cp. Mt pht ban hng ban dt sn tin trin thnh cc
Lnh tn thng xy ra trong khong thi gian t 2 4 tun, thng li so v nhng thay
i mu da vnh vin. Pht ban ngoi da thng ch mt bn v khng vt qu ng gia
thn. Vic c tn thng cng lc nhiu khoanh da (dermatome) khng lin k nhau hu nh
khng bao gi xy ra nhng BN c chc nng min dch ton vn, mc d trong 20% trng
hp tn thng c nhim trng ln cc khoanh da k cn. S hin din ca mt t tn thng
da ln cn cng khng c g l bt thng hoc c tm quan trng v tin lng g nhng BN
c chc nng min dch y .
Chn on
Biu hin da ca zona r c chn on lm sng thng l chnh xc. Tuy nhin v tr
hoc hnh dng ca cc tn thng ngoi da c th khng in hnh (c bit nhng BN c
h min dch b suy gim), khi cn c s xc nh ca lab. C th nui cy virt, nhng virt
Varicella Zoster yu t v tng i kh hi phc t cc mu bnh phm ca nhng tn thng
da. nh lng min dch hunh quang trc tip nhy cm hn nui cy virt, chi ph thp hn
polymerase c ch trong vic tm DNA ca virt Varicella Zoster trong dch v cc m (Gilden
DH, et al. 2000).
au dy thn kinh sau herpes (c nh ngha l au tn ti trn 30 ngy sau khi ni pht ban
hoc sau khi lin so) l bin chng ng s nht i vi nhng BN c chc nng min dch
y . C t l khi pht ln thi gian tn ti ca au dy thn kinh sau zona, c lin quan trc
tip vi tui ca BN (Choo PW v CS 1997). T l khi pht c bo co ca au dy thn
kinh sau zona bao qut t 8 70% v tng khi tui i cng cao. Trong mt nghin cu (Choo
PW, Galil K, et al. 1997), t l lu hnh ca au dy thn kinh sau zona l 8% sau 30 ngy v l
4,5% sau 60 ngy. Khi so snh vi nhng BN tr hn, nhng ngi la tui 50 c t l lu
ngoi da ca virt Varicella Zoster c bit l t 6 26% nhng BN b suy gim min dch
(Gnann JW, Whitley RJ. 1991). a s BN, bnh lan ta ch gii hn da, tuy nhin t 10
50% BN cng c chng c ca tn thng ni tng (nh vim phi, vim no, hoc vim gan).
Ngay khi dng liu php acyclovir truyn tnh mch, t sut ca BN zona c lan ta ni tng l 5
15%, vi phn ln t vong do vim phi (Gnann JW, Whiltey RJ. 1991).
Hoi t vng mc cp tnh do virt Varicella Zoster thnh thong gp nhng BN c chc nng
min dch y , d rng cc bo co gn y hn u tp trung vo cc bnh mt nhng
BN nhim HIV (Ormerod LD, et al. 1998). Nhng thay i v th gic bt u nhiu tun hoc
nhiu thng sau khi zona khi. Bnh zona trc c th gy tn thng bt k vng
khoanh da no (khng nht thit l dy thn kinh tam thoa), ng nhim trng vng mc c l
mc phi qua ng mu. Soi y mt cho thy nhng tn thng dng ht, hi vng, khng
xut huyt. nhng BN nhim HIV, cc tn thng nhanh chng lan rng v kt tp li, t c
Chin lc x tr v chng c i km
iu tr zona d y nhanh vic lin so, hn ch nng v thi gian ko di au cp tnh v
mn tnh, v gim bin chng. nhng BN b tn hi min dch, thm mt mc tiu iu tr na
Liu php khng virt ng ung khuyn ngh cho zona ngi ln c chc nng min dch
bnh thng vi chc nng thn bnh thng
Acyclovir 800mg mi 4 gi (5 ln mi ngy) trong 7 10 ngy.
Famciclovir 500mg mi 8 gi (3 ln mi ngy) trong 7 ngy.
Trong nhng nghin cu c i chng gi dc, acyclovir (800mg ngy 5 ln) rt ngn thi gian
bi xut virt, lm ngng s hnh thnh tn thng mi nhanh chng hn, y nhanh tc lin
so, v gim nng ca cn au cp (Huff JC, et al. 1998: Morton P, Thomson AN, 1989;
McKendrich MW, 1986; Tyring S, et al. 1995). Mt tng phn tch cho thy acyclovir tt hn c
nhng BN tui trn 50, valacyclovir (1000mg mi 8 gi) v acyclovir cng mang li mt tin
lnh da tng ng nhau (Beutner KR, et al. 1995). Valacyclovir rt ngn mt cch c ngha
thi gian trung bnh khi hn cn au c lin h n zona (38 ngy so vi 51 ngy, P = 0,001).
T l BN cn au vo thi im 6 thng l 25,7% nhm acyclovir l 19,3% nhm
valacyclovir (P = 0,02). Ko di tr liu valacyclovir t 7 ngy ln 14 ngy khng mang li thm
li ch g.
Famciclovir (500mg mi 8 gi), mt tin cht ca penciclovir, c kt qu tt hn so vi gi dc
trong vic lm gim thi gian bi xut virt, hn ch thi gian hnh thnh tn thng mi v y
gian ko di ca au thn kinh sau zona trung bnh l 163 ngy nhm gi dc v 63 ngy
nhm famciclovir (P = 0,004) (Tyring S v CS 1995).
Valacyclovir v famciclovir c em so snh trong iu tr zona nhng BN c chc nng
min dch y v c chng minh tng ng v mt tr liu, xt c v tin lnh da ln
khi au (Tyring SK, et al. 2000). Valacyclovir v famciclovir c a chung hn acyclovir
trong iu tr zona v c bilan dc ng hc tt hn v ch dng thuc n gin hn. C ba
loi thuc u an ton mt cch l thng v c dung np tt. Khng c chng ch nh no
i vi vic s dng cc thuc ny, mc d cn phi iu chnh liu dng nhng BN b suy
thn. Hin cha c thuc no trong s cc thuc trn c c quan Qun l Thc phm v
Dc phm Hoa K chp thun cho s dng ph n c thai. Cc thuc khng virt dng bi
Zona mt
Nhng BN b zona ca nhnh I thn kinh sinh ba in hnh c cc triu chng au na bn mt,
v cc tn thng trn, vng quanh nhn cu v mi. Nu khng tr liu khng virt, khong
chng 50% nhng BN ny s c cc bin chng v mt (nh bnh l gic mc, vim thng
cng mc, vim mng mt hoc vim gic mc nhu m), mt s trong cc bin chng ny c
tim nng gy m (Cobo M, et al. 1987). Liu php khng virt ng ung lm gim cc bin
chng mt mun t khong 50% xung cn t 20 30%. Nhng BN b zona mt nn c mt
Bnh zona nhng BN HIV (+) cng tng t nh bnh zona nhng ngi c chc nng
hiu lc. V nguy c ti pht nhng BN ny, bnh do virt Varicella Zoster nn c iu tr
cho n khi cc tn thng lnh ln hn. Vi trng hp bnh him gp do cc virt Varicella
Corticosteroid
C hai nghin cu lm sng quy m ln, c i chng lng gi vai tr ca corticosteroid trong
kt hp vi acyclovir. Trong c hai nghin cu (Harrison RA, et al. 1999: Wood MJ, et al. 1994),
nhng BN dng corticosteroid c s tng va phi nhng c ngha thng k tin lnh da
v gim nh c cn au cp tnh. Liu php kt hp mang li mt cht lng cuc sng c
ci thin, th hin qua vic gim s dng thuc gim au, thi gian c gic ng khng t
qung di hn v thi gian tr li sinh hot thng l sm hn. Tuy nhin khng c nghin cu
no chng minh c bt k tc dng no ca corticosteroid trn t l mc bnh hoc thi gian
ko di ca au dy thn kinh sau zona. Liu php corticosteroid khng nn s dng nhng
khuyn ngh s dng corticosteroid trong zona m khng c liu php khng virt song hnh.
iu tr triu chng
dng thuc phin) tc dng di, gii phng c kim sot (ung hoc dn ln da) c a
chung hn. Vi m hnh dng gii thch c ch bnh sinh ca au thn kinh hu zona m
ch rng vic sm gim nh cn au cp tnh c th ngn chn s khi ng c ch trung ng
ca au kinh din, bng cch gim nguy c au thn kinh hu zona (Gnann JW, Whitley RJ.
1991).
chn lc
hng ngy l
3600mg (chia lm 3
ln)
nu dung np c nhiu BN
tng dn n ch
phm c nng
cao; c th cn nhiu
ngy n nhiu tun
l t n kt qu
ti a; c th mua
khng cn n thuc
Cc th nghim lm sng chng t rng opioid; cht chng trm cm 3 vng v gabapentin lm
gim c nng hoc thi gian ko di ca au dy thn kinh hu zona, d dng mt mnh
nhng BN b tn hi min dch. Tui cng ln, vng da tn thng c din tch cng rng, v lc
n khm au cng d di, tt c l nhng ch t tin on ca au dai dng (Harrison RA et
al. 1999: Whitley RJ, et al. 1999). Nhng BN p ng nhng tiu ch ny nn c hng thng
vo iu tr. Tt c nhng BN zona mt nn c tr liu khng virt nhm mc ch d phng
bin chng mt. Vi BS vn cn xem liu php khng virt l khng bt buc nhng BN tr
hn b zona khng bin chng, mc d liu php c li ch v nguy c tai bin rt thp.
Liu php khng virt c th thnh cng nhng BN n khm sau 72 gi?
Nhng nghin cu v thuc khng virt u s dng cc thit k tng t nhau. Cc BN c
chn vo nghin cu trong vng 72 gi sau khi pht cc tn thng. Trn thc t, cc BN
thng n khm trn 3 ngy sau khi ni cc tn thng da, nhng t c d liu hng dn tr
liu trong tnh hung ny. Liu php khng virt c khi u cng sm, c may c p ng
lm sng cng cao, nhng mt s BN vn c li ngay c khi iu tr c bt u sau 3 ngy
(Wood MJ, et al. 1998; Decroix J, et al, 2000). S hin din ca cc mn rp ni tng ng vi
vic virt cn ang sao chp v y c th l mt du n nhn bit BN c l vn c li nu
c tr liu khng virt.
khng virt khng ngn nga c chng au hu zona (McKendrick MW, et al. 1989; Jackson
JL, et al. 1997; Alper BS, Lewis PR. 2000). au dy thn kinh sau zona vn c th xy ra trn
nhm ph bnh nhn c iu tr khng virt. Trn gi thuyt, kt hp thuc khng virt vi
gim au, chng trm cm cu trc ba vng hoc thuc chng ng kinh ngay lc khi pht
zona c th lm gim chng au dy thn kinh sau zona (Dworkin RH, Portenoy RK. 1996;
Bowsher D. 1997). Nhng bc tip cn ny cha c chng minh hiu qu nhng cn c
kho st thm.
C th d phng zona?
Vcxin chng OKA ca virt Varicella Zoster hin c Hip hi t vn v Thc hnh tim
chng khuyn ngh cho vo din tim chng ph qut tr em. Loi vcxin ny lm tng p
ng t bo lymph T c c hiu cho virt Varicella Zoster nhng ngi gi huyt thanh
dng tnh. Liu vic tng cng min dch do vcxin em li c lm gim t l mc hoc gim
nng ca zona nhng ngi ln tui hay khng ang c kho st trong mt th nghim
lm sng (Oxman MN. 1995).
Hng dn x tr
Hin khng c mt hng dn x tr chnh thc no c ban hnh bi cc hi chuyn nghip
ti Hoa K.
Kt lun v khuyn ngh
Zona c th xy ra bt k ngi no tng b thy u nhng thng gp hn khi tui i
nh BN c m t trong trng hp minh ha. Bt buc s dng liu php khng virt
nhng BN zona mt, ch yu d phng cc bin chng mt c tim nng gy m. Nhm
BS Bi Khnh Duy
1. i cng :
+ Ngun gc ho hc:
- V c: kim loi, mui kim loi, kim v cc dn xut ca chng nh cc oxyt, axit.
2.1. Lm tng cng hay hn ch, thm ch cn tr s bc hi nc qua da. C loi lm tng
din tch tip xc ca da, gip bc hi nc qua da d dng hn, lm mt da, chng s ngng
2. 3. Tu theo dng thuc v t dc, thuc s ngm vo da nhiu hay t, nng hay su.
Nhng thng c 3 loi tc dng trn cng phi hp vi nhau. V d: loi thuc h ,ng thi
lm tng cng bc hi nc da, lm mt da, lm tn huyt, nhng li khng cho php thuc
ngm su vo da. Ngc li, thuc m lm cn tr bc hi nc da, gy xung huyt, dn
mch.
+ Thuc bi ngoi da cn c tc dng ton thn, gy nn nhng bin i sinh hc nht nh,
do thuc ngm vo dch lm ba, vo mu, tc ng ln u dy thn kinh th cm ngoi vi,
hoc tc ng ln cc trung tm ca thn kinh thc vt.
3.3. Thuc cn ngm qua da theo ng nang lng, tuyn b, ngi ta chng minh rng:
mt cht mui vo c th pht huy tc dng phi thng qua vng da c nhiu mch mu.
Xoa, mit thuc ln da to thun li cho s hp thu thuc, nht l dng thuc m.
3.4. Cc vng da c tn thng hp thu thuc khc vng da lnh, vy tit dy, t chc x so
hay qu sn lp sng hn ch thuc ngm qua da.
3.5. S hp thu thuc qua da cn ph thuc vo c tnh ca cc cht ha hc c s dng,
cc cht d bay hi nh clorofoc, it, thu ngn s c hp th mnh, cc cht ho tan trong
m s ngm vo da chm hn, cc cht mui ho tan trong nc s ngm vo da, i vo h
tun hon.
da, trng thi cc phn ph ca da, kim toan ca da, c tnh ca cc hot cht c s
dng, dng thuc v dung mi c dng, phn ng ca cc thuc trn da v hin tng
phn ly ion ca chng. nh hng v tc dng phi hp cc yu t trn s quyt nh mc hp
4.1. Cu to chung ca mt cng thc thuc bi: thng gm 2 thnh phn chnh:
+ Hot cht: c tc dng iu tr, nh it c tc dng dit nm, axit salicylic lm bong vy...
+ T dc: l phng tin vn chuyn hot cht, a dn hot cht ngm vo da, bn thn
t dc khng c tc dng iu tr, nhng n vn c mt vai tr quan trng, thuc ngm nng
hay su ph thuc vo dng thuc, t dc c dng trong cng thc thuc bi.
+ Bt (poudres .powder).
+ Thuc m (pommades.ointment.).
+ Thuc h (pates).
+ Kem (crme.cream).
+ Thuc du (huiles).
+ Mt s dng khc:
- Vecni (vernis).
- Cn dn (colles).
Hot cht c pha trong t dc (thng l cc dung mi lng) thnh mt cht lng ng u,
T dc thng l nc, cn, cc cht ho tan d bc hi (te, axton, clorofoc, i khi dng
glycerin), cc cht ny ngm mnh.
+ Dung dch trong nc: t dc thng dng l nc ct, nn dng loi nc ct mi ch,c
pH trung tnh, trong nhiu trng hp cn dng dung dch ng trng so vi huyt thanh
ngi bnh, mun vy cho thm vo dung dch mt lng natri clorua hoc mt mui trung tnh
khc, hoc mt cht ng (gluc, saccar).
Vi mt s cht nc, khng to thnh dung dch thc s m to thnh dung dch gi, cn gi
dung dch keo (solutions colloidales) trong c nhng ht v cng b, treo l lng trong dung
dch. Cc cht dng albumin v dn xut cc loi x phng, cc cht mu ho vo nc s cho
- Dung dch jarish gm c: axit boric 20 gam, glyxrin 40 gam, nc ct va 1000 gam.
- Dung dch Milian gm: xanh mtilen, tm gentian, rivanol, (nh nhau) 1 g, cn 70 10 gam,
nc ct va 1000 gam.
- Dung dch Castellani: fuschin, axit boric 0,60 gam, axit phenic, axton, 1,0 gam,
resocxin, cn 70 3,0 gam, nc ct 50 gam.
Nhn chung dung dch c tc dng nng, nht thi thng dng trong giai on cp tnh hoc
bn cp.
mi trng m t dung dch thuc trong vng 24h- 72h. p gc c tc dng lm gim vim n,
chng xung huyt, chng chy nc, st khun, chng nga, sch m, b vy tit.
10 pht, 3-4 ln mi ngy, c tc dng gim vim trong trng hp vim cp tnh, chy nc
nhiu nh chm cp tnh.
- Gc nng: tm gc bng nc nng p ln da, lm gin mao mch, tng cng thc bo, du
vim nhim.
- Dung dch dng bi ln da c tc dng st khun nh dung dch milian, dung dch tm mtin
1%.
- Ngm, tm:
Ngm v tm dung dch thuc tm pha long 1/10.000 iu tr cc bnh da nhim khun.
Tm bng hi lu hunh tn sinh vi t l thch hp iu tr gh.
- Bt tan (talc) tc magi silicat t nhin, hay dng ln vi km oxyt, tc dng ht nc v cch
nhit.
Thng dng thuc bt rc ln trn tn thng ang vim nhiu, cp tnh hoc ang chy
Khng dng dng thuc m trn cc tn thng ang giai on cp tnh hoc chy
Cc t dc thng dng l:
- Vaselin: l cht thng dng nht, chit xut t cn ct du ho, mu trng, trong sut, mm,
chy 35oC, khng c mi v, trung tnh, khng b axit v kim ph hu, khng b nh hng
ca khng kh, m, khng tan trong nc, vaselin khng ht nc,v vy khi pha ch loi
thuc m c hot cht ho tan trong nc, phi trn ln vaselin vi lanoline.
+ V d v thuc m:
- M arievitch:
axit salicylic 6 gam.
+ Thnh phn gm hot cht v m (vaselin v lanolin) nhng c nhiu bt hn, thng t l bt
trong cng thc h l 30%- 50%, cc loi bt thng dng pha ch thuc h l: oxyt km,
amidon, kaolin, canxi ccbonat, magi ccbonat.
+ Tc dng thong da hn thuc m, khng ngm su bng thuc m, lm gim vim, gim
xung huyt, chng ngng t huyt, lm kh da, khng hn ch s bi tit v bc hi da,
+ V d:
- H Brocq:
Km oxyt 30 g.
Lanoline 30 g.
Vaseline 40 g.
Ichtyol 3 gam.
oxyt km 15 gam.
Bt tacl 15 gam.
Vaseline va 100 gam.
C tc dng mt da, bo v da, ngm va phi.Thng dng dng thuc kem cho tn
Km Sunfat 0,03 g.
ng Sunfat 0,0 6 g.
Km oxyt 5 gam.
Lanolin 5 gam.
Nc vi 10 gam.
Vaselin 10 gam.
+ Tc dng nng, du da. Dng trong tn thng cp tnh hoc tn thng nng.
+ V d: du km.
Oxyt km 40 gam.
Du lc 60 gam.
Ngm: thng dng cho cc tn thng u chi, mi ngy ngm 1-2 ln.
- Dung dch thuc st khun dng ngm ra, p gc cc thng tn da trt lot, nhim
Dung dch Rivanol 1o/oo , dung dch (dd) yarish( c Axit boric3g, glycerin 40ml, nc ct 1000ml)
dd becberin ,dd NaCl 9o/oo , dd KMnO41/4000, nc l bng, nc l ch ti.
- Dung dch thuc mu dng bi vo cc tn thng da trt lot , nhim khun: dung dch tm
5.2. Thuc tr gh: du DEP ( diethylphtalat ), kem Eurax, dd pemethrin 1% du Benzyl benzoat
33% dd kem Kwell , m dim sinh 10%( cho tr em) 30% (cho ngi ln).
- Cn BSI 1,2,3%
- Cc dung dch thuc mu( ni trn) bi cc tn thng cht lot, nhim khun 7-10 ngy
u.
- H nc ( thnh phn oxyt km, bt talc, glycerin, nc ct ) mt da, gim vim, st khun
lm kh tn thng , che chn bo v vng tn thng, bi ngy 2 - 3 ln dng cho vim da,
Eczema cp.
- Kem m Corticoid: bit dc kem Eumovat, kem Tempovate, Temproson, m Flucinar, kem
Benovate, m Dermovate, m Diproson, m Celestoderm, Aristocort.bi Eczema, vim da
giai on bn cp v mn tnh
Kem Eclaran, Kem RetinA, m Locacid, kem Erylik, kem Differin, kem Isotrex
5.6. Thuc tr vy nn
- Gudron, Coaltar
-Tazaroten
5.7.Thuc bi tr mn cc
m km oxyde chng hn, bi thuc ng vo vng tn thng ngy 1 ln, trnh dy ra vng
da xung quanh gy trt lot ) .
Cn Chloralhydrat Salicylic 3%
M Leucodinin B 10%
6.1. Thuc bi khng nhng c tc dng ti ch m cn c tc dng ton thn, thuc bi ngm
6.2. S dng thuc bi ngoi da phi ph hp vi tnh cht bnh l, giai on bnh, mc
bnh, vng da, c khi c tui, gii, thi tit, ngh nghip. V d: eczema cp ang trt, chy
dch, m, vy tit cn ch nh dng dung dch p gc, ngm, ra, thuc mu... Eczema
mn dng dng m gim vim, gim cm, bt sng, vng np k nn hn ch bi dng m gy
lp nhp, b da. Mt s thuc khng bi c vng mt, vng sinh dc.
6. 3. Vi cc bnh cn nguyn bnh sinh cn cha r, nu nhn nh chnh xc tn thng, ch
nh thuc bi ph hp c th lm bnh hoc khi.
6.4. Vi cc tn thng ang c nhiu dch m, vy tit nn cho ngm ra, p gc cc dung
dch st khun 1-3-5 ngy cho gim vim, sch m, b vy tit, sau ch nh tip cc thuc
bi ph hp vi giai on sau.
6.5. Khng nn bi mt thuc thi gian qu di, cng khng nn lin tc thay thuc lm kh
nh gi kt qu iu tr, cng nh nhn nh chn on ng sai... Thng mt t bi thuc
khong 10- 15 ngy.
6.7. Theo di k bnh nhn trong thi gian dng thuc c th iu chnh kp thi.
C khong 200 thuc thuc nhm ny, chng c 4-7 lin kt i, mt vng cyclic ni phn t v
c cng mt c ch tc dng. Khng thuc no c kh dng sinh hc ( bioavaiability) ph
hp khi dng thu ung. Thu ho tan km nn rt kh to dng tim tnh mch. Tc dng ca
mng t bo, lm tng tnh thm mng t bo, lm cho cc dng ion dch chuyn
(kali,glucoza i ra, natri i vo ). Mt s thuc thng dng nht ca nhm ny l amphotericin
B, nystatin, natamycin.
2. Amphotericin B (fungizon)
mu, gim kali, magie mu, thiu mu, toan ho ng thn, au u, bun nn, nn, mt mi,
gim cn, i khi thy gim tiu cu, gim bch cu.
Thuc c dng tim truyn: 1 ng 50 mg ( 50. 000 n v), liu thng thng 0, 25 mg / 1 kg
th trng. Ngoi ra c dng vin v dng m.
h thng do thuc khng tan trong nc., khng hp thu vo t chc v rt c khi dng ng
tim.
4. Pimaricin (natamycin):
5. Candicidin.
nystatin dng trong iu tr cc bnh nm gy ra. Thuc c dng vin, kem v arosol.
Griseofulvin c sinh tng hp t penicillium griseofulvun. Thuc c dng vin, kem. Dng
ung hp thu tt sau khi ba n c cht bo.
khc him gp nh bun nn, nn, cm gic kh chu ming, au khp, au dy thn kinh
ngoi vi, ng lm, ln, ngt, nhn m, mt ng. C th c gim bch cu, tng bch cu i kim,
bch cu nhn nht l khi dng ko di, nhng thay i ny s hi phc sau khi ngng
thuc.
7. Flucytosine.
5- fluorocytosine ( flucytosine) l mt dnc ht c fluor ca pyrimidine, tan trong nc.
Thuc c dng vin nang ( capsule) 250 hoc 500 mg, liu khi u bnh nhn c chc nng
thn bnh thng l 150 mg/ kg/ ngy.
Tc dng ph : khi dng n thun, tc dng ph him gp, c th ban d ng, bun nn, i
khi gy vim gan. Khi dng kt hp amphotericin B, t l c tc dng ph ln ti 15-30%,
thng gp gim bch cu, gim tiu cu, gim sn tu, vim i trng, vim gan, ri lon men
gan v phosphataza kim, bnh nhn c th t vong do nhim trng huyt, xut huyt ni tng.
Cc thuc nhm azole bao gm biazole ( c vng 5 cha nit) v triazole ( cha 3 nit). Cc
thuc mi thuc vo nhm th hai, bn vng hn trong c th.
Ph tc dng : ph tc dng ca azole trong in vitro rt rng mc d nng thuc khc nhau
tu theo iu kin th nghim. Thuc c tc dng vi
10. Ketoconazol:
Bit dc nizoral , dng vin 200 mg, kem hoc fungicid vin 200 mg.
Tc dng ph : hay gp nht l kh chu d dy, rut, ban da, vim gan him gp nhng c kh
nng gy t vong, vim gan ca ketoconazole rt ging vim gan do isoniazod ( xut hin ch
yu trong 3 thng u s dng thuc, bun nn, ri lon tiu ho xut hin nhanh, vng da,
hoi t t bo gan thnh mng, khng lin quan n liu dng ), ngoi ra c th gp kh ming,
nga da, au u, chng mt. Thuc c tc dng gy ung th ( teratogenic) nn khng dng
cho ph n c thai v cho con b. Tc dng hormon: thuc c ch tit corticoid
v testosterone, tc dng ny ph thuc liu dng v thi gian, thuc lm gim kh nng tnh
dc, gim hoc mt tinh trng, v to...
Tc dng vi nm da, candida, trichomonas, nm tai do aspergillus, dng dng cream, dung
dch 1%, dng vin 100 mg, bit dc canesten, v calcream. Trong invitro ngi ta thy vi
nng 1 microgam trn 1 ml c ch trn 98% ca 324 loi nm ngoi da, trn 96% ca
1147 loi nm men candida, trn 80% ca 78 loi nm lng dng (dimorphe) v 17/23 loi
Mt s ch phm c dng dng bt, dung dch, dng kem., vin t 200- 500 mg, c bit
dc nh canesten.
11. Econazol [ 1- ( 2,4 dichloro- 3- P- chlorobenzyl) oxy- phenthyl ]- imidazol nitrat.
12. Miconazol :
Thuc c tc dng mnh vi nm da. candida, vi khun gram (+). Thuc c t dng mnh, nng
Cc bit dc: miconazol ointment 2% dakatrin dng bt, dng kem v dng gel.
12. Chlormidazol:
Tc dng ph : kh chu d dy, rut gim kali mu, kh da, mt mi, ban da, nga, chng
mt, lon cm, bt lc i khi xut hin.
Thng s dng dng vin 100 mg ung, c tc dng ton thn. Dng iu tr nm da,
nm men v cc nm h thng khc.
14. Fluconazole:
T dng ph : thuc dung np tt, tc dng ph hay gp nht l bun nn, i khi xut hin ban
d ng, tng bch cu i toan, hi chng Stevens-Johnson, hoi t thng b nhim c (
epidermal necrolysis)...
Thuc c t dng vi nm da, candida v mt s vi khun gram (+). S dng dng kem 5%
bi ngoi da.
14. Virconazol.
lu : khong 30% bnh nhn c ri lon th lc, hin vn cha r c ch v t h khi ngng
thuc, 10% c ri lon cc ch s sinh ho v gan, 5% c ban, ban . Thuc c thi tr ch
yu qua gan nh men CytP450 c th c tng tc vi nhiu thuc khc. Thuc c th dng
im nh: phn b c da, tc, mng, c tc dng dit nm, dng trong nhng trng hp
bnh nm nng thng kt hp vi bnh thiu ht min dch ti ch hoc ton thn, dung
np v an ton ca thuc cao.
1.i cng.
- Trng c l mt bnh vim nang lng tuyn b thng xut hin vng mt, ngc,lng, hay
gp la tui thiu nin, thanh nin.
- Biu hin lm sng c th nh: c mt s nhn trng c, n mc nng trng c cc, vim
ty, nang bc, ngc ngch, to so li, so lm to.
- Bnh nh hng n tm l thm m , bnh nhn lo lng v tn thng thng xut hin
mt.
Tuyn b ch tit ra cht b (Sebrum) vo phn trn nang lng, bi tit ra da c tc dng
lm da mm mi, chng ngm nc v c tc dng phn no chng vi khun, nm.
Do c th a da du tuyn b to ra, tng ch tit cht b, cht b tit ra nhiu m khng thot
- Cc yu t nh hng:
+ Yu t ni tit
+Trng c do dioxin.
3.1.V tr: thng gp vng mt, ngc, lng (nht l vng lin b), phn trn cnh tay.
- Trng c vim ty: bao quanh nhn trng c l khi vim ty 1-3cm ng knh, vim
sng cng, n au, sau ha m.
- Trng c nang bc: c cc nang bc chm di da, c v x bao quanh, trong cha cht b,
m.
4. Th lm sng
4.7. Trng c ngc ngch (Acne conglobata): c cc nang bc, cha cht ly nhy, vim u ht,
cc nang bc, c ng thng d cc nang vi nhau, sau to thnh so dm d.
4.8. Trng c (Acne Rosacea): mi, hai m v sau gin mch, c th km theo sn trng
c, mc nng thnh mi s t (Rhinophyma).
5.Xt nghim
cc nhn trng c (u trng, u en), sn vim c nhn trng c gia, mn m, vim ty,
nang bc.
7.iu tr
7.1.Thuc bi ti ch
- Tretinoin: tretinoin (Retin-A) l mt loi Retinoic acid (bit dc Retin-A, Locacid, Differin)
dng dung dch v dng gel, c tc dng tiu sng, chng li dy sng c nang lng, lm
cht b thot i c, phn no tc dng lm gim nhn trng c chng vim v chng vi
khun. Cch dng nh sau: bi ngy mt ln vo bui ti, bi mt lp mng qua m, khng
nn bi vng da quanh mt, mt s bnh nhn da nhy cm d phn ng c th bi cch nht
hoc cch hai ngy mi bi 1 ln. Tun u bi thuc c th c tc dng ph da hi , rt, rc
vy.t bi thuc thng ko di 4-8 tun c khi 12 tun.Tretinoin thch hp cho tn thng
u trng, u en v c mt s dng tn thng khc.
- Benzoyl Peroxide (Bit dc Oxy 5 - 10, Panoxyl 2,5 - 5 - 10, Eclaran). Nhm thuc bi
sau hng ngy bi thuc sau 1-3 gi lau ra i. Ngi ta cn thy dng nh nhm thuc
ny c tc dng lm gim tuyn b, tiu sng tiu nhn trng c, gim vim. Bi 1 lp mng
vng c trng c vim, mt s bnh nhn bi thuc nhng ngy u da c th v bong vy
nh sau qua i.
loi 10%, bit dc kem Fostex ( thnh phn c lu hunh,Salicylic acid, resorcinol).
- Thuc bi khng sinh ti ch ( m khng sinh) thng dng thuc bi c cha Erythromycin
(Bit dc Eryfluid, Erthrogel) hoc Clindamycin (Bit dc Dalacin T, Cleocin T) v
Benzamycin (c Erythromycin 3% v Benzoyl peroxide 5%).
-Thuc khng sinh: ch yu dng nhm thuc khng sinh c tc dng lm gim s lng vi sinh
vt P.acnes: Tetracyclin 250mg 2-4 ln/ngy hoc Doxycyclin 100mg 2vin/ngy, Minocyclin
-Khi c trng c mn m, vim ty c thm vai tr ca vi khun khc (t cu, lin cu) nn
chuyn dng mt t khng sinh khc nh Ampixilin, Cephalosporin hoc Trimethoprin.
-Tr liu hormon c la chn: ch dng cho bnh nhn n b trng c. Thuc trnh thai (oral
contraceptives) c tc dng c ch s tng tit Androgen ca bung trng. Thng dng loi
cyproteron acetate (Bit dc Dian 35) 1vin/ngy, chng ch nh cho bnh nhn b u v v
vim nim mc c t cung. Trong cc ca dng thuc m trng c li tng ln th ngng thuc.
nang bc, ngc ngch). Thuc c tc dng lm gim ch tit cht b, gim sng ha nang lng
v gim s lng P.acnes. Bnh nhn n nu ch nh dng Isotretinoin phi m bo trc khi
dng thuc l ang khng c thai, trong thi gian dng thuc v sau khi dng thuc 1-3 thng
- Chch nn nhn trng c: dng ci chch nn nhn trng c (extractor Schamberg) chch nn
nhn trng c, lm thot mn m v nang trng c s mau lnh hn. Ch v khun v bi
- Phng php lt bng bng kha vch: dn bng kha vch ln mt vi giy ri bc i, lm
nhiu ln c khi n 30 ln, cho n khi nhn thy lp lp lnh, mc ch l lm bt nt vt tc
- Xoa bp da mt: hng ngy ch nn ra mt 2-3 ln, ra mt bng tay nh nhng trnh lm
- C th ra mt ngy 2 ln bng x phng Acne aid bar c tc dng ty bt cht b nhn da.
.Ht, bo da(Dermabraion)
15. U MM LY
Do Batchman m t t 1817.
Ri rc t hoc nhiu trn mt vng da no , th ng gp nht l vng sinh dc, mt, l ng,
ngc.
iu tr:
(nhng n tht), c qung bao bc xung quanh, c khi xut hin dng nh nh sng
(papillome corn).
1.1. Ung th t bo gai lot xi: l hnh dng lm sng hay gp nht .
bcng chc thm nhim xung di qu c gii hn ca thng tn. Trn b mt vt lot ri
rc c th thy chm trng mu sa, khi n vo n ra nhng khi nh mu trng nh mt
nhn do t bo lot b ung th sng ho, nhn thy r khi chiu nh sng Wood. Mt vi trng
+ U hoc hng, kch thc bng ht u trn, cng gii hn khng r, ging nh dng u ca
ung th t bo y, nhng khc v b c nhng vy tit mu en rt dnh, khi cy ra gy
chy mu.
+ Khi u mu trng hng gm nhng thu nh lin kt vi nhau, thng xut hin trn nhng
1.3. Ung th t bo gai nng: t gp, ging ung th t bo y nng; ch phn bit c bng
m bnh hc.
2.Tin trin .
+ Ung th t bo gai c mt khuynh hng lan rng v xm ln h thng bch huyt, xm ln
vo t chc ln cn, lot ph hu phn mm, sn xng, mch mu ln v cc dy thn kinh ,
nhim khun ph.
+ Di cn hch xut hin sau mt thi gian, thay i tu trng hp lm cho tin lng xu.
4. iu tr ( ung th t bo y v t bo gai).
+ Ung th t bo gai c th dng phng x, quang tuyn liu php ( tia X, tia radium ) ch nh
trong thng tn rng m phu thut khng ct ht c.
5000 r.
+ Dng cht ng v phng x coban: dng kim c cht ng v phng x cm vo t chc ung
th.
+ Vi u va phi dng bi cc dung dch: podophyllin 25- 30% hoc colchicine 1%, bi nhiu
ln ( hay dng cho ngi cao tui).
17. UNG TH T BO Y
1. i cng.
ch khc
Tn thng thn mnh, bng, c dng mt mng n c hoc c khi nhiu mng. Mng
+ Th xi c n .
Th ny khu tr nhiu nht mt, c mt hoc nhiu u ni cao, mu vng sp, b mt bng
phng , bng m, i khi c nhng gin mch nh, thng ri rc c vt sc t nh, mt
chc nh sn. i khi c ch mm n lm do trong u c nhng kn v trong kn c cha cht
dch mu vng nht hoc i khi c dch mu.
mt, nht l m v thi dng, khi u l mt mng cng v sau tn thng l mng mu
sp vng hoc mu trng ng vng, khng c gii hn r, lin tc vi da lnh, i khi b mt c
vi gin mch v ri rc c mt vi vy da t dnh.
3. Tin trin .
Hai c tnh c in l tin trin chm v khng c di cn.Tuy nhin cng c thng tn tin
trin nhanh thnh lan rng, lot, tr thnh ph hu t chc mnh. Tn thng lan su xung
gy chy mu nhiu do ph hu cc mch mu ln di da, ph hu v chn p cc si dy
thn kinh, xuyn vo sn v xng di, km theo bin chng nhim khun c hi.
4. Chn on.
- Da vo lm sng.
18. VY NN
I. i cng
Vy nn l mt bnh da mn tnh do vim v cha th cha khi hon ton. Bnh rt thng
gp, chim 2-3% dn s th gii. Hin nay, c rt nhiu phng php iu tr nhng bnh
thng khng tr hoc d ti pht sau khi ngng s dng thuc. Cc thuc iu tr vy nn h
nhn ca vy nn hin nay c chng minh c lin quan n p ng min dch qua trung
khi pht sm thng gp tui 16-22. Loi ny c din tin bt n v khuynh hng lan
rng ton thn. Loi ny c lin quan mnh n tnh di truyn. Tri li, vy nn khi pht mun
thng gp tui 57-60. Loi ny thng nh v khu tr. Loi ny thng t c lin quan
cht tin vim, cn cc cytokine Th2 l nhng cht chng vim. Trong vy nn, loi Th1 chim
u th cn Th2 t hn.
IV. Mc tiu iu tr hin nay
Mc tiu iu tr hin nay
Mc tiu iu tr bnh vy nn hin nay ch yu da vo nhng im chnh sau:
- Ngn cn s xm nhp ca cc t bo T hot ha t t bo ni m vo thng b v b;
- Ngn cn qu trnh sn xut cytokine Th1;
- Trc tip khng li cc p ng ca cytokine Th1;
Vy nn hin nay vn cha th cha khi hon ton m ch lm gim, sch thng tn v ko
di thi gian ti pht. C nhiu phng php iu tr v da vo tui, phi, dng lm sng, v tr
sang thng cng nh s lan ta ca bnh.
Thuc u im Tc dng ph
v da non kch ng da
u im Tc dng ph
VII. iu tr h thng c in
Bng 3: Thuc iu tr h thng c in
Thuc u im Tc dng ph
phi, c ch ty xng.
C ch tc ng Thuc
OKTcdr (anti-CD4)
CTLA4-Ig
Denileukin diftitox
(DAB389-IL2)
IL-10
IL-4
IL-11
Alefaceft:
Alefaceft l mt protein ti kt hp, bao gm on tn cng IFA-3 (khng nguyn lin quan
chc nng bch cu) v on Fc ca IgGI ca ngi. Thuc ny c C Quan Thuc v Thc
phm Hoa K (FDA) cng nhn trong iu tr vy nn mng trung bnh v nng vo thng
1/2003.
Alefaceft ngn chn s tng tc gia LFA-3 (khng nguyn lin quan chc nng bch cu)
nm trn t bo nhn din khng nguyn v CD2 nm trn t bo T bng cch c ch cnh
tranh. iu ny gip ngn cn s dn truyn cc tn hiu ng kch thch gia t bo nhn din
khng nguyn v t bo T.Alefaceft cn c tc dng c ch min dch. Alefaceft c ch s tng
sinh hot ha ca t bo T nh bng cch c ch s tng tc gia LFA-3 v CD2, ng thi
gy st gim lng t bo T qua mi lin kt gia t bo T v t bo killer t nhin.
Alefaceft c hiu qu trong iu tr vy nn trung bnh n nng (> 10% din tch b mt c
th). Liu trung bnh l 15 mg/tun (tim bp) trong 12 tun. C th iu tr t 2 nhng thi
250 t bo/mL, thuc phi c ngng cho n khi CD4>250 t bo/mL. Nu CD4 < 250 t
bo/mL lin tc trong 4 tun, alefaceft phi c ngng lu di.
Khng c tc dng ph nghim trng cng nh nhim trng c hi hay nhim c c quan c
bo co trong cc nghin cu.
Efalizumab
Efalizumab l mt khng th n clon IgG1 c nhn ha trc tip chng li bn n v CD11a
trong LFA-1. Efalizumab c iu ch t t bo bung trng chut ng Trung Quc v c
nhn ha nhm lm gim tnh sinh min dch. Thuc ny c FDA cng nhn trong iu tr vy
nn vo thng 10/2003.
LFA-1 nm trn t bo T v c chc nng nh mt phn t kt dnh. LFA-1 gm c hai bn n
thin p ng ca bnh. Tnh trng ti pht thng xut hin khong 2 thng sau khi ngng
iu tr v c khong 5% bnh nhn c hin tng rebound.
Thuc thng c dung np tt, tc dng ph thng gp nht l hi chng ging cm, nhc
thnh nin (4-17 tui), liu Etanerceft l 8,8 mg/kg/tun (ti a 50 mg/kg/tun). Thuc c s
dng qua tim di da nn bnh nhn c th t tim. Liu dng c th 1 ln/tun hoc 2
ln/tun. V tr thng nht trong tim di da gm bng, i v cnh tay. gim thiu phn
ng v tr tim thuc, bnh nhn nn tim mi v tr cch nhau 1 inch v cch bn.
Tc dng ph thng gp nht gm phn ng ni tim tm thi v nh, nhim trng h hp
Cc thuc khng TNF-a c th gy nh hng n thn kinh v lm nng thm hoc gy khi
pht suy tim sung huyt. V vy, khi cc du hiu v triu chng mi ca thn kinh cng nh
suy tim sung huyt xut hin, bnh nhn phi ngng ngay cc thuc khng TNF-a.
Infliximab
Infliximab l mt khng th n nhn chut-ngi gn kt v c ch hot ng ca TNF-a.
Thuc ny c cng nhn trong iu tr vim khp dng thp v bnh Crohn. Ging nh cc
thuc khng TNF-a khc. Infliximab cng c hiu qu trong iu tr vy nn v vim khp vy
nn. Liu thng s dng t 5-10 mg/kg/tun (tim tnh mch). Cc tc dng ph khng mong
mun gm nhim trng, nhc u, chng mt, bng, nh hng tiu ha, chc nng gan bt
Adalimunab
Adalimunab l mt khng th n clon IgG1 ngi trc tip khng li TNF-1 ngn chn s
tng tc ca cc th th b mt t bo P55 v P75. Adalimunab cn gy ly gii t bo vi s
hin din ca b th. Thuc ny c FDA cng nhn trong iu tr vim khp dng thp vo
thng 12/2002.
Liu ca Adalimunab trong iu tr vim khp dng thp ngi ln l 40 mg, tim di da,
khp dng thp. Hin nay, hiu qu ca thuc ny trong iu tr vy nn v vim khp vy nn
cc bnh da do vim.
Cc dn xut ascomycin i din cho mt nhm macrolactam khng vim mi. Pimecrolimus
ph v dng dn truyn tnh hiu ca ni bo ca th th t bo T bng cch c ch s hot
ha v s tng sinh t bo T.
Pimecrolimus vi dng kem 1% c hiu qu v dung np tt trong iu tr chm th tng tr
con v ngi ln. Dng thuc bi v ung ca pimecrolimus ang c nghin cu nhiu trong
iu tr vy nn v bc u c hiu qu tt.
Rosiglitazone
Rosiglitazone maleate l mt thiazolidinedione ung c Hoa K cng nhn trong iu tr i
tho ng loi 2 v hin ang c nghin cu trong iu tr vy nn. Thuc ny l mt ng
vn mnh v chn lc ca PPAR-g (th th hot ha yu t tng sinh peroxisome). Cht ny c
tc dng c ch sn xut cytokine v thc y s bit ha t bo.
Tazarotene
Tazarotene l mt retinoid, gn y c cng nhn trong iu tr vy nn mng vi dng ung.
Tazarotene chuyn ha thnh cht hot ng, acid tazarotenic v c thi gian bn hy t 7 12
IX. Kt lun
Vy nn l mt bnh do phn ng min dch gy vim. Cc thuc c ch min dch hin nay c
hiu qu trong vic kim sot vy nn n mt mc nht nh nhng cng cn nhiu bt li
19. VY NN (PSORIASIS)
1. i cng.
nm trn nhim sc th s 6 c lin quan HLA- DR7, B13, B17, B37, BW 57, CW6...
vy nn.
nam v n xp x nh nhau.
+ V tin trin, bnh tin trin mn tnh, hu nh sut i nhng lnh tnh, tr mt vi th nng,
c th sinh bin chng nh vy nn th khp, vy nn da ton thn, cc t vng bnh xen
k cc t bnh thuyn gim. Cht lng cuc sng b gim st, bnh nh hng nhiu n
tm l, sinh hot, thm m.
+ iu tr bnh vy nn cn nan gii, c rt nhiu loi thuc, nhiu phng php c p dng,
song cha c loi no cha bnh khi hn c, mi dng li mc lm bnh , tm khi v
lm sng, hn ch ti pht, mt s loi thuc nhiu tc dng ph c hi, t tin... nn
cn gii thch r cho bnh nhn v bnh tt c s hp tc tt, v sau khi iu tr bnh
, tm khi v lm sng, cn cho bnh nhn phc iu tr duy tr v phng trnh ti pht.
2.1. Gen gy nn bnh vy nn nm trn nhim sc th s 6 c lin quan HLA, DR7, B13, B17,
BW57, CW6.
2.2. Yu t di truyn chim 12,7% (theo Huriez) v 29,8% (theo Bolgert) di truyn tri xuyn
60%.
2.3. Cng thng thn kinh (stress) lin quan n pht bnh v vng bnh, bnh nhn b vy
nn thuc tp thn kinh d b kch thch, hay lo lng...
2.4. Yu t nhim khun: vai tr cc nhim khun khu tr lin quan ti qu trnh pht sinh v
pht trin bnh vy nn (vim mi hng, vim amidal,...), m ch yu l vai tr ca lin cu. Vai
tr ca vi rut, vi rut ARN c men sao m ngc to phc hp min dch bt thng cn cha
c thng nht.
2.7. Ri lon ni tit: bnh thng nh khi c mang nhng sau bnh li ti pht hoc nng
hn.
2.8. Ri lon chuyn ho trn da: ch s s dng oxy ca da vy nn tng cao r rt, c khi hn
Hot ng gin phn v tng hp ADN ca lp y tng ln 8 ln, tng sinh t bo thng b,
nht l lp y v lp gai dn n ri lon qu trnh to sng (qu sng v sng). Bnh
thng chu chuyn t bo thng b (epidermal turnover time) l 20- 27 ngy nhng da vy
nn chu chuyn ny rt ngn ch cn 2- 4 ngy.
trong s tng trng biu b, dn truyn cc tn hiu gin phn trong vy nn, EGF, TGF lin
quan n s tng trng v bit ho cc t bo sng (keratinocyte), c vai tr ca IL1, IL6, IL8,
nhm trung gian ho hc eisaconoides, prostaglandin, plasminogen, vai tr cc lymph T hot
ho, tng lymphokines, tng sinh biu b hot ho qu trnh vy nn.
Tng nng IgA, IgG, IgE trong mu bnh nhn vy nn, tin trin, xut hin phc hp min
dch, gim b th C 3.
3. Lm sng:
3.1. V tr tn thng:
Tn thng phn ln xut hin u tin vng da u (51% theo Huriez) v vng b t ( hai
ci tay, u gi, da xng cng), khu tr mt vng hoc ri rc nhiu ni, c khi khp ton
thn, thng c tnh cht i xng, tn thng mt dui nhiu hn mt gp.
3.2. Tn thng c bn :
Tn thng c bn ca vy nn l - vy.
+ m mng kch thc to nh khc nhau vi milimet- mt vi cetimet, c khi hng chc
centimet (cc mng ln c th mt vi v tr), gii hn r, hi g cao, nn cng cm, thm
nhim (inflammation, indurated) nhiu hoc t, c khi vy trng chon gn ht nn ch cn
li vin xung quanh rng hn lp vy. S lng cc m: mt vi m ti vi chc, hng
trm m tn thng tu tng trng
S c ch bnh sinh bnh vy nn.
trng. Vy nhiu tng nhiu lp, d bong, khi co vn ra nh bt trng, nh phn, nh vt nn,
ri l t . Vy ti to rt nhanh, bong lp ny th lp khc li n ln. S lng vy nhiu.
+ Hin tng Ko'bner (Ko'bner's phenomenon) c th gi l hin tng "chn thng gi tn
thng", hay gp trong vy nn ang vng, l trong nhiu trng hp tn thng vy
nn mc ngay trn vt so, vt xc da, vt m, vt tim chng...
vy theo phng php Brocq (Grattage de Brocq), dng dao m hay curt co nh nhiu ln, t
- Du hiu v hnh (pellicule dcollab) tip tc co s n mt lp mng mng, dai, trong sut
bc c nh v hnh.
+ Triu chng c nng : nga t hoc nhiu, thng nga nhiu giai on ang tin trin, triu
chng nga 20- 40% s ca, mt s khng nga m c cm gic vng vu, nh hng thm
m.
+ Tin trin: bnh mn tnh hu nh sut i, cc t vng bnh xen k cc t bnh thuyn
gim, bnh lnh tnh, bnh nhn sng kho mnh sut i, tr mt s th nng nh vy nn th
4. Cc th lm sng.
4.1. Vy nn th chm git (psoriasis punctata, psoriasis guttata).
ti vim amidal do lin cu, vim tai gia, chu tc dng tt vi tr liu khng sinh, c th t
L mt th nng, t gp (1% theo Goerkerman). Da ton thn ti, bng, ph n, nhim cm,
Triu chng ton thn: st cao, rt run, ri lon tiu ho, suy kit dn dn c th t vong do mt
4.7. Vy nn o ngc:
L vy nn xut hin vng np k nh nch, np di v, rn, np k mng, bn. Tn
thng l cc mng gii hn r lan rng hn ra ngoi v tr k. Tn thng c th cht ra, c
vt nt, vy m tch t li d nhm vi bnh do candida v hm k do lin cu.
4.8. Vy nn tr em: thng tui ang ln, xut hin sau mt vim ng h hp trn, sau
tim chng... bnh pht t ngt tn thng thnh chm, git , vy mng ri rc khp ngi,
5. M bnh hc.
+ V tr.
+ Tn thng c bn: m , nn cng cm, ph vy trng nhiu lp.
+ Du hiu Ko'bner.
+ M bnh hc da.
+ vy nn.
7. iu tr.
khi hn c.
M salicylic 2%, 3%, 5% c tc dng lam bong vaayr, chng li hin tng sng, lm gim
triu chng bong vy nhng khng c tc dng trn triu chng vim thm nhim nn cng
cm ca vy nn.
M Sabouraud 1 cng thc ni ting cha vy nn, thnh phn gm goudron, du cad, dim
sinh, Resorcin...a. salicylic.
Trong 2 tun u hng ngy bi Anthralin, nng 0,1% - 0,3% sau 10-20 pht tm ra
thuc i.
Ch trnh hin tng kch thch da, khng tm nc nng sau khi bi thuc trong vng 1 gi,
u im ca thuc m corticoid l bnh nhanh, tng i sch, bnh nhn a thch. Nhc
- Bi 1 t 20- 30 ngy , sau ngh thuc 1 thi gian sau nu cn mi dng tip t khc.
di 100 g/ tun, tng ng bi 16% din tch b mt da c th, thng sau 1-2 tun,
nhiu sau 4-8 tun iu tr. Khng bi thuc vo vng mt, bi xong phi ra tay, c th gy
tng can xi huyt hoc li dt thm ko di, thuc ny kh t tin.Hin nay cn c loi m
daivobet (calcipotriol kt hp betamethason)
PUVA tr liu : PUVA tr liu l phng php ni ting trn th gii iu trvynn c ca ngi
ph bin nhiu nc l phng php quang ho tr liu.
- Hiu qu min dch gim s lng v gim hot ho lympho T ( TCD3,TCD4, TCD8), c ch
- Lm sch tn thng nhanh chng, c hiu lc trong giai on vng v ti pht bnh.
Tc dng ph : mt s bun nn, da, nga, ni phng nc, trn thc nghim sc vt c 1
s c nhn mt, gada...
, vic pht hin ra nhm Retinoid ( Vitamin A acid) c coi l mt " cuc cch mng" ging
nh l vic pht minh ra thuc cortocoid.
thng ho qu trnh bit ho t bo sng.iu bin min dch v chng thm nhim vim biu
Ch nh.
Vy nn khp.
Vy nn da ton thn.
Vy nn mn m.
Liu dng : tun u nn dng ngy 10 mg, sau tng dn liu dng 20-25 mg/ ngy, khi c
vim mi l c th t c liu ti a.
Dng thuc 1 vi thng n 6-12 thng hoc gim liu dng liu duy tr trnh ti pht.
Tc dng ph :
dng cho ph n tui sinh ( m bo trc khi dng thuc, trong khi dng thuc v sau khi
ngng thuc 2-3 thng khng c thai). Retinoid khng gy t bin tinh trng nam .
7.2.3.Methotrexate.
Methotrexate ( MTX) l thuc c ch min dch,l mt cht i khng axit folic, c tc dng c
ch tng sinh tng hp axit nucleic, c tc dng c ch tng sinh t bo thng b trong bnh
vy nn, chng vim gim ho ng ng ca bch cu a nhn, gim sn xut IL8 trong bnh
vy nn. Thuc ny l loi thuc c ch c tc dng ph c hi nht l vi gan, mau nn ch
yu ch dng chi vy nn th mng lan to v mt vi th nng nh vy nn khp, vy nn
da ton thn, vy nn din rng> 50% din tch c th v ch yu nn dng cho ngi kho
mnh 50 tui tr ln, khng nn ch nh dng cho ngi tr nht l ph n tui sinh hoc
vy nn thng thng mc nh v va.
Theo Fitzpatrick 1997 thi gian dng MTX theo ch 3 phn ( Triple dose regimen).
- Tun 1 ung liu test : 2 vin MTX x 2,5 mg , cch nhau 12 gi , 7 gi sng ung 1 vin , 7 gi
ti ung 1 vin, th cng thc mu.
Theo di bnh gim th no nu cn tun sau cho ung 2-1-1 ( sng th hai : 1 vin, ti th
hai : 1 vin, sng th ba : 1 vin, sng th t : 1 vin, cc ngy khc khng ung thuc), v nu
chuyn bin chm tun sau cho ung 2/2/2: th 2, th ba, th t mi ngy 2 vin MTX, sng 1
vin 2,5 mg , ti 1 vin 2,5 mg vi liu ny cc nghin cu cho thy 80% s bnh nhn
nhiu trc v sau iu tr, trong qu trnh iu tr thuc MTX 1 thng 1 ln cn nh k kim tra
cng thc mu, chc nng gan, thn (SGOT, SGPT, urea, creatinine...) v MTX l loi
thuc c hi , c th gy h bch cu, tiu cu, tch lu gan gy thoi ho hoc x gan, yu
lc, dng trong ghp tng phng v iu tr s thi ghp v bnh mnh ghp, v cng l
thuc iu tr bnh vy nn.
Cyclosporin A l c tc dng c ch min dch, gim hot tnh ca lympho T c thng b v
chn b vng da vy nn, c tc dng gin tip ln gin mch v qu sn thng b cng nh
hot tnh ca t bo vim.
Ch nh:
- Vy nn mn m.
- Vy nn khp.
Chng ch nh.
Liu dng : 2,5 mg/kg/ ngy n 5,0 mg/ kg/ ngy ung chia lm 2 ln ( thng dng nht l liu
Nu sau 4 tun c chuyn bin lm sng th duy tr liu thm 6 tun cho n liu cng c
thp nht c hiu qu. Nu sau 6 tun vi liu 5 mg/kg m khng c kt qu th ngng thuc,
Sau khi Sau khi c chuyn bin lm sng chp nhn c dng liu duy tr di ngy ( c th
dng liu trnh lin tc trong 2 nm).
Nhc im :
- t tin.
- Cao huyt p gp 10,6% s bnh nhn.
- Ri lon chc nng thn, tng creatinin huyt thanh, trong tr liu di ngy mt s bnh nhn
-ACTH
- Gim mn cm, chng d ng khng c hiu: Can xi clorua, khng histamin tng hp.
- Cc thuc y hc dn tc iu tr bnhvy nn
Vy nn l bnh da mn tnh hay ti pht nhng lnh tnh, ch yu iu tr ngoi tr, bnh nhn
cn c hng dn ngy cng t ph thuc vo thy thuc, gii thch cho bnh nhn mt
cch ph hp bnh nhn trnh cc yu t bt li c th gy ti pht, vng bnh nh cng
thng thn kinh, vi chn thng... bit cch t theo di v iu tr theo s kim tra hng dn
+ Thuyt phc bnh nhn"chung sng ho bnh" vi bnh, khng ha hn l s cha khi hon
ton bnh ny cng khng khng nh bnh khng th cha khi c trnh tm l bi quan,
nn duy tr trng thi hi vng.
+ 7.5 iu tr vy nn mn m:
CHN
2. Cn nguyn.
a s tn thng nhanh chng thnh i xng hai bn, thng b lng bn tay, bn chn k
tip nhau hoc c khi ch c bn tay hoc bn chn.
+ Tn thng c bn tin pht l cc mn m kch thc t 2-4 mm, mc thnh tng t trong
vng vi gi trn nn da bn tay bn chn bnh thng, sau quanh tn thng c qung ,
nn vim sm mu, mn m thnh m, mu trng vng, chm su khm vo thng b,
phng hoc hi phng ln.
Thng khng nga hoc khng au, nhng cng c khi c cm gic nga,au trc khi ni
mn m.
4. Xt nghim:
- M bnh hc: biu b c cc khoang cht y bch cu a nhn v c hin tng xp bo,
ph v thot bo lc u l bch cu a nhn v sau rt nhiu bch cu a nhn hnh thnh
mn nc, mn m biu b , lp sng.
Chn b thm nhim vim quanh mch mu dy c bch cu n nhn v bch cu a nhn.
5. Chn on.
- T a nhim khun.
6. iu tr :
Methotrexat 15 - 25 mg mi tun ( sng ung 1 vin 2,5 mg, ti ung 1 vin 2,5 mg 3-4 ngy
1.i cng
thnh h m, st mt mi, suy yu, kh chu, tng bch cu mu ngoi vi. l nhng c
im ni bt ca bnh.
- C th t nhin pht bnh hoc trc bnh nhn b bnh vy nn, vy nn th khp.
- Bnh khi pht t ngt, bt u d i nhanh st cao 40oC, trong vng 1 ngy da tr
nn rc nh bng la, ban rt mnh, lan ta thnh m rng c khi da ton thn
(erythrodermie) nhng mt v lng bn tay chn thng khng b, da rc, cng hi n, vng
np gp, sinh dc li c nhiu tn thng.
- Triu chng ton thn: thng st cao, nhc u, rt run, mt nhiu, kh chu, th trng suy
- Cc mng ngn tay chn dy hoc tiu mng, c cc h m di mngdn n bong mng,
v sau c rng tc.
- Tn thng nim mc t gp: vim li trt gai, vim mng tip hp, vim quy u.
3.Xt nghim
- Cy mu thng m tnh
- D ng thuc bi nhim c mn m.
- Hi chng Reiter.
5. Tin trin
6. iu tr
PUVA (quang ha tr liu) ung thuc cm ng nh sng Prosalen v chiu tia cc tm song
UVA. PUVA khng dng trong giai on cp cu nhim c ban u m dng khi bnh
hn.
1. nh ngha:
2- Bnh sinh:
L bnh hay gp trn th gii. N chim 1-2 bnh nhn da liu vng n i ( ni ma ng
ko di) cha thy s khc bit ln v t l gi cc nhm ng i v qua cc nm nh ng hay
gp ph n ( 58- 60 % bnh nhn). Tui ca bnh nhn trung bnh l 35 v c bit c
qun o hoc qua cn trng c tr trong qun o cng cha c chng minh.
C nhiu tc gi hy vng rng bnh do mt loi siu vi khun nh ng khng c chng minh
4.M bnh hc :
Bin i gii phu bnh khng c hiu, ph v thm nhim nh trung b, c hin tng xp
bo ( Spongiosis ) lp th ng b, c th c sng. Nu c mn
n c th d i lp sng.
5. Lm sng:
mt mi. Tn th ng tin pht th ng hay pha trn thn ng i: , cnh, cng tay, c. C
th mt, u hay thn d ng vt. Tn th ng l cc m trn hay lp c gii hn r,
mu nht trn ph vy. m tn th ng c ng knh 2- 5 cm hoc c khi rng hn. Tn
Chn on :
Khi khng in hnh, bin dng ( ban my ay, xut huyt , li chen...) th
mai (+).
- Vy nn th chm git i khi cng d nhm vi vy phn hng dng liken (lichnoi'd )C hai
6. iu tr :
Lm sng:
L mt th liken ho khu tr r nht v hay gp nht, thng hay ni c hai bn c,
gy, i, vng sinh dc, hu mn (bu, m h, nim mc hu mn, np k mng).
Nga l du hiu u tin, do thng gi l " nga li ken ho" khu tr mt vng da,
c sn yu t ch st( c o, tht lng) m t lp nhp (kh h ) bnh nhn ri lon thn kinh,
hi nhn , hi cm, vng gia c sn nh san st bn nhau, mu sm, mt bng dng li ken,
i khi c vy da, c vt gi x c, vng trung tm rng hn c, mu sm dy cm, hn da ni
r thnh vt cho nhau, gia cc hn da c sn dt, bng.
khun ph. nim mc m h c th c b trng dng bch sn. bn, nch c th th li ken
ho ph i, thnh m xi cm , thnh khi u rt nga .
m vim b thn kinh c th n c hoc i xng, hoc ri rc nhiu ni, tin trin
hng thng hng nm, hay ti pht, ngy cng cm cng sm mu hoc bc mu dng bch
bin. Do nga gi nhiu thnh nhim khun ph, ni inh nht p xe cnh tn th ng. Bnh
2. Cn nguyn :
Nguyn sinh bnh ca vim b thn kinh cng ging nh ca eczema th ng rt phc
tp nhng ni bt l:
- Yu t cng thng thn kinh, suy nhc thn kinh (lm nn cho bnh, c khi l hu qu
ca bnh).
3. iu tr :
histamin, thuc gii cm, ch n , ngh ngi, trnh bi quan lo lng u c tc dng.
- Tr ng hp dai dng : radio tr liu (lc 1-2 ly Al, cch 5 ngy / 1 ln , mi ln 300 -
400 r).
- Vim b thn kinh : xanh metylen 1 % + Novocain tim trong da quanh vim b thn
kinh , lm gim vim , gim nga.
20 ln.
24. MN TRNG C
A. I CNG
Mn trng c l bnh thng gp, thng tn vi nhiu mc khc nhau hn 90% thanh
Din tin khi t nhin trong a s trng hp, nam ko di trc khong 20 tui, n khong 22
25 tui.
Ba bc cn phi lm khi iu tr:
+ nh gi nng ca mn.
+ La chn thuc sao cho thch hp vi tnh trng bnh ca bnh nhn v tnh trng da ca
bnh nhn.
+ Gio dc bnh nhn: bnh nhn cn phi c tham vn v tc dng ph ca thuc, thi gian
iu tr bnh lu, gim bt lo lng, v c bit cn phi tun th iu tr.
Da vo:
S lng sang thng.
c im ca sang thng:
+ Khng vim: c u en hay u trng
+ C vim: sn, mn m
+ Cc (nt), nang.
nng Tn thng
05 nt (cc) hoc
tng s lng tn thng vim >
Mn nng
50hoc
tng s lng sang thng > 125
cc yu t ha hng ng bch cu. Lipase thy phn triglycerides thnh axit bo t do. y
l cht kch thch khi u v l cht sinh comedon. Nhng yu t ha hng ng bch cu a
nhn ti thnh nang lng. Cc bch cu a nhn phng thch hydrolase lm yu thnh nang
lng gy vim v v phng thch thnh phn comedon vo lp b. Phn ng vim d di hnh
thnh mn trng c m v nang. Cc vi khun khc cng gy vim bng cch kch thch cc c
ch min dch.
D. IU TR
1. Cc thuc iu tr:
BNG 2: THUC IU TR THEO C CH BNH SINH
Thoa ti ch
Tretinoin
C Khng bit
Adapalene Khng Khng
C Khng bit
Tazarotne Khng bit C th
C Khng bit
Benzoyl Khng Khng
C (gin C
peroxide Khng C th
tip) C
Erythromycine Khng C th
Khng
Sulfacetamide Khng C Khng
Khng
sulfur Khng C th
C C
Acide azelaic
Ton th
C (gin Khng Khng Khng
Thuc nga
tip) Khng C C th
thai Khng Khng C C
Erythromycine Khng C C (gin C
Tetracycline C tip)
Isotretinoin
Ti ch
Retinoids
a. Tretinoin
+ Tc dng th pht: kh da, kch thch da, hng ban trc vy, tng mn trng c tm thi (2
3 tun u iu tr).
+ Gn y c dng Tretinoin vi tinh th hoc polymer c tc dng tt nh tretinoin nhng tc
dng ph t hn do thuc xuyn qua lp thng b v ngm thng vo nang lng.
b. Adapalene
C hai dng ch phm c s dng trong iu tr mn l dng gel v cream, tuy nhin
Nhm Retinods c tc dng tiu comedons, ngn s hnh thnh comedons, chng vim
nhng do tc dng ph ca nhm thuc ny rt nhiu nn hn ch dng trn lm sng, thng
ch dng cho nhng trng hp comedons n thun; trng hp c vim th thng s dng
khng sinh trc sau mi dng. Tc dng ph thng gp nht ca nhm thuc ny l: kh
da, da, kch ng da, hng ban trc vy, nhy cm nh sng Tc dng ph thng gp
trong thng u iu tr nhng cng c th gp trong sut qu trnh iu tr nht l nhng bnh
nhn s dng thuc khng u.
Benzoyl peroxide
L mt cht c kh nng dit khun vi ph tc dng rng. Thuc dng cream, gel v cht
lm sch c nng t 2.5-10%. Thuc lm gim ng k P. acnes v acide bo t do tuyn
Khng sinh
Hai khng sinh dng ti ch l clindamycine v erythromycine dung dch tan trong cn
(hydroalcoholic solutions) c s dng rng ri trong hai thp k qua. Mt ch phm mi
hn di dng gels v lotions c khuynh hng lm gim kch thch da. Nhng thuc ny c
tc dng gim s to khm ca vi trng P. acnes cng nh c hiu qu chng vim trc tip
thng qua c ch s ha ng ng ca neutrophil. Trong mt th nghim lm sng m i
Acide azelaic:
Thng dng di dng cream 20% c tc dng trn sng phu ng, ngn chn comedons, c
tc dng kim khun, ngoi ra khng thy tnh trng vi trng khng. Tc dng ph l nga
v cm gic bng ti ch.
Ton thn
iu tr bng hormone
iu tr mn trng c bng thuc nga thai ung em li nhng thnh cng trong nhng
thp nin gn y, phng thc iu tr ny l mt khm ph mi cho bnh nhn n. Ln u
tin vo nm 1997 FDA chp thun dng mt loi thuc nga thai kt hp, ba pha, bng
ng ung trong vic iu tr mn trng c, thuc ny gm norgestimate 0.215 mg v ethinyl
placebo.
Nhn chung mi loi khng sinh bng ng ung u c tc dng ph, nhng cc tc dng
ph thng c ch nht l: nhy cm nh sng khi dng nhm tetracycline (c bit l
doxycycline), chng mt khi dng minocycline, ri lon tiu ha khi dng nhm erythromycine,
d ng thuc khi dng trimethoprim-sulfamethoxazone. Ngoi ra, tt c cc khng sinh ng
ung u thc y tnh trng nhim candida c bit l candida m o.
Mn trng c khng khng sinh:
Ti chu u, trong nghin cu t 6 nc: Anh, Ty ban nha, , Hy lp, Thy in
v Hungary nm 2002 v vn khng thuc 622 bnh nhn nhn thy 515/622 trng
hp c khng thuc. T l khng t nht 1 loi khng sinh l Hungary (51%) v cao nht ti
Isotretinoin:
trnh tiu sng. Hiu qu lm sng ca isotretinoin trong iu tr acne th rt ngon mc, thng
lm gim hn 90% sang thng trong vng 3 thng iu tr; kt qu iu tr ca n ko di nu
dng 1 t iu tr trong 20 tun s t c s ci thin ca mn trong vng 3 nm hoc hn
Tc dng ph thng gp l da, mi, mi, mt kh, chm do retinoids cng hay gp nht l
mt gp bn tay v cng tay. Ch nn kim tra chc nng gan, thn, bilan lipid trc v sau
khi iu tr. Bt li chnh ca thuc l gy qui thai, v th ch c c con sau khi ngng thuc
1 thng.
sinh.
Mn nng hoc khng iu tr s x dng isotretinoin. Isotretinoin cng c x dng trong
mn trung bnh khng khng sinh hoc c nhiu so hoc bnh nhn c tnh trng tm l
BNG 3: IU TR DA VO DNG MN
Ti ch
Tretinoin X X
Adapalene X X
Tazarotne X X
Khng sinh X X
Acide azelaic X X
H thng
X X
Thuc nga thai X X
Erythromycine X X
Tetracycline X X
Doxycycline X X
Minocycline X
Isotretinoin
3. Phc iu tr:
Nu bnh nhn l n:
Vic s dng thuc nga thai bng ng ung nh l mt iu tr thay th cho bt k iu tr
no c m t trn nu bnh nhn mong mun trnh thai. [Lu : ch c mt bng chng
da trn s m t mt s bnh nhn cho rng hiu qu tc dng ca thuc nga thai bng
ng ung b gim khi kt hp vi khng sinh bng ng ung trong vic qu trnh iu tr
bnh da.]
Gi v sinh da tt.
F. KT LUN
iu tr mn l mt ngh thut, cn phi phi hp gia thy thuc v bnh nhn. Vic chn la
v s dng thuc phi ty thuc vo tnh trng da ca bnh nhn, nng ca mn cng nh
vic chp nhn v tc dng ph ca thuc , tnh trng kinh t v tm l ca bnh nhn.
Bc s Hong Vn Minh
Nhn k thy c gii hn r hi g cao trn mt da, cao hi bong t vy cm ( khi i nng ng
- TC c nng: Nga rm ran sau khi i nng hay ngi ch nng ra m hi.
- Phong v nh dt trng, mt cm gic ,teo c u chi, thn kinh tr, hng kheo ngoi c khi
sng to.
- Vy phn hng Gibert : 1/2 ngi pha trn, m hng to nh khc nhau, m m 2-4
cch mng, cc m con 5mm-1cm mu hng, vng ngh gii hn r, b c dim vy, gia xu
Dt mu trng hng, nhn 1-5-7 cm ng knh, mt hoc vi m mt, thn mnh hoc tay
chn, xung quanh ra m hi thm ( tng nhim sc).
3. iu tr
26. NM MNG
A. Bnh nm mng
1. nh ngha:
L bnh mn tnh v thng gy bin dng mng.
S nhim nm mng thng khng theo qui lut ng dng hay i xng v thng
c thy b nhim mt hoc hai mng.
Nguyn nhn gy bnh:
- Nm dermatophyte.
- Nm Candida.
- Nm mc (Seopulariopsis, Hendersonula...)
2.4. Lon dng ton mng (TDO: Total dystrophic onychomycosis), l dng sau cng ca lon
dng mng khi ton b mng b tiu hy do hu qu ca ba dng nhim trn.
2. Cc yu t nh hng n kt qu iu tr:
2.1. Biu hin lm sng ca tn thng:
Bnh nm mng c th c cc biu hin rt khc nhau. Dng nhim lc u thng nh, nh
thng pht trin chm hn cc mng tay. Mng tay ci v chn ci pht trin chm hn mng
c im Phn loi
1 2 3
(f)
2mm)
Tui (a) 15 25 25 60 60 80
vy i hi tr li ko di hn.
1 - 3: iu tr ti ch: loi b phn mng nhim bnh (ct hoc co). Dng thuc bi
ti ch cho n khi mng khe mc tr li.
3 - 6: iu tr ti ch vi t l thnh cng thp, cn ty thuc vo tc pht trin
ca mng. Nn iu tr ng ung vi nhng mng mc chm hoc dng nhim nm phn
gn ca mng.
6 - 9: iu tr bng ng ung. Dng phc iu tr cho nm mng tay. (Vd:
itraconazole 2 t: 200mg x 2ln/ngy, trong 1 tun/thng).
tng ng.
20 30: Xem xt rt mng (vd: p bt urea), tip tc iu tr vi thuc ung.
6. ng dng:
6.1. Chn on lm sng:
- D dng chn hng iu tr thch hp.
- D on hiu qu iu tr.
6.2. Trong nghin cu:
- a ra nhng tiu chun chn bnh.
S lng bnh 52 46
bnh/nng)
rng tn thng < 2/3 > 2/3 < 2/3 > 2/3
(tng ng vi chiu di
ca mng, tnh t b t
do)
25 27 19 27
(% dermatophytes)
Hiu qu lm sng (thng 82,6% 78,3%
18)
C. Kt lun:
cn tiu chun hn trong iu tr nm mng v chun ha vic chn bnh trong cc cng trnh
nghin cu.
D. Ti liu tham kho
1. Fungal Nail infection. D. T. Roberts, E.G.V. Evans, B. R. Allen, 1990.
2. Color atlas and Synopsis of Clinical Dermatology. Thomas B. Fitzpatrick, M. D., Richard Allen
Johnson, M.D., Klaus Wolff, M.D., Dick Suurmond, M.D.
3. Traditional management of Onychomychosis. Journal of the American Academy of
Dermatology, September 1996.
4. New classification of onychomycoses-With SCIO, type and length of therapy become more
calculable. DerDeutsche Dermatologe.
27. NM TC
1. Chn on nm tc.
- Nga
- Rng tc da u: tc rng tha u ton u, tha nhiu nht vng trn nh thi dng. C
th a da du bng mt, nhn, l chn lng dn rng.
nh tc.
- Rng tc giang mai: Rng nham nh nh " dn nhm" vng hai bn thi dng, c tin s
quan h tnh dc nghi vn, c o ban, sn giang mai, xt nghim giang mai (+). Tc tha u
3. iu tr:
Bnh nm da ly truyn theo kiu exogen(yu t ngoi lai) do cc nguyn nhn sau:
nh thc vt...
Thng thng nht l ly truyn gia ngi v ngi do tip xc vi nha bo, si nm t tn
thng ca ngi b bnh nm, do ngi bnh gi si nm, nha bo vng vi ra qun o,
chn chiu (nm chung, tm git chung dng chung qun o lt, ging tt, lc, m...).
Yu t ni ti .
Cng trong hon cnh iu kin sinh hot v sinh nh nhau ti sao c ngi b mc bnh nm
da c ngi khng b mc ? Phi chng l yu t c a ca tng c th v lin quan n yu t
sinh l da, v kh nng p ng min dch c th vi nm da l qua trung gian t bo, v vy
tng c th c khc nhau nn c nh hng n pht sinh pht trin ca bnh nm da.
Ngi ta thy nhng ngi b nhim nm da c kh nng khng kim v kh nng trung ho
kim thp hn so vi nhng ngi bnh thng v ngc li KNKK v KNTHK nhng ngi
khng mc bnh nm da, th cao hn so vi nhng ngi b bnh nm da., ngha l cht
lng lp sng ca da km th d mc bnh nm da. Ngi ta nghin cu v tha nhn do
Bnh nm da ly truyn theo hng trc tip v gin tip. Trong hng trc tip l ch yu.
V vy phng nm da lan truyn xm nhp vo da ca c th th khu v sinh c nhn
rt quan trng.
+ Phi tm ra sch s bng nc sch, nhit nc tu theo tng ma, tm dng x phng
phi thch hp, trnh x phng c nhiu cht kim qu lm kh da, gim sc chng ca da
+ Sau khi tip xc vi mi trng bn nhim khun, nhim nm hay du m th phi ra chn,
tay, k c sch s, ch cc k np da.
+ i vi ngi lm cng tc ch bin thc phm hoa qu, bia th cn phng nhim nm men
gy vim mng, vim da, nn phi c gng tay, chn i ng. Sau gi lm vic phi ra sch tay
chn v lau kh, ch u mng, np, k tay, k ngn chn, tt phi thay hng ngy.
+ Ngn nga nhim nm da ly lan, khi c ngi b nm da th nn cch ly, luc qun o, phi
nng, qun o sau khi git cn ln tri trong khi phi nng.
+ Khng dng chung qun o, ging chiu, chn p, m, lc, khn qung, giy tt.
+ Khi xy xt phi ra sch bng thuc st khun, trnh iu kin thun li cho nhim
khun, nhim nm xy ra.
+ Khng c co da v bi cc thuc linh tinh nh pin n, kin khoang, khi b nga vim da
cn i khm chuyn khoa v iu tr theo ng phc , thi gian, ng thuc v liu lng
dng.
+ Trnh nm da u v tc: c nhn phi lun lun gi sch da u, tc trnh bi, trnh m
t, cn i m nn, thch hp, trnh qu cht v qu b phi gi u sch hng tun, trng
nc l da, l bi.
+ Mi trng: ni phi thong mt, nh ca phi cao ro, sch s, trnh bi bm, nc tm
dng phi sch (nc ma, nc my, nc ging) phi c x, chu, phi c dy phi ngoi
chi chn, thm tri trong nh phng nm k. Ngi ta cn dng bt mikofen cha 1%
NaPCP vi bt tale, rc vo tt phng nm (gn y c s dng rng ri Hungari).
+ Dng x phng nizoral phng nm, x phng sastid phng cha nm lang ben, ang c
ng dng.
+ Nhng dung dch ho cht khc c tc dng chng nm:
Nipagin.
Formalin 1-2%
+ Vit Nam b mn- khoa Da liu- H.V.Q.Y u tin nghin cu ng dng phng php
trn ca Hungari tm NaPCP v ZnSO4 vo qun lt phng chng nm tht lng, mng,
bn cho b i thu c kt qu tt, gim c 3 ln mc nm da mi so vi l i chng
Nhng 2 qun lt ( git sch) vo dung dch NaPCP 1%, vt ro ri nhng vo dung dch
ZnSO4 1%, phn ng gia 2 cht s to ra Zn (PCP)2 (km pantachlorphenolat) bm vo vi v
Sau phi kh qun mc thay i trong 2 tun. Mi qun ngy git mt ln bng nc
thng (khng git bng x phng). Sau 2 tun li nhng li qun vo dung dch ho cht trn.
Ch loi tr khng s dng cho cc trng hp ang nhim trng cp tnh hoc vim, lot
mc u tin.
1.1. nh ngha :Pemphigiod bng nc (BP) l bnh da bng nc lnh tnh, xut hin da v
nim mc, cn nguyn cha r, c ri lon t min c t khng th IgG quanh lamina lucida
v mng y ca biu b, tin trin mn tnh.
1.2. L bnh t gp, thng xut hin ngi trn 60 tui tuy nhin c gp mt vi ca tr em.
Cn nguyn cha r.
Cha r yu t kt hp HLA.
Khng nguyn BP nm trn b mt t bo tri di trn phiu sng (lamina lucida) ca mng t
- Mt s thuc c th gy nn Pemphigiod.
th.
nn da vim hay trn nn da bnh thng. V l loi bng nc, phng nc di biu b nn
thng nguyn vn khng b v, thng cng, cng chc. Bng nc cha y dch, c khi l
bng xut huyt, khi v thnh vng trt ph vy tit, m trt ny khng c xu hng lan rng
ra xung quanh nh bnh Pemohigus v nhn chung khi lnh khng li so.
Du hiu mit da Nikilsky (-). Bng nc hnh trn, hnh oval, xp xp hnh cung, hnh vng
hoc hnh vn vo, ri rc ring r tng ci, khu tr mt vng hoc trn lan, kh v, t gy au.
Triu chng ton thn ch c khi bnh nng, tn thng da lan rng.
4. Cc th lm sng.
4.1. Pemphigiod si : c nhng mng si, mng m bn nch ging Pemphigus si.
5. Xt nghim.
5.1. M bnh hc :
Phng nc di biu b, c thm nhim vim chn b gm cc bch cu i toan, bch
cu n nhn v a nhn, cc lymphocytes. Bch cu a nhn xp tng hng mt ng tip
gip biu b, chn b.
- Min dch hunh quang trc tip gn 90% bnh nhn c lng ng IgG , gn 100% s ca c
- Min dch hunh quang gin tip 70% s bnh nhn BP giai on hot tnh c khng th
chng mng y lu hnh.
Pemphigus.
7. Tin trin .
Tin trin thay i ty trng hp: khu tr hoc lan ta, thi k thuyn gim tip theo l ti pht.
8. iu tr.
- Corticoid bt u vi liu 40- 100 mg/ ngy dng 2-3 tun thy 70 - 80% p ng tt sau gim
liu dn v dng liu duy tr.
30. PEMPHIGUS
1. i cng:
nh ngha : Pemphigus l bnh da phng nng, c th gy cht ngi, tin trin cp hay mn
tnh , l bnh t min, bng nc lp biu b da v nim mc gy nn hin tng ly gai (
acantholyse).
2. Cn nguyn.
+ Lm sng : bnh hay sy ra mt cch t ngt mt ngi kho mnh hay ngi c th
tng suy sp.
v phng nc tnh cht l nho ( khng cng), d v, v nc, phng nc mc trn da lnh,
v sau cht rng d chy mu, vy tit.
C trng hp bng nc xut hin to ngay.
Duhring) c th nho nhn nheo. Trong cha cht nc mu vng chanh, c khi tr ln c v
c th thnh m thc s.
Bng nc xp xp lung tung trn da nhiu nht cc chi, qua nhiu t tin trin bng nc
lan dn ln v lan ra c ngi, bng nc cn c th xm nhp vo quanh mng gy hin
tng vim quanh mng rt kh chn on.
vt lot nhiu khi trn mt vng c tnh a dng bng nc, vt trt lot, vy tit vt lot.
Nhng thc hct l nhng giai on tin trin trn ca bnh mi bng nc ch tn ti 8- 15
ngy . Sau v ra thnh vt trt hay thnh vy tit. Nhng vt trt ca bng nc ln cn tn ti
hng thng khi khi khng li so. Tr pemphigus hoi t khi khi mi li so.
Du hiu Nikolsky (+) : ngn tay lt mnh trn da thy da trt theo tay do t cc cu ni
gia cc t bo gai. Du hiu ny c gi tr ln nhng ch dng tnh trong cc t cp c khi
cn gp n trong Duhring.
Tnh cht c nng khc Dhring : Dhring c tin triu nga rt, nhng khi pht bng
Tn thng nim mc trong bnh Pemphigus c th gp thng xuyn, nim mach ming b
tn thng trc tin.
C khi b tn thng trc tin mi, mt trong m thy nhng vt trt khng u n, c khi
thy rt to mu ti c th trn c mng trng nh mng gi li khi c vt trt xung
quanh chn rng nim mc vm ming ri rc c cc vt trt ng ring r hay ng tp
trung.
Cc nim mc khc nh hu, hng, mi, sinh dc, mng tip hp cng c th b tn thng.
Triu chng ton thn : ton trng bnh nhn b nh hng rt sm c th lc u cha st
ngay, v sau st dai dng c khi st cao thnh tng t nht l khi c nhim trng.
Ri lon tiu ho: xut hin thi k cui ca bnh , bing n, nn ma, a chy, cn thy c
ri lon v tm thn. Ph, c th tn thng thn.
Chc nng tuyn thng thn : 17 setosteroid nc tiu gim, c tn thng thng thn
pht hin khi m t thi.
Tin trin thng xu: t vong t 6 thng n 2 nm, tin trin tng t, tnh trng c kh hn
mt cht nhng n khng tr li bnh thng.
Bnh nhn cht do suy mn dn v cc bin chng phi hp nh vim phi, vim cung phi,
ur huyt tng.
nhanh hn sinh thit.Co nn phng nc pht ln phin knh soi knh hin vi thy t bo gai
t cu ni lin gai gi l chn on t bo hc Tzanck (+) tnh.
Tn thng nhiu ph tng gan, thn, lch, tim, hch tu xng, phi v cc tuyn ni tit
+ Cn sinh bnh hc : bnh hay gp ngi gi yu trn 40 tui xy ra t ngt ngi kho
mnh khng ly lan, khng c tnh cht gia nh.
- Min dch hunh quang gin tip pht hin IgG trong huyt thanh bnh nhn 75-90% nht l
trong giai on hot tnh ca bnh.
V nguyn nhn hng tm do vi trng cha kt lun : mt s thuyt hng v siu vi trng ly
nc tim vo phi g cho p mt s phi g cht mt s d dng nhng cha c cng nhn
r rng.
- Duhring c tin triu bo trc : rt, au. a dng rt , sn ph, bng nc cng, bnh
vng ln sau khi bi hoc ung Ioduakali.
thng gt chn, quanh mm, khoeo. Bng nc tng i su,nn khi trt gy ra lot khi
li so teo da. Tin trin lu di n gi khng khi.
Nhn gia vng xm mu xung quanh mu ti gi l hnh huy hiu to nhiu vng hnh
ng tm.
+ iu tr :
Tin lng rt xu trc kia 100% t vong, t khi c corticoid tin lng c tt hn, gim t l
t vong cn 40%.
Thuc c kt qu hn c l corticoid .
Corticoid liu u 300 - 500 mg/ ngy, sau gim liu rt t t xung v gim dn xung n
lc no khng c tn thng mi th gi l liu duy tr. Duy tr cho n khi no ht tn thng
trn da v nim mc.
Hin nay cn dng methotrexat c nhiu tin trin tt, mt tun ung mt ln 15- 20 mg cho 15
ngy, phng h BC, HC. Tn thng ca gan thn, c th gy qui thai ( cm cha sau 1
nm ung).
rn.
Bng nc nhanh chng v ra c khi bnh nhn khng v pht trin thnh t chc si. trn
c vy v chy nc. Tn thng ny c khi mi hi rt kh chu, thng cc tn thng hay
lin kt vi nhau lm thnh mng ln c khi n chim ht c mng lng, bng, c khi c xung
quanh cc mng... Mc d tn thng si nhng xung quanh vn cn hnh nh ca bong nc
vng ra xem nhn hoa ca nm chen cht nhau hoc mt mng da si cao 1 cm rng 10 cm,
mi hi thi, c th suy on trc l bng nc.
Sau mt thi gian tin trin hoc do iu tr, nhng mng si ny kh i v rn li ri n thp
dn xung mt hn li mt mng da thm mu.
Tnh cht c nng c nga, rt nhng tht thng tr tn thng nim mc ming rt au.
+ Tin trin bnh: bnh tin trin vi thng n nm tth t vong v suy mn, v bin chng
thn, tiu ho, h hp.
+ iu tr :
Dng coticoide, dng cc loi khng sinh hay dng aureomycin 1 g/ ngy ko di hng nm,
Ti ch chng nhim trng ra dung dch mui, thuc tm v bi cc dung dch mu, t cc si
bng nitrat bc 10% hoc no , t in, Laser CO2 .
dn dn ging ngi da bong vy ton thn. Nim mc t tn thng nhng hay gy rng
tc, mng. Tin trin lu di 2-3 nm hoc lu hn na, c trng hp bnh gim i nhng tm
thi. Ton trng bnh nhn gi c lu di hn. V sau bnh nhn bt u yu dn, ri suy
mn do cc bnh phi hp nh vim phi, HC gim dn dn, BC i toan tng t.
+ M bnh hc: bng nc hnh thnh ging nh cc loi Pemphigus khc nhng khu tr th
gn nh bnh thng. Trong vng b tn thng th hin tng ly gai r rt v t bo gai ni lnh
bnh trong huyt tng ri n trng ln , n tch ri ci n khi ci kia. n giai on da
th khng thy bng nc hc thy rt t nhng vn thy c hin tng ly gai. Trong trung b
+ Chn on khc :
vy kia.
+ iu tr :
- Ti ch : thuc st trng.
trung b c nhiu t bo thm nhim v hnh nh n ging vim da m thng thng hoc
ging vim u chi lin tc ca Hallopeau.
Bt u ngi ln, u tin l bng nc hoc cc mng bong vy ging trong vim da
Bng nc : tnh cht bng nc nh vin, khng u n , d v ra thnh vt trt. C khi nhiu
bng nc kt hp li bng mt bng nc ln v cng trt bng mt mng trt.
C trng hp vy kh mng bong d dng. Nu tn thng trn ngi i khi ging sng
dng vy nn.
Du hiu Nikolssky (+) giai on sm, sau c th khng thy cnh cc bng nc kh.
Mng bong vy: hay phi hp vi cc bng nc v tn thng rt ging chm kh. Khu tr
Tin trin : lu di, dai dng hn v lnh tnh, c mt s trng hp c th chuyn sang
Pemphigus thng thng hay Pemphigus vy l.
31. RNG TC
( Alopecia).
1.i cng:
S pht trin ca tc trn da u xy ra theo mt chu k hot ng khng lin tc. Pha u tin
l pha pht trin (pha mc tc, pha hot ng active phase) gi l anagen c hot ng gin
phn mnh. Tip theo mt pha gi l catagen trong s gin phn t ngt ngng li. Ri
tip n l pha ngh (pha ngng li) gi l telogen. Pha telogen lng my, lng mi, lng nch,
lng mu ko di hn da u v vng ru cm. Thi gian ca cc pha ny dng nh ph
- Do tt nh tc (trichotillomania)
- Nhim khun:
+ Nm : nm kerion.
+ Vi rt : zona.
+ Protozoa: leishmania (n bo).
- U sc t.
thnh so.
Cn gi l bnh pelade.
3.1.2. Cn nguyn: thng gp ngi ln, tr tui ( trc tui trung nin), t l nam / n l
2/1.
Cn nguyn cha r, c vai tr ca yu t di truyn, min dch, ni tit, lin quan ti stress,
nhim khun . Hin nay ngi ta cho rng c mt qu trnh t min chng hnh lng. C th
kt hp vi vitiligo, suy cn gip, addison, vim tuyn gip hashimoto, nhc c nng, hi
chng Down, thiu mu c tnh.
3.1.2. Triu chng lm sng: rng tc thnh tng m, tng vng, khu tr thnh m hnh trn,
bu dc, mt hoc nhiu m, thng mt vi m kch thc vi cm ng knh, khng c du
hiu vim no, khng triu chng, da trn nhn ging nh so, c th thy mt s si tc thanh
(exclamation point hairs). Triu chng c nng : khng au, khng nga.
- Rng tc ton b (alopecia universalis).Rng tc vng u, rng c lng my, nch, mi, lng
Biu hin mng: lon dng, a mng c hng trm h lm nh nh" khu""ng t".
pht.
Nu bnh xut hin sau tui thiu nin th 80% s mc tc li v t gp rng lng tc ton b
(alopecia universalis).
Nu c bin i mng v rng tc ton phn (alopecia totalis) th tin lng khng tt hoc cc
m lin kt thnh tng di vng nh, tin lng cng khng tt.
3.1.3. M bnh hc da: nang tc gim kch thc, thm nhim lympho quanh mch,thm nhim
3.1.4. iu tr: khng c thuc c tr, kh nh gi tin lng v nhiu khi ngu nhin tc mc
li.
- Tm l liu php, tr gip tm l ca thy thuc l cn thit, cn gii gii thch l loi rng tc
ny hu ht s mc li.
- Vitamin B, C, A. Bepanthen.
- An thn.
- Bi m corticoid v ban m
- Corticosteroid tim trong tn thng.Triamcinolon actonide 3,5 mg/ml, thng mt ln.
- Corticoids ung thng lm mc tc.Cn ch tc dng ph v khi ngng mt thi gian bnh
c th ti pht.
- Tr liu min dch ti ch dng DNCB, nhng gy vim da tip xc d ng ti ch, sng hch
ln cn.
C th bi minoxidil.
3.2.1. nh ngha: AGA cn gi l chng hi tin trin ,xut hin do t bm sinh di truyn v
tc ng ca androgen ln nang tc u.
truyn n b.
3.2.2. Cn nguyn : nam b nhiu hn n.Nam 20- 40 tui.N xut hin mun hn, 40% tui
60-70.
Phn ln bnh nhn (c nam v n) c ni tit bnh thng nhng ti ch c tng biu hin
3.2.3. Triu chng lm sng: tc rng tha mng i mt cch t t n ng, thng rng tc
to thnh mt ng pha trc hnh ch M, vng trn thi dng ri rng vng nh hu
qu l li mt vnh tc hai bn v vng chm ca u (hnh v). Vng ny khng bao gi
rng tc trong bnh ny.Bnh ny c nghch l l n ng b AGA lan to li mc nhiu lng gii
tnh th pht nch, mu, ngc, ru cm. Theo phn loi ca Hamilton type I, rng tc dc g
trn, type II rng vng trn v khi u vng nh chm. Type III, IV, V c hai vng lin hp ni
trc ra sau.
3.2.4. Xt nghim: tc (trichogram) thy tng t l phn trm tc telogen (bnh thng 80-
90% cc si tc anagen, telogen 10-15%).
M bnh hc:nhiu nang tc pha telogen, nang tc gim kch thc gn nh teo hon
ton.Tc chuyn thnh lng t, si tc ngn gim ng knh.
2.3.6. iu tr: khng c phng php iu tr c hiu lc cao ngn s tin trin ca AGA.
Tc gi ( Wig).
Cy ghp tc (hair transplantation). Chuyn cc ming ghp m nang lng t vng g vin
Tng t l phn trm pha telogen (tc u ty) tc b chuyn nhanh t pha anagen
3.3.2. Cn nguyn:
- Sau t m c st cao
- Mt s thuc khc.
+ Lm sng : cc nguyn nhn thng i trc rng tc telogen 6- 16 tun. Biu hin lm sng
ltng rng tc, tc mng tha i, bnh nhn lo lng, s hi h s b hi.Thy thuc thng
c chng kin cc ti plastic cha tc rng ca h. Rng tc lan to vng u, vut tc thy
mt vi si hay nhiu si b rng (tc giai on telogen hoc tc u ty, hnh di cui (club
hairs)) rng lan to c mt bn v sau u, cc tc mi mc li ngn, mnh hn tc c v
ui thon nhn hn.
3.3.4. Xt nghim :
3.3.5. Tin trin: v sau tc mc li. Tuy nhin nu rng nghim trng v ti pht sau nhiu ln
c thai k tip nhau (cha nhiu ln) c th tc mc li khng hon ton. Sau nguyn nhn
tc ng tc c th rng ko di trong vng 1 nm.
+ iu tr: khng cn iu tr g c bit, vitamin B liu cao, calcium, v sau tc s mc li , gii
thch cho bnh nhn l cn ch i.
3.4.1. nh ngha : rng tc anagen l kiu rng tc lan to, khi u nhanh v kh r rt, n
gy nn km hm s mc tc hoc lm h hi cc si tc anagen chuyn nhanh
Thuc c im rng tc
Warfarin
Colchicine
Cc thuc chng U
Cyclophosphamide nt
Cytarabine nt
Dacarbazine nt
Dactinomycine nt
Daunorubicin nt
Etoposide nt
Fluorouracil nt
Hydroxyurea nt
Ifosfamide nt
Mechlorethamine nt
Melphalen nt
Methotrexate nt
Mitomycin nt
Mytoxantrone nt
Nitrosourea nt
Procarbazine nt
Thiotepa nt
Vinblastine nt
Vinoristine nt
Ngun gc nm ca g
Bromocriptin
C l rng tc telogen
Thuc chn H 2
Khi u 1 tun n 11 thng, c l rng
Cimetidine
tc telogen .
Clofibrate
trn.
Isotretinoin
hin so. C th pht hin cc du hiu lm sng c trng ca bnh chnh vng rng tc.,
- Thiu ht pht trin v ri lon di truyn : ichthyosis, lin kt X n, nevi biu b, ly thng b
bng nc, epidermolysis bullosa ( GAREB). Nm u ( tinea capitis), nm kerion hoc favus.
- U tn sn ( neoplasms):
- Tc nhn vt l, ho hc.
3.6.2. Cn nguyn : dch t hc: monilethrix l mt bnh him gp, c hai gii b bnh t l nh
nhau, thng xut hin tui nin thiu, c c im di truyn tri kiu mendel, xuyn
khng hon ton. mt s ngi b th nh tc hu nh bnh thng phi khm k mi pht
hin c.
+ Cn nguyn: cha r, bin i c tnh chu k trong qu trnh chuyn ho bt thng bi tit
cc amino acids pht hin thy argininosuccinic acid trong nc tiu mt s trng hp.
3.6.3. Lm sng: bnh thng xut hin ln u tui u th, biu hin bng ri lon s pht
trin ca tc, tr em b hi hoc tc tha v d gy n ni da u ph ton tc ngn. Thng
gp sn dy sng nang lng thng gp lm da u th rp x x, c biu hin kh da, c
bit r vng chm.
Vng trn, nh, vng chm l v tr hay gp,him khi quan st thy bnh monilethrix vng mu,
cng chn, lng my v lng mi.
3.6.4. Xt nghim :
M bnh hc : nang lng pht hin thy s mng i c tnh chu k ca thn tc, xen k s dy
ln cu bao r bn trong i nghch vi s co nh li. Nang tc thng dn n nhng c v nh
l cch bin i ny l hu qu ca s bt thng ca tc hn l nguyn nhn.
o khong cch gia cc nt cc thy tng i hng nh. Kch thc c xc nh l 312-
625 m.
3.6.5. Chn on v chn on phn bit: phn bit vi lon dng di truyn v mc phi lm
gy tc, xt nghim: di knh hin vi quang hc thn tc phn bit vi bnh tc gy dn c
ht (trichorrhexis nodosa), bnh tc xon vn ( pilitorti) v tt nh tc.
3.6.6. iu tr: thuyn gim nht thi sau khi dng bc x ion ho vng u nhng khng nn
dng nhiu, corticoid ti ch khng tc dng.
Giang mai II thng hay gy rng tc, rng tc kiu rng tha, thng rng vng thi dng
v vng gy, rng nham nh khng u, c v nh" gin nhm" , iu tr giang mai tc
s mc tr li.
Chn on ch yu hi tin s quan h tnh dc nghi vn, khm pht hin cc du hiu khc
ca bnh giang mai nh o ban, sn giang mai II, mng nim mc, hch v xt nghim huyt
thanh chn on giang mai dng tnh. iu tr bnh giang mai tc s mc li.
iu tr tm l liu php thuyt phc bnh nhn b thi quen nh tc, nu cn cho thuc an
thn, v thuc khng histamin tnge hp nu c nga da u, thuc bi m corticoid c khng
3.9. Rng tc do nm :
Bnh thng gp la tui tr em, hc sinh, lynhim trong gia nh, vn tr, nh trng, loi
ly t sc vt sang ngi do b, m sc vt.
bm cht nh i "bt tt" nh tc b " nhng chn vo bt" cht b trng thc cht l cc bo
t nm bm quanh chn tc.
Mt loi nm tc na l do chng Favus ly truyn t ngi sang ngi qua lc, m, qung
o hoc qua tip xc trc tip, thng b t lc cn b hoc tui thanh thiu nin. Tn thng
ch yu gp da u, c cc m trn vy sau mng ng vy g cao mu sm, vng
nht, vng ti vin nham nh, c cc " nghin Favus" , c khi n hng chc ci ng ring
Bnh trng tc ( tc bt- Trichosporosis nodosa- Piedra) c 2loi piedra trng ( do trichosporum
beigelie) v Piedra den ( do peidra Hortai Fonreca) Vit Nam a s l Piedre en. Biu hin l
c nhng ht nh hnh thoi, bu dc hoc trn, mu en, cng, x x bm chc vo thn tc t
1-2 cm cch da u tr ln. C si tc c n hng chc ht, mu tc khng b nh hng, tc
khng b gy.
Chn on bnh nm tc nn cn c vo :
- Hi k thin s bnh s.
Chn on phn bit vi sng lin cu, vim da da du, vy nn. vng da u.
iu tr :
Ti ch: Bi cn BSI 1%, dung dch castellani hoc m clotrimazol 1%, kem nizorral, kem
lamisil.
Ton thn : cho ung khng sinh chng nm griseofuvil hoc ketoconazol (nizoral vin ),
itraconazole, terbinafine, vitamin nhm B, nng c th.
Phng bnh : khm pht hin bnh nm tc gia nh v trng hc c nhng ca bnh nh v
ngi mang khng triu chng iu tr kp thi trnh lylan
1. V tr
Thng vng h:
2. Tn thng c bn:
Sn cht: Sau vi ngy do nga gi, cc sn cht ra( sn cht)mu , trn c vy tit mu
nu, c khi nhim khun c m, ( sn cht nhim khun) , nga Sn cc: a phn sn cht
khi, mt s lu ngy thnh sn cc vi mm, 1-2 cm ng knh, cm cng mu thm en, rt
4. Dch t.
- Gh nhim khun: k ngn tay, ngn c tay, sinh dc ngoi tn thng l mn nc, ng
5. iu tr v phng bnh.
Ti ch:
- Sn cht nhim khun bi thuc mu (dd xanh metilen 1%, dd tm metin 1%) khi kh bi m
- Sn cc: dai dng kh iu tr cht acid trichloracetic 33% hoc t in. laser co 2, m
saliccylic 5-10% m corticoid.
Ton thn:
- Chng nga, khng histamin tng hp chlophenirramin 4mg 2-4 vin/ ngy 0,501 ng v
- Phng bnh vng c cn trng hoc hnh qun cua vng c cn trung mc qun o di che
kn, giy tt xoa u Dep chng cn trng t.
- Vitamin C, A, B1, B6, B12.
- An thn.
- Corticoids khng dng v lm bnh ti pht, vng bnh nng hn, ch dng cho vy nn th
do ton thn v vy nn mn m.
33. T A
1.Chn on:
- V tr: 2 lng bn tay, lng bn chn (u ngn, mt di, mt di ngn, ria ngn, vm lng
bn tay, m ci, m t, vm lng bn chn0.
- Tn thng c bn: Mn nc su, chm di da, nh khm vo da, kch thc 1-2 mm,
khng t v.
- Nga nhiu:
2. Th lm sng
+ Gh:
Tn thng l mn nc ng hang.
Nh khu bt c ci gh.
Nga nhiu v m.
4. iu tr
- Ti ch:
Ton thn:
- Vitamin c 0,50 2 vin/ ngy hoc ascorvit 500mg 2ng/ ngy tim tnh mch chm.
Hn ch x phng.
- T a l bnh d ng, c th a d ng, tc nhn kch thch l vi khun ( t cu, lin cu) : ho
cht; mt s trng hp l nm.
34. TN THNG C BN
1. nh ngha:
+ Tn thng c bn l tn thng n gin nht, phn nh nhng bin i bnh l c bn
nht ca da. Ngi ta thng quen phn bit tn thng c bn nguyn pht thng tng ng
vi qu trnh thng tn u tin v tn thng c bn th pht din t tin trin ca qu trnh
+ Mun chn on bnh ngoi da phi bit phn bit, phn tch tn thng c bn.
2.1. 1. Dt vim: do gin mch, xung huyt nht thi trung b, n knh lm dn mu s mt
dt , b ra mu tr li , li xut hin dt , thng c mu hng , ti, tm, sau khi khi, ln
khng li di tch g hoc hi rc vy da mng, sm mu.
Dt do xm tr vo da (tattoo).
+ Nng hoc su, d v hoc kh v, khi v li vt trt, ng vy tit, lnh thng khng
li so.
2.2.2. Bng nc (bulla): kch thc vi mm n 1-2 cm nh trong bnh zna, bnh duhring-
brocq...
2.2.4. Mn m (pustule): tn thng lng, g cao, bn trong cha m nh trong bnh chc ly
(impetigo), thu u (varicella), vy nn mn m.
Chia thnh:
+ Sn vim: do thm nhim t bo chn b, nh sn giang mai II, sn trng c.
+ Sn khng vim: do tng sinh thng b (tng gai nh trong sn ht cm) hoc do trong
+ Sn c nhiu loi hnh thi khc nhau, nh sn trn, dt hi bng trong bnh vim da thn
kinh; sn hnh chp nn, khu tr chn lng trong bnh dy sng nang lng; sn hnh a
gic,mu tm hoa c (bnh liken phng), c loi sn to dt thnh m mng nh trong bnh vy
nn.
Sn ph n, g cao,do thot dch, gin mch to nn sn my ay, c tnh cht nht thi.gii
hn r,l chn lng dn rng.
+ Xut hin t ngt, bin i nhanh chng (mt vi gi, mt vi ngy) khng li vt tch g
trn da.
+ C khi km a lng, kh th .
2.3.3 - C (tubercule):
L tn thng chc, g cao hn mt da, thm nhim ton b chn b ,h b.kch thc gn
nh sn.
C vim mu hng, hoc vng, mu ng, g cao trn mc da, tin trin thng thnh lot,
li so hay vt teo da, v d: c vim trong luput, lao, c giang mai III.
2.3.4- Cc (nodule):
Tn thng chc, ban u chm ,sau g cao, kch thc bng ht ng, qu cau, tn thng t
chc di da.
2.3.5- Gm (gomme):
L cc nhng tin trin qua 4 giai on: cng, mm ra, v m lot v lnh so.
2.3.6- U (tumor):
Tn thng da v t chc di da, chc, g cao, kch thc thng ln hn 1cm, pht trin
ging nh cc.chia thnh 2 lai u lnh v u c tnh.
thnh tng im hay m, mng trt, , rm dch, rm mu do xy xt, ng, hay do tn thng
2.4.4- Vt xc (excoriation): su n chn b nhng thng gn, thnh ng, vt, rm mu.
2.5.1- Vy da (squame,scale): bnh thng lp ngoi cng ca biu b l lp vy da, bong khi k
c, khi tm,nhng s lng t; khi b bnh l(vim, sng) th rc vy da nhiu. C nhiu loi
vy da nh trong bnh nm lang ben vy mng, mnh d, vy da trong bnh vy nn trng vn,
nhiu tng nhiu lp, s lng vy nhiu v ti to nhanh.
lot (ecthyma).
2.6.3- Si (vegetations): tng gai thnh sn, thnh tia, thnh bi,thnh m pht trin trn cc
sn, c, cc hoc trn mt vt lot c sn. V d: Si trong vim da m si, lao da si, ung th
da, do virut nh trong si mo g.
do mt sc t melanin.
2.7. Mt s im cn ch .
+ Cn phn bit tn thng c bn nguyn pht (primary lesions) nh dt, sn, cc, u, mn
nc... xut hin u tin, sm nht, do qu trnh bnh l gy ++nn vi tn thng c bn th
pht (secondary lesions), xut hin v sau do nga gi, haydo hu qu ca iu tr.
+ Cn khm xt t m, ton din, phn tch v tr, kch thc, mu sc, hnh dng, cch sp xp,
35. CC BNH NM DA
( Dermatomycoses).
1. i cng.
1.1. Tnh hnh : nc ta vng nhit i thch hp cho bnh nm da pht trin, n ng hng
th hai sau eczema (nhng trong qun i bnh nm da ng hng u).
+ Nm mc thnh si, chia t bi cc vch ngn c l thng nguyn sinh cht lu thng
trong lng si nm. Nhiu si chng cht to thnh h si nm, khi gi hnh thnh bo t,
thng c hnh trn, 2 v, v ngoi dy, c sc chng cao vi iu kin ngoi cnh, nguyn
sinh cht c c d tr nhiu cht dinh dng, nh vy bo t chnh l c quan ly truyn v
bo v ni ging ca nm.
+ Ngi bnh ly sang ngi lnh (ng chung, dng chung ), y l vc t chnh.
+ Nhit 27-300C
+Ri lon ni tit (candida), suy gim min dch, dng khng sinh lu ngy, dng thuc c ch
min dch.
+ C min dch nhng tnh khng nguyn thp v khng c hiu. Nn vic dng khng
nguyn chn on v phng bnh nm da cha c kt qu cao.
Theo Nguyn Cnh Cu ( 1994) , khm 5663 qun nhn c 2634 ngi b bnh ngoi da (
Gh : 13,17%.
1.7. Phn loi bnh:da vo tnh cht v c im ca nm gy bnh chia thnh cc loi sau:
Nm lang ben.
Nm vy rng.
Trng tc.
- Nm da (Dermatomycoses).
Epidermophytie.
Trichophytie.
Microsporie.
- Cc bnh gy nn do nm Candida.
ti, gia m tn thng c xu hng lnh, hi bong vy da. Tn thng pht trin li tam dn ra
ngoi vi.
-Tin trin: lnh tnh nhng nu khng iu tr trit d tr thnh nm da mn tnh hay ti
pht.
- Cc th lm sng:
Nm da nhim khun: do bnh nhn gi, tn thng b trt dn n nhim khun ph, xut
Nm da vim da, eczema ho: do bnh nhn ch xt, gi, hoc bi thuc mnh (axit, pin n,
kin khoang...) lm tn thng trt, rm dch, chydch, vim lan to, n...
- Chn on cn lm sng:
xc nh loi nm.
+ Vy phn hng Gibert 1/2 trn, m m, m con, m c gii hn, vin, vy mng ra m.
iu tr :
3.1. Nguyn tc: pht hin sm, iu tr kp thi trnh ly lan trong n v ri mi iu tr.
- Kt hp bin php VSPB, git luc qun o phi nng, ln tri khi phi.
-Trnh bi cc thuc hi da nh acid, pin n, kin khoang, trnh thi quen mc qun o lt
2.2.. Nm k chn:
- V tr bnh thng thy xut hin k ngn c bit hay gp k ngn chn.
nc, i giy tt b hi (nu n, cng nhn cu ph, cng binh hnh qun d ngoi, vn ng
vin bi li).
-Triu chng lm sng: tn thng bt u gia k ngn 3-4, (hay gp nht mt s ngi c
cu to gii phu ngn 3-4 st nhau) ri dn dn lan sang k ngn khc. Tn thng ban u
bt trng hi bong vy, ni mt s mn nc, nga nhiu, gi trt da, c nn , c khi vim n,
sng ty do nhim khun th pht, khi bnh nhn c th st, hch bn sng. Nm c th
lan ln mu bn chn, xung mt di bn chn,oi khi c mn nc su dng t da lng bn
chn (d ng th pht).
vng...
3.iu tr :
3.1. Nguyn tc: pht hin sm, iu tr kp thi trnh ly lan trong n v ri mi iu tr.
- Kt hp bin php VSPB, git luc qun o phi nng, ln tri khi phi.
- Trnh bi cc thuc hi da nh acid, pin n, kin khoang, trnh thi quen mc qun o lt
cht, v khng nn dng si nhn to.
Bi cn BSI 2%, ASA dd castellani,nu cn ung Griseofulvin 1g/ngy x 20-30 ngy, hoc ung
Nizoral hay Sporal.
trng, hng (nht l khi i nng khi ra m hi th mu thng m hn, i khi c mu nu. Cc
- Triu chng c nng: nga, nht l khi nng ra m hi hay i nng v, nga rm ran.
- Chn on phn bit: cn chn on phn bit nm lang ben vi cc bnh da khc nh: bch
bin, sng lin cu dng vy phn,vy phn hng Gibert hay erythrasma
3.1. Nguyn tc: pht hin sm, iu tr kp thi trnh ly lan trong n v ri mi iu tr.
- Kt hp bin php VSPB, git luc qun o phi nng, ln tri khi phi.
- Trnh bi cc thuc hi da nh acid, pin n, kin khoang, trnh thi quen mc qun o lt
cht, v khng nn dng si nhn to.
Bi dung dch Hyposunfit Na 30% sau 2-3 pht bi tip dung dch HCL 3% to dim sinh iu tr
lang ben, gh.
-Triu chng lm sng: khi nhim nm xut hin nhiu vy da, vy bm trn nn da bnh
-Tin trin: khng bao gi t khi, mang tnh a phng, d ly lan trong gia nh, cn phi
iu tr kp thi.
-Triu chng lm sng: b mt mng sau lan dn ra cc mng khc (hng thng). Thng b bt
dn, mng trng mn hoc mu vng mn ra nh rut sy. Mng dn dn b n vt, x x bin
- Chn on phn bit: cn phn bit vi bnh vy nn mng, cc mng cng b mt lc v trn
da cng c tn thng, vy nn mng xt nghim nm m tnh. Cc bnh mng khc: vim
quanh mng do vi khun, hoc bnh mng do nm men Candida (bnh ny thng gy vim
quanh chn mng, i khi c dch m).
iu tr bo tn: khi tn thng mi t mng, vt t (1/3 mng) th tin hnh nh sau: Ngm
mng vo nc m 40- 50 0C, co gt phn mn n khi au rm mu th thi sau chm
cn it 10 %, m arievich, hoc bi kem Nizoral kt hp vi ung thuc chng nm nh gricin,
sporal.
Khi ton b mng nhim nm th bc mng bng phu thut (nhanh gn nhng au, chy mu,
tai bin do phu thut c th xy ra, st si nm li ti pht ) p dung dch ureplast trc 3
ngy ri bc khng au, khng chy mu, kt hp bi thuc ti ch v ung thuc chng nm.
Ch : khng nn dng thuc chng nm vi ngi c bnh gan, thn, ph n mang thai v tr
em di 6 tui.
2.6 Nm tc:
2.6.1. Bnh trng tc (hay cn gi l bnh tc ht) cn nguyn do cc loi nm piedra alba gy
trng tc trng, v piedra nigra gy trng tc en. Vit Nam thng gp loi piedra nigra ch
yu gy tn thng tc. iu kin thun li nm gy bnh khi tc m, nh gi u ban
dm, i m ngay sau khi gi u, hay gp n nhiu hn nam, ly truyn khi dng chung m
- Chn on cn lm sng: cho si tc vo lam knh c KOH 20% soi knh hin vi tm bo t
nm v si nm.
- iu tr :
van, hay hnh rn b bong vy ranh gii r, tc b pht gy cch da u 1 vi mm, c khi ch
cn chm en, chn tc c th c b trng nh nhng trong bt, hay cn gi chn tc "i bt tt"
vy da thng c mu trng hay mu trng xm. Triu chng c nng: rt nga. Bnh c th
ly t ch mo sang ngi.
Th thm nhim mng m: b vng u, c cc m nang lng (p xe nang lng) lin kt
thnh 1-2 m vim mnh, gii hn r, trn mt y vy m, cy cc vy ra c cc h lm c
m mu vng, m rt hi, trng ging t ong, tc b tri (Kerion de celse).
Chn don phn bit: trn lm sng cn chn on phn bit vi cc bnh sau:
- Rng tc pelade.
- Rng tc da du.
3.1. Nguyn tc: pht hin sm, iu tr kp thi trnh ly lan trong n v ri mi iu tr.
- Kt hp bin php VSPB, git luc qun o phi nng, ln tri khi phi.
- Trnh bi cc thuc hi da nh acid, pin n, kin khoang, trnh thi quen mc qun o lt
cht, v khng nn dng si nhn to.
3.2. iu tr c th:
Phc d iu tr cc qun y:
Trng hp nm din rng, mc nhiu nm, ti pht nhiu ln, hay do Trichophyton rubrum th
cho ung khng sinh chng nm: Griseofulvin 0,25g x 4 vin/ngy x 1 thng, kt hp vi bi
thuc nh trn.
BNH
1.1. Yu cu .
Xt nghim nm gy bnh cng tng t nh xt nghim vi khun gy bnh. Nhng bnh nhn
nghi ng do nm gy nn c tin hnh xt nghim trc tip soi di knh hin vi hoc c
nui cy trn cc mi trng thch hp xc nh tnh cht sinh ho hc t nh r lai nm
gy bnh.
+ Bnh phm : trc khi lm xt nghim bnh nhn phi ngng thuc iu tr khng nm t
nht 1 - 2 tun.
+ Nu khng ngng thuc th nm tm thi " bin mt" " th ln" lm cho k thut vin tm
khng ra.
+ cc thuc mu lm cho da b nhum mau, xanh hay tm, , lm che khut cu trc ca vi
nm.
mt, chan, tay, bng, bn, k chn, mng tay,v.v... vy da bnh phm c ly t cc ni vim
Dao u nhn, dao trch, ko, kim, que cy, phin knh sch, lame, gc, bng cn 70o C, n
cn t. Knh hin vi.
luyn th dung dch KOH c thm glycerin theo cng thc sau hoc dung dch DMSO.
+ Ly bnh phm : dng knh lp c phng i t 5-6 ln quan st ni b vim nhim trn
da tn thng ri dng bng cn 70o st khun qua lai tr bi, cht bn. Sau dng dao
h v trng trn ngn n cn, co ly vy da hay cht sng vo phin knh sch cng c
h trn ngn n cn, ly bnh phm, nu l tc, lng th dng ko ct, ri ct tc hoc lng
ngn khong 0,1-1 cm dn bnh phm vo gia phin knh.
+ Khi ly bnh phm xong ta nh 1-2 git dung dch KOH 20% vo gia bnh phm. Sau t
ln trn bnh phm 1 lame sch v trng, dng u mi dao n nh xung lame dn u
bnh phm trn lam knh, nhit phng 45 pht ri soi hoc h phin knh bnh phm trn
+ Tr li kt qu :
- Soi c si nm, on si nm hoc c bo t nm.
. Crystalvioet 2%.
. Cn etylc 20%.
. Oxaltamonium 0,8%.
. Iod 1,3%.
. KI 2%.
. Polyvinylpyrrolydon 10%.
. Safranine.......... 0, 25%.
. Alcohol 95.........10 %.
Thng do cc khoa ly bnh phm trc tip t bnh nhn gi n phng xt nghim nm
1.3.2. Lm tiu bn :
Dng que bng hoc que cy c bnh phm pht ln lam knh sch h v trng trn ngn
n cn ( kh c nh nhit phng).
Ch : pht thnh mt lp mng u trn phin knh vi ng knh khong 0,5 - 1 cm.
1.3.3. Sau khi tiu bn bnh phm c c nh xong nhit phng hoc h trn ngn n
cn c nh bng nhit hoc cn metilic th ta tin hnh nhum theo phng php nhum gram
nh nhum vi khun: nh 1 git dung dch s 1 1 pht, ra nc, cho 1-2 git dung dch s 2
1 pht ri trng nc, sau nh vi git dung dch 3, trng tiu bn bng nc sch, tip
theo nh 1-2 git dung dch s 4 yn 1 pht. Sau trng tiu bn cho ht mu , kh
Tiu bn nhum xong kh ri soi di vt knh du, quan st trn vi trng nu thy mn
men thng bt mu tm ( gram dng ) v c hnh dng l hnh cu, hnh van, c khi thy
rt lu n kt qu nui cy v theo kinh nghim cho kt qu cao hn phng php soi trc
tip. Trong thc t ngi ta thng kt hp 2 phng php.
Phng php soi trc tip nm t bnh phm ch cho ta bit bnh phm c nm hay khng c
nm, mun bit nm thuc loi ging no th tacn phi nui cy trn mt s mi trng
Ngi ta thng cy vo mi trng sabouraud c thnh phn ppton 10 gam, glucoza 40 gam,
chlorocit 100 mili gam, actidon 500 mg, thch 20 gam, nc ct va 1000 ml. Trong mi
trng trn c chlorocit nhm mc ch c ch mt s vi khun, cn actidion ( cyclohexamit) l
mt khng sinh c kh nng c ch mt s tp nm thng c mt trong khng kh hay ly
nhim vo bnh phm. Vi mi trng trn c ng dng nui cy nh loi nm ngoi da.
Bnh phm l cc vy da c ly t bnh nhn cy vo mi trng t t m 28o C trong
khong 10- 14 ngy, nm c trong bnh phm s pht trin hnh thnh khun lc mu sc
khun lc,th cht ca khun lc v tip tc lm tiu bn quan st vi th di knh hin vi
xc nh ging loi nm. Mt s trng hp phi nui cy tip trn mi trng la chn xem
tnh cht, c im sinh ho hc ri da vo kho phn loi nh loi nm. Trong vic nh
men thng ging khun lc vi khun dng kem, da vo tnh cht khun lc, vi c im vi
th cng vi tnh cht sinh ho hc ca tng loi ng ho, ln men cc ng khc nhau m
ngi ta nh loi. Trong cc loi nm men candida gy bnh th ngi ta thng thy loi
trng , mi ng 0,5 ml, c kim tra v trng v vi khun v nm . Sau cy bnh phm trc
tip vo mi trng trn t mi trng nhit 37o C sau 24 gi c th kim tra soi trc tip
di knh hin vi nu c nm candida s xut hin t bo hnh trng, hnh cu v thng c
chi nh dng hnh s tm, mt u nh ( hnh con lt t), loi candida albicans th c xut
hin dng chi ng ging " mm gi".
ta cng ng dng phng php chn on huyt thanh . c bit cc loi nm gy bnh h
thng trong c th ngi cng hnh thnh cc khng th m thng qua huyt thanh c th pht
hin ra nm, v cc loi nm ny do cu trc ca khng nguyn khc nhau nn to ra cc
php l dng ng vt kho mnh lm thc nghim nh chut lang, chut nht trng, th...
Nhng trng hp bnh nhn nghi ng mc bnh nm cn chn on xc nh, th ngi ta ly
mt t bnh phm t ni nghi ng nhim trn c th bnh nhn, ri nghin trong dng c v
quan t chc kt lun v lm tiu bn xt nghim nm ( gia phu bnh l, soi trc tip , cy
nm v.v...) . Trng hp bnh phm l vy da th ngi ta co hoc nh lng ng vt, ri
dng giy rp mn c nh trn m da, sau p bnh phm vy da vo v bng li theo di
1.i cng.
-nh ngha: chng mt (Rosacea) l mt ri lon dng trng c mn tnh ca nang lng
tuyn b vng mt i km vi tnh nng phn ng ca mao mch vi nhit, sc nng xut hin
- Bnh ny trc kia gi l trng c ( Acne rosacea) nhng khng phi lc no cng c km
trng c, u tin c th b trng c v sau b chng mt. Bnh gy nh hng v thm m.
2. Cn nguyn v dch t hc.
Bnh thng xut hin la tui 30-50, n nhiu hn nam, nhng chng mi s t
(Rhinophyma) li gp ch yu nam.
-C tin s t lu c cn bng mt, tng ln khi c cc kch thch nhit khi n ung thc n
ung nng, ru.
Giai on 2: chng mt, ban dai dng thng xuyn vng m, mi, km theo c dn mao
mch (telangiectases).
Giai on 4: ban thng xuyn su hn, gin mao mch dy chi cht, c cc sn, mn m c
cc cc hnh trn mu c, vng gia c thc ph cng dai dng, c trng c.
4. Xt nghim :
M bnh hc da: mao mch dn, xung quanh c thm nhim t bo vim khng c hiu ( giai
on 2) c cc sn v dn mch, thm nhim vim quanh nang lng t bo dng biu m,
C sn, mn m.
V sau tng sn m lin kt, tng sn tuyn b, c nt cc, bin dng mi mt, mi s t.
- Lupt h thng: ban vng mi m,hi n, st, mt mi, rng tc, st cn, au
6. Tin trin :
Ko di nhiu nm, hay ti pht, sau nhiu nm bnh c khi t thuyn gim, n ng c
th b chng mi s t (Rhinophyma).
7. iu tr :
gel.
Ton thn :
Dng Metronidazol nhiu c th gy gim bch cu nn dng thay bng : Tetracyclin 250 mg 4
vin ngy x 3 tun hoc Erythromycin 1 g/ ngy chia 2 ln trong 2-4 tun.
Sau dng liu duy tr tng t Tetracyclin 250 mg 2 vin/ ngy x 9 tun xen k t ngh
thuc.
Cc ca bnh nng dng Isotretinoin 0,5 mg/ kg/ ngy trong 20 tun hoc dng liu thp 0,1 -
0,2 mg/kg/ngy.
Phng bnh :
1.1.i cng:
+ Chong phn v l tai bin d ng nghim trng nht, mt phn ng t ngt, din bin vi
tc nhanh, xut hin t vi giy cho n 20-30 pht sau khi khng nguyn (d ng nguyn)
vo c th v c biu hin bng try tim mch, sc v suy h hp. Nu khng c x tr kp
thi c th nguy hi n tnh mng.
1.2. Cn nguyn : thuc phn ng p ng min dch tp I kiu trung gian IgE; xy ra
ngi mn cm vi khng nguyn hnh thnh IgE c nh trn t bo mastocytes v Basophil ,
1.3. Nguyn nhn : cc cht c kh nng gy phn ng chong phn v rt nhiu v c chia
lm 3 nhm sau:
+ Do thuc : y l nguyn nhn hng u trong bao gm cc thuc: Khng sinh : Penicillin,
Steptomycin, Sunfamides.
- Ni tit t.
- Mt s loi vitamin
+ Do cn trng : ong t
2. Lm sng:
Chong phn v do thuc ch yu xy ra bng ng tim ngay sau khi th phn ng, hoc
khi ang tim trong vng mt vi pht, c bit c trng hp sau khi ung thuc , nh thuc vo
mt, mi, li hoc bi thuc vo da, nim mc. Mc nng ca sc phn v ph thuc vo
khng thi gian t khi d nguyn xm nhp vo c th n khi xut hin cc triu chng sc u
- Du hiu thng gp nht l suy tim mch cp ( mch nhanh, nh kh bt hoc mt mch,
huyt p tt c th khng o dc, nhp tim nhanh nh hoc ngng tim ).
- Cc triu chng khc c th c hoc khng nh : ban my ay da, au bng d di, a chy,
nn ma, xut huyt tiu ha
3. iu tr :
Phi khn trng, chnh xc kp thi v lin quan n sinh mng ngi bnh
- X tr : Yu cu x tr ngay, ti ch xy ra sc phn v.
- Tip tc tim Adrenalin liu nh trn c 10 - 15 pht / 1 ln cho n khi huyt p tr li bnh
thng.
39. ECZEMA
A. Chn on eczema
2. Tn thng c bn.
- Mn nc nh bng y tm u kim.
- Nng, t v.
- n t di ln ht lp ny n lp khc.
3. C nng: Nga
4. Tnh cht: Tin trin mn tnh hay ti pht nhiu thng, nhiu nm, tnh cht khng khi.
5.Gii phu bnh l da: c hin tng xp bo, (Spongiosis) tin hnh thnh mn nc.
B Chn on th eczema.
1. Eczema vi khun.
- D nguyn thng l cc cht ho hc trong cng nghip, sinh hot nh ho cht, cao su,
xng du, m, cht im tang, xi mng, crm,.....
vng m trn c m , hnh mong nga sau lan ra u, thn mnh vim , nhim mn
V tr i xng 2 bn nch, np, np khu tay, np kheo chn, 2 c chn, mt trc cng chn.
Tn thng tnh cht liken ho, dy cm, cng,thm mu, b mt c sn, c khi c giai on
vn chy dch.
4. Eczema da u .
C. iu tr eczema
- Ti ch: ra ngm, p gc dung dch Rivanol 1% hc dng dch nitrat bc 0,25% hoc dung
dch berbenri 1% 1-3 ngy u. Sau bi thuc mudung dch tnh Metin 1% dung dch xanh
Metilen 1%, dung dch Milian hoc bi h nc.
- Ton thn.
Khng sinh chng bi nhim Ampxilin 0,25 4-6 vin / ngy/ x 5-7 ngy chng d ng chng
nga.
2. Eczema bn cp:
Gim vim gim chy nc, bt u kh, ln da non Bi m Cocticoit + khng sinh.
M Celesytodezem - Neomycin.
1. Cn nguyn.
- KST gh o hang lp sng, trng qua chu k 3 ngy thnh KST gh.
2. Cch ly truyn:
V tr: k ngn tay, ngn c tay, ci tay, b trc nch, quanh rn, mng chn sinh dc ngoi (
gn 100% nam gii b gh c tn thng quy u thn dng vt).
*Nga nhiu v m.
- Sn nga do cn trng
- Vim da m.
7. iu tr
Nguyn tc:
- Boio thuc vo bui ti, bi kiu quang du, bi 3 ngy lin mi tm git thay qun o.
- Du DEP ( diethylphytalat).
- M dim sinh 10% cho tr em, 30 % cho ngi ln.
Dung dch axit Clohydric 6% xy ra phn ng ho hc lm gii phng dim sinh mi c tc dng
tr gh.
nc ct 350 ml
Bi ngy 2 ln
- Lic Wenming ( vi ti, dim sinh nu trong nc si) thuc ny d gy vim da).
- Vi gh nhim khun ngoi thuc bi iu tr gh cho bi thm thuc mu (dung dch xanh
metilen 1% dung dch thuc tm metin 1%) vo cc mn m , vt trt).
Chng nga: Khng Histamin tng hp nh Chlopheniramin 4mg 2 vim /ngy, Tra 1 vin, ti
1 vin.
Vitamin c, B1 Nu l gh nhim khun cho thm 1 t khng sinh Ampixilin 500mg 3 vim /
ngy x 7 ngy.
ng y: tm l ng ( t tc dng) Du ht mu ch.
41. HT CM ( VERRUCAE)
Bnh pht trin trn mt s th a c bit khi c nhng iu kin thun li, hay ti pht
thng c lin quan ti suy gim t bo T h tr do suy gim min dch t bo.
Bnh d ly v t ly nhim.
khc vi lao da xi lc ban u). Ht cm khng au, tr khi quanh cc mng ly nhim do
chn khc hn ht cm lng bn tay c v lm sng v t chc hc. Dung mao a dng, c
ci thnh u sng nhn mu vng c, i khi trong. gia hi lm x x c gai nh, c ci
thnh ht cng, khm su vo trung b trn da c da dy sng nh chai, qua lp sng c th
thy ht cm nh l mt a trn mu vng c, phi ly lp sng dy mi l r ht cm. Mt
c im l n au chi, c khi nhiu ht cm cm li thnh mt m dy sng.
Thuc chung: tm l liu php, tim mu t thn, vitamin A, C, Interferon ( ch dng cho cc
ht cm by, ri rc).
ng y : xt l ta t, k ni kim..
hoc m gn cht.Bnh xut hin t b v ko di dai dng, c khi bin thnh ung th t bo
gai. Ban u Lawwandowsky v Lutz cho l mt lon sn bm sinh, hin nay nhiu tc gi cho
l do vi rt. Nh ng cng cn nhiu tc gi vn cho l do mt Naevus ht cm.
3.iu tr:
Thc s Nguyn T
1. nh ngha.
Bnh c t l t vong cao 25-100% ). Nguyn nhn t vong phn ln do iu tr khng hiu qu
ngay t u.
2. Cn nguyn.
Bnh thng xut hin ngi ang kho mnh b nh th ng, sau khi s dng cc thuc ni
Phn ln cc trng hp u gp ngi dng trn mt loi thuc, c ngi dng ti 4-5 loi
khc nhau.
+ Do nhim trng.
3. Lm sng .
N gp gp 2 ln nam
+ Bnh tin trin cp tnh trong mt vi gi, i khi t ngt xut hin st cao, rt run, nh
trng ngc, suy nhc c th, nhc u, mt ng, au ming, n khng ngon, au v nhc c.
Trng hp nh c kh nng tin trin thnh nng sau 2-3 ngy vi mt bnh cnh lm sng rt
+ Tn thng da:
- Bng nc lng nhng ging nh bng la. Cc tn thng ni trn nhanh chng lan rng,
sm, nhng m da b trt. Bnh nhn c cm gic au rt, du hiu Nikolsky (+ ).
- S nh sng.
- Vim lot m o, m h.
- Vim ty.
- Ri lon nc in gii.
+ Cc bin chng:
- Hp thc qun.
- Hp m o.
5. Chn on.
5.1. Chn on xc nh da vo
+ Hi chng Kawasaki (hi chng hch - da- nim mc): bnh gp nhiu ngi Nht Bn.
6. iu tr.
Sau khi ct corticoit liu cao nn cho synacthene 25 mg, 10- 15 ngy/1 ng, cho dng t 1- 3
ng.
+ Cyclophosphamid (100 mg- 300 mg/ ngy tim tnh mch trong 5 ngy)
Dng cyclophosphamid ngn chn nhim c qua trung gian t bo. + Vi cyclosporine A
1. i cng.
1.1. nh ngha.
1.2. Cn nguyn.
+ Do thuc: h st, gim, an thn c bit khng sinh nhm Penicillin, Sunfamides.
+ Do tim vacin, huy thanh.
+ Cc bnh nhim khun: vim phi, vim mng no, vim no, nhim khun rng ming
2. Lm sng.
Bnh khi u t ngt st cao 39- 40o, nhc u, mt mi au vim hng ming v sau ton
trng ngy cng nng.
+ Da: xut hin mn, bng nc hoc ban xut huyt mt tay, chn sau xut hin tn
thng ban hnh huy hiu ton thn km theo vim mt hoc tt c cc hc t nhin (ming,
Bnh ngy cng nng bnh nhn mt mi au khp, hn m, lon nhp tim, vim mng c tim,
- Vim da Herpes.
- Pemphygus.
- Hi chng Lyell.
3. iu tr
trng/ 24 gi; th trung bnh dng: 1,5- 2 mg/1 kg th trng/ 24 gi. C th kt hp vi khng
sinh nhm t gy d ng (macrolit).
Ti ch: xoa bt talc, chm sc h l tt sau bi thuc mu: eosin 2%. Dung dch milian, dung
44. LAO DA
khun lao gim c lc Bacille Calmette Gurin - BCG c th gy nhng thay i m bnh hc
ging nh nang lao, nh ng khng c s tin trin nng v c khuynh h ng t lnh li
nhng thay i x ho.
1. S ly truyn ca bnh.
- ng ly truyn qua tip xc: trc khun lao c a n da t c quan ni tng hoc
him hn t bn ngoi. C ng i b luput lao di tai v nh mt bnh nhn lao phi xu
tai eo khuyn, kim khu dnh n c bt ca bnh nhn. Cc nhn vin phc v ging
ng phu tch, cng nhn l st sinh c th b ly trc tip t nhng bnh phm qua da b xy
xt. Tuy vy i a s tr ng hp trc khun lao c a n da t cc ph tng b lao:
nh lao phi, lao hch lymph, lao x ng. Chnh v th lao da lun l biu hin th pht ca
nhim khun lao. Lao da nguyn pht l iu rt him. T cc ph tng (phi) trc khun lao
n da bng nhiu ng:
- ng lymph : trc khun theo cc khe gian bo v mch lymph n trc tip vng tn th
ng da, ng lan truyn ny th ng xy ra lao hch. Luput lao hay ni mt v trc khun
truyn ny gp trong luput lao, lao hch, lao sn hoi t v mt s th lao khc.
- Lan truyn do tip cn : qu trnh lao lan truyn dn sang t chc ln cn v sau cng n
mt vng da no . Cch lan truyn ny gp trong lao hch lymph v lao x ng .
- T tim truyn : mt lao ph tng nng ang tin trin c nhiu trc khun, nhng trc
khun ny c th ly nhim cho vng da v nim mc. Th d lao phi nng c th b lao nim
Trn bnh nhn lao da ta pht hin t 3- - 40 % c lao hch km theo, 25 - 30 % c lao phi.
Cn c th pht hin lao sinh dc v bung trng.
- Do c lc ca trc khun.
- Do s l ng ca trc khun.
bnh nhim trng khc ri sau mi b bnh lao ( tr em sau si). Bnh nhn nghin r u.
2. Lm sng :
Hnh nh lm sng ca lao cn ph thuc vo tui, gii, c tnh v gii phu hc vng da b
tn th ng v s lin quan nhiu mt yu t min dch v d ng.
Nhm th nht : lao da thc s, luput th ng hoc luput lao , lao hch, lao da ht cm, lao lot
c im :
Cc hnh th lm sng.
Triu chng lm sng: c lao ( Lupome) mu vng vng nu kch th c bng u inh ghim
hoc to nh ht u, b mt trn bng, c t vy, hoc cht, da lot. C lao mm bng d nn
xung ging nh tht ng. n knh c lao xp xung, nhn qua knh c lao trong sut mu vng
10- 20 nm.
- Luput lao phng: mng hypome khng ni cao trn mt da c lao pht trin chm.
- Luput lao lot : lot nhanh ph hu cc t chc mt mt cnh mi hoc mt c vnh tai. Luput
T chc bnh l ca luput lao : c lao khu tr trung b thnh thong c t bo bnh xe, c
khuynh h ng b u ho nn mm, cc nang lao c th ring r, c th hp li thnh m xm
nhim. Cc dy h v dy chun trong nang lao b ph hu. Th ng b pha trn teo, sng, lp
gai lp sng qu sn. C th tm thy BK trn th ng tn.
- Ung th (Cancers)
- Nm su .
knh xung khng xp ( khng ging c lao) cc sn ln dn khng to thnh mng. Vng gia
dy sng sau xi ln nt n n vo mng xi th pha i din c git m phi ra. Xung
V tr khu tr mu bn tay, ngn tay 1, 2 c khi khu tr trn da bn tay bn chn cc vng da
khc t gp . Nam gii b nhiu hn n gii.
Gii phu bnh l giai on u c cu trc ca nang lao , bn cnh cn c s thm nhim
khng in hnh gm t bo lymph, t bo bnh xe, t bo x, t bo a nhn, dy h dy
chun b ph hu. giai on sau th ng b qu sn. Lp sng v lp gai b ko di v i su
vo trung b, BK c th c nh ng t.
Chn on khc:
- Vi bt xi : mu sm v c t b.
Lm sng : Triu chng u tin l nhng sn bng bng u inh ghim, lot nhanh, cc sn
T chc bnh l: cc vt lot ln thy cc nang lao in hnh, vim nhim khng c hiu gm
t bo lymph, bch cu a nhn, t bo bn lin t khi thy. T bo khng l trung b vng
c hoi t th c nhiu vi khun lao.
Lot giang mai l lot nng, thm nhim, x cng, xt nghim c xon khun.
Lot h cam.
iu tr bnh lao da
Phc 2RHZ
4 RH
- 2 thng v 4 thng.
Ln hn 50 kg - 600 mg/
ngy. Tr em 10 mg / 1 kg / ngy .
Tr em 5 mg / kg cn nng.
- Pyradinamit - Z.
> 50 kg - 2g / ngy
Tr em 35 mg/ kg.
2- Phc 4 loi thuc: p dng nhng ni c t l khng thuc cao cho 3 loi nh trn thm
mt loi na nh ng ch trong 2 thng u.
2S . HRZ / 4 RH.
45. LUPT BAN H THNG
1.nh ngha :
Lupt ban h thng l mt bnh a h thng nng, nghim trng, bnh ca m lin kt v
mch mu, biu hin lm sng thng gp l st (90%) , ban da (85%) ,vim khp v tn
Lupt ban h thng l mt bnh a h thng, bnh cht to keo, bnh ca m lin kt, bnh
t min, cn nguyn cha r, c c ch min dch, c cc t khng th (khng th khng nhn-
ANA).
- Nguyn nhn do thuc: mt s trng hp bnh xut hin sau khi dng Hydralazine, thuc
Vai tr ca virt trong cn nguyn sinh bnh lupt ban h thng c nghi ng t lu,
quan st trn knh hin vi in t ngi ta thy cc ht mu m ging ht virus thn,da, tuy
nhin cha c bng chng chc chn. Mt s trng hp gia tng khng th chng virus
- Tn thng thng xut hin vng mi m to thnh hnh cnh bm, vng trc tai,
vng da h nh mt, cng tay, mu bn tay, ngn tay, c khi lan ta nhiu ni: u mt, ngc
Tn thng l ban thnh m mng mu , tm, sng hoc hoc ban dt sn, hi
ph n, thng khng nga, hoc thm nhim hi cng, c khi hi c vy, c khi cht ra ng
vy tit.
Tn thng xut huyt, sn xut g cao s thy kiu vim mao mch
(vasculitis), c khi lot ra thng tay, cng chn hoc c tn thng ban my ay km xut
huyt hoc c bng nc.
- Hi chng Ryn ( Raynaud) xy ra > 20 % s bnh nhn SLE v c khi l du hiu i trc
nhiu thng hoc hng nm, khi pht do lnh hay xc cm, biu hin 2 bn tay, cc ngn
trin nng, u cc ngn tay xut hin cc nt phng nc, vt lot nh, cc so trng, i
khi u ngn rn li, x cng ngn (Sclerodactily).
mch bn tay, cc ngn tay kt hp vi ban . Li mao qun nn mng quanh co khc
khyu.
- Mi vim , rc vy, nim mc ming, li c cht lot ging nh vim ming p t (20%)
thng vm khu ci (80%), thng gp bnh nhn c SLE da nng, c khi gp lot nim
mc ming c xut huyt hoi t vm khu ci, nim mc ming, li.
on.
- Kh chu.
Rng tc khng so thng l rng tclan ta trong SLE u c ban , vy hi ging kiu vim
- Bnh thn, ri lon thn (31-55%). Protein niu, nc tiu c hng cu , hi chng thn h,
mt s c th c suy thn.
- Tim mch: vim mng ngoi tim ( 20-30% s bnh nhn), c th c ting c mng tim, trn
dch mng tim, t hn l vim c tim, hn hu l vim ni tm mc.
- Phi : 20- 40% s ca . Trn dch mng phi nh n trung bnh. Vim phi lupt.
- Thn kinh : bnh l thn kinh ngoi bin (14%), cn ng kinh (15%) ,v tm thn c cn
- Gan, lch : gan to 30 - 35% s bnh nhn, him khi c vng da, lch to ( 20%).
- Tiu ha: c cc du hiu d dy, rut nh au bng, bun nn, i khi a lng.
Du hiu mt vim kt mc thng c 2 bn (15%) ph quanh mt, xut huyt di kt mc
vim mng mch nh.
4. Du hiu xt nghim.
- Thiu mu tan huyt vi phn ng Coombs dng tnh v tng hng cu li.
Gim b th C3.
-Di lupus: th nghim min dch hunh quang trc tip chng minh c lng ng hnh ht v
hnh cu IgG, IgM, C1q thnh dng di dcng tip gip chn b - biu b, vng da tn
thng dng tnh 90%, vng da bnh thng v lm sng c phi nng dng tnh 70-80%,
vng da bnh thng v lm sng khng phi nng dng tnh 50%.
5. Chn on.
5.2. Ban dng a (discoid) ban g cao, gii hn r c vy sng dnh cht kh cy, dy sng
st thy.
5.4. Lot ming khng au,hoc lot hu hng khng au, thy thuc khm, quan st thy.
5.5. Vim khp: Vim khp khng trt xc, hai hoc nhiu khp ngoi bin,sng, au, trn
dch.
5.6. Vim thanh mc : vim mng phi, ting c mng phi, trn dch mng phi, vim mng
5.7. Ri lon thn : protein niu > 500 mg/ ngy, c cn lng t bo.
5.8. Ri lon h thn kinh trung ng: ng kinh hoc cn vng thc tm thn.
T bo LE dng tnh.
Anti Sm (+).
SS B ( Anti La).
- St.
- Mt mi.
- St cn.
- Rng tc.
- Vim khp.
- Tn thng thn.
- T bo LE (+).
- Gii : n.
- Vim da tip xc, vim da mn cm nh sng cng thng b vng h ( mt, 2 cng bn tay
).
Tin lng : l bnh nng, bnh h thng, t l sng st c sau 5 nm chim 93% s bnh
nhn.
iu tr :
- Ngh ngi.
-Trnh phi nng : i nng i m nn rng vnh, che mng, UVA lm trm trng bnh. Trnh
nh nng t 10 gi sng n 3 gi chiu.Trnh da b phi nng trc tip, dng kem chng
nng.
- Corticoids 60 mg/ ngy, gim liu t t, chm, khi t hiu qu lm sng trnh cn bng
pht.
1.i cng.
Nm 1872 Kaposi tch lupt mn dng a (CDLE) khi lupt h thng (SLE).
+ nh sng lin quan n s xut hin bnh hoc lm trm trng bnh.
3.1. V tr : thng b vng mi, m ,hnh cnh bm, vng mt, u, trn, tai, cng tay, mu
3.2. Tn thng c bn :
Ban u l cc sn g cao lin kt thnh mng, mng mu sng, mu hng hnh trn, oval,
hnh nhn hay a vng, g cao, gii hn r nhng vin b khng u. Mu sng, g cao, hi
n.
bm thm.)
thng c tng nhim sc mu nu, thm da. Phn b cc m tn thng ri rc, ring r
tng m.
nhim sc hoc trong nim mc ming m teo da, c mng trng nim mc ming,
li, vm khu ci.
- Triu chng tan thn: thng khng c triu chng g, i khi nga nh. Lupt dng a l
bnh ch yu ch c tn thng da m khng c tn thng ni tng v ton thn.
4. Xt nghim :
- Min dch hunh quang dng tnh tn thng c hot tnh sau khi b bnh 6 tun. Th
nghim di lupt ( lupus band test) thy lng ng IgG dng ht ( > IgM) ng ni biu b -
chn b ( iu kin l tn thng cha c iu tr bi m corticoid ti ch), m tnh vng da
tn thng thnh so v vng da bnh thng, cn trong lupt h thng (SLE) th nghim
ny dng tnh vng tn thng v c vng da bnh thng c phi nng v khng phi nng.
- M bnh hc vng da tn thng thy dy sng, biu b c teo da, c nt sng nang lng,
5. Chn an : Chn on xc nh da vo :
- Vy nn th mng.
- Nm da vng mt.
- Liken phng.
7. iu tr:
Hydroxychloroquin 250 - 300 mg/ ngy hoc Quinacrine 100 mg 3 ln/ ngy.
Ch kim tra chc nng gan trc , trong v sau iu tr, khm mt trc,trong v sau iu tr.
+ Dch t hc:
- Yu t thun li pht sinh : st, mt nc, gim tit nc bt, ung khng sinh lm gim cn
bng vi khun.
+ Bnh s:
Bnh nhn c ung khng sinh hoc c cc yu t thun li khc nh b st, b mt nc, b
gim tit nc bt.
Triu chng nim mc: hu nh khng c. Mt s bnh nhn c thay i v gic hoc cm
gic kh nut.
+ iu tr :
Khi tm ra nguyn nhn v loi b th bnh khi. Tuy nhin bnh nhn khi c th dng cc
1.Cn nguyn :
Chi Aspergillus thuc lp lp bt ton ( Fungi Imperfecti), c chia lm 7 nhm, c khong 100
loi , trong c 20-30 loi c th gy bnh nh A.aureus, A.flavus gy vim da, A.niger gy
vim tai, phi, d ng, hen, A.nidulans, A.versicolerr,A.terreuss gy vim da chn, tay, vim
quanh mng, A.keratitis gy vim gic mc, c bit A.fumigatus v A.flavus hay gy vim phi.
+ Vim phi: phi thng u tin gy vim ph qun vi triu chng xut tit nhiu m,
kh kh, trong dch ph qun c nhiu t bo nm, bnh nhn thng st, kh th, ho, ngi
xanh xao ri dn n vim phi vi nhng triu chng ging nh lao phi. Bnh nhn c th
dn n vim mng phi, vim m mng phi ri lan sang tim. Ngoi ra nm cn c th pht
3. Xt nghim:
+ Soi trc tip: Bnh phm l vy da soi trc tip trong dung dch KOH 20% tm si nm, cc
bnh phm khc ( dch m, m...) nhum gram soi tm si nm, bo t. Nu l nm ni tng
cn sinh thi chn on m benh hc, nhum PAS, Methenamine silver thy cc si nm c
vch ngn, phn nhnh thnh hai, to gc 45o, i khi c th thy b phn sinh bo t ca
nm.
+ Nui cy: trn mi trng thch hp pht hin nhim nm v nh loi nm. Mt vi loi
nhy cm vi cycliheximide. Mi trng chun nh loi phn ln Aspergillus l Czapek (3%
sucrose) v malt extract agar.
NaNO3 3 gam.
K2HPO4 1 gam.
ng knh 30 gam.
Thch 15 gam.
Nc va 1000 ml.
xut hin Chu u, 90% trng hp bnh nhn l nam gii, thng la tui 40-50, thng
gp ngi lm ngh nng.
1. Cn nguyn : l nm Paracocidioidess brasiliensis, ngoi ra cn hai loi khc l P.teanis v
P.cerebriform. Almeida xp loi ny vo chi Paracocidioides. Nm 1941 Conant v Howel
t tn nm l Blastomyces brasiliensis. Lai ny c th tm thy trong t.
+ Bnh nim mc : thng gp ming, mi, hng. Tn thng ban u l nhng u ht, si
trn nim mc ming, li t lan dn ra to thnh mng trt hay lot, c xen k nhng m
xut huy v nhng m mu vng nht. Bnh c th lan n vm ming, li g v thanh
i. Khi b bnh bnh nhn hay tng tit nc bt, chy nhiu di.
+ Bnh da: bnh hay gp mt, u chi hoc thn mnh. Tn thng thng l cc sn,
sn m, u lot dn dn tr thnh u gai, si dy sng. T chc di da cng b vim v dn n
lot hoi t su, c vin b dy tng sng. Bnh nhn thng khng au hoc au t.
+ Bnh phi : thng c cc triu chng nh ho, khn c, kh th,kh kh,khng st. Bnh
cn c kim tra bng chp X quang, 80% trng hp pht hin hnh nh thm nhim, hnh
nh ht k, tn thng mng phi.
3. Xt nghim :
Soi trc tip :bnh phm l dch t cc u, hch, dch nim mc hay m soi trong KOH 20% s
pht hin thy cc t bo nm men, kch thc ln ng knh 10-30mm, c chi kch thc 1-
2 mm. C th nhum gim sa hay nhum gram thnh t bo nm bt mu , t bo to, mc cc
chi nh.
nhn v thnh thong to mu , sau mt thi gian mt mu. Khi nui cy nhit 370 C
dng nh " bnh li", t nhng t bo con ny pht trin tip tc mc chi to thnh mt chui
t bo. T t bo m c th xut hin 200- 300 t bo chi. Gia pha si v pha nm men thay
i d dng khi nhit nui cy thay i.
4. Chn on phn bit : cn chn on phn bit vi cc bnh nm h thng khc, lao ph,
lao hch.
5. iu tr :
hi hn.
1. Cn nguyn.
nng s dng creatinine trong phn chim lm ngun nitrogen.Trong phn chim b caua tch
+ Vim da:
- Thng t gp.Tn thng thng xut hin chn, tay, mt. Tn thng l vt lot c ranh
gii r, hnh trn hoc a cung, gia mu tm, xung quanh c qung mu hng, di l
dch v m. Tn thng c th lan rng ri c th hoi t v thnh vt lot nng, tin trin mn
tnh.
+ Vim phi: nm c th xm nhp vo phi khi ht phi nm v gy vim phi, khi biu hin
st nh, ho, tit dch v c pht hin bng X quang.
Khi mng no b nhim cryptococcus th triu chng lm sng biu hin ban u l st nh,
au u, bun nn, nn, chng mt, chong vng, lo mt. Khi tin trin nng th au u d
di, cng gy, st cao, ri lon nhn thc, mt tr nh, i khi ph, gay mt, lit dy thn kinh
+ Xt nghim trc tip: nhum bng mc tu vi cc bnh phm dch, m t tn thng ra hay
men.T bo nm c pht hin trong t chc khi nhum PAS hoc methinamin silver.
+ Nui cy: nm c th mc khi bnh phm trn mi trng sabouraud hay thch mu, 370C
khun lc dng kem soi c nhiu t bo nm men vi nhiu chi nh.
5. iu tr:
1. Cn nguyn .
c bit gn y loi nm penicillium marneffei thng xut hin nhiu bnh nhn nhim HIV
/ AIDS v c mang tn bnh t xut bt ng (emerging pa sthogens).y l mt loi nm
lng dng (dimorphism), phn lp c ln u tin t tn thng gan chut tre (Rhizomys
sinensis), mt loi ng vt rt ph bin ng Nam . Thng thng loi nm ny t gy
bnh, nhng n li ni r ln gy bnh nhng ngi nhim HIV, c bit giai on AIDS.
quc , Hng Kng, Lo, Indonesis ... Vit Nam cng gp mt s trng hp bnh nhn AIDS
mc bnh do P. marneffei.
Tn thng da, c cng c th xut hin nhng nt sn ging nh u mm ly, dng trng
c mn m,cc, ht, lot v c p xe di da.
3.Xt nghim: P. marneffe l loi nm lng dng, hnh th khc nhau khi nui cy nhit
khc nhau.
5. iu tr.
Khi b nhim bnh cp tnh c th dng amphotericin B .Tuy nhin cng c th dng itraconazol
v ketoconazol cng c tc dng. Itraconazol c th dng iu tr duy tr.
Bnh nhn thng gp nam gii, kho mnh, di 30 tui, t gp tr em, hay gp nhng
ngi lm vn, lm rung, th n, trng hoa hoc bn hoa, nhng ngi tip xc vi t, c
+ Th da- bch huyt: l th hay gp nht. Khi da, nim mc b xy st, sang chn nm d c
+ Th nim mc: tn thng thng l u nh dng mn cc c m, lot thng xut hin nim
+ Th xng khp : bnh nhn thng b au, vim, cng khp, ch yu khp ln nh khp
Th lan to: nhng ngi bnh thng c th b sporotrichosis lan to nhng him, ch yu
nhng ngi suy gim min dch. Bnh nhn thng biu hin mt mi, ho, st nh, tn thng
thu trn ca phi, c th ho ra mu, dn dn to thnh hang phi. Thng thng bnh nhn
c nhng biu hin c quan khc, c bit da v xng, c th gp p xe no, vim mng
no.
3. Xt nghim
+ Soi trc tip: bnh phm l m, dch m tn thng nhng kh pht hin . Sinh thit m
nhum PSA.GMS c th thy nhng th sao" asteriod bodies", nhng t bo nm hnh oval,
hnh iu x g.
Nui cy : bnh phm cy vo mi trng sabouraud nhit 20oC- 26 oC, nm pht trin
+ Chn on min dch: test da: dng 0,1 ml khng nguyn sporotrichin c pha long gp
4. Chn on:
Chn on phn bit: vi lao da, giang mai, sn do cn trng, leishmaniasis, phong ,
chromoblastomycosis, actinomycosis v cc bnh nm su khc.
5. iu tr:
n nay vn c ng dng l ung dung dch iodua kali liu tng dn t 2- 4- 6- 12 gam trong
ngy, trong nhiu tun. Vi th lan to iodua kali tc dng , c th dng thuc chng nm nh
itraconazol, ketconazol v amphotericin B.
(Bnh gilchrist).
2.2. Th ph tng: thng thng nm c th gy vim phi khi c triu chng st,kh
th,hnh nh X quang ging nh lao k,dn dn bnh c th lan vo da vo no vo xng
3.Xt nghim
+ Soi trc tip t m trong dch KOH 10% hay nhum gram c th thy nm dng t bo nm
men c kch thc 8- 14- 24 .
+Nm c th nui cy pht hin trn mi trng sabouraud t cc bnh phm, khun lc
phng,mu trng, c lp si men.Di knh hin vi si nm trng mnh phn nhnh,c bit c
nm men.
5.iu tr.
MADURAMYCOSIS)
Bnh hay gp vng nhit i v cn nhit ,cng gp vng n i. Bnh hay gp ngi
lm rung, ry,ngi chn gia sc,i chn t, hay gp nam hn n ( t l 3/1 n 5/1), tui
20- 45, nhng ngi sng nng thn hay b nhng gai m, vt xc nh to iu kin cho
1. Cn nguyn:
phu thuc vo tng loi nm gy bnh. Khi khng iu tr kp thi bnh s lan xung su, vo
xng dn n xp xng. Bnh c th ko di hng chc nm lm cho bnh nhn b suy kit
dn n t vong.
3. Xt nghim :
Soi trc tip: ly dch m soi trong dung dch KOH 20% thy cc m ht ng knh c th
15mm, hnh trn. Nu thy cc si nm mnh, dng knh di 1 mm th l vi khun
Actinomyces, nu thy cc si nn to , th, ng knh ln 2-4 mm th l nm
nhm Eumycetes.
M hc : sinh thit t chc ni tn thng ri nhum PAS hoc methenamin silver pht hin
nm.
Nui cy : nu soi trc tip pht hin nm Eucomycetis, cc ht cn ra trong dung dch nc
mui v khng sinh, cy vo mi trng Sobouraud c khng sinh, mi trng khng c
ngho cht dinh dng nh mi trng bt ng, mi trng thch- khoai ty, dextrose kch
thch to bo t. Nu soi thy vi khun, mi trng nui cy c th l thch mu, Sabouraud
hoc mi trng dch chit tim (BHI) , mi trng Lowenstein, nui cy nhit 25 v 370 C.
5. iu tr :
bnh Paget khc eczema ch ranh gii r, c b trn hoc bu dc, khng c tn thng tin
n xung quanh; tn thng c b con chch ngoi vi, hi g cao so vi da lnh, di lp
vy tn thng c mu ti, c khi c dn mao mch hoc b mt sn si d chy mu, nn
hi cm, nm v c th b co ko. Tin trin mn tnh.
- Da vo hnh nh lm sng.
+ Chn on phn bit vi chm vi khun, nm candida, vim da mn tnh do lin cu.
4. iu tr v d phng.
1. i cng.
1.1. nh ngha: l bnh gy nn do trc khun Hansen, bnh c tnh cht ko di v ly, c
biu hin ton thn nhng ni bt v thng xuyn nht l triu chng da v mt s dy thn
kinh.
1.2. Danh t : phong, phung, ci, hi, bnh Hansen nay thng nht gi l bnh phong.
Bnh phong c t lu i, cho n nay theo s liu ca H.Sansarricq, Scal v Walter trong " S
phn b bnh phong trn th gii":
Tng s bnh nhn 10.786.000 , Chu u 160.000 Chu Phi 3.500.000. Chu 6.475.000
(trong ng nam 5.510.000). n 1,5 - 2 triu , Trung Quc 1 triu. Chu m(ch yu
nam m)400.000.
Xu hng th gii hin nay l ct t ly lan bng rifampicin,iu tr bnh phong bng a ha tr
liu, iu tr ti gia nh, ti bnh vin nh cc bnh khc tin ti thanh tan bnh phong.
2. Dch t hc .
Trc khun hnh gy, khng cn, khng toan v phng din nhum, kch thc 1,5- 6 micron ,
nhum bt mu ti theo phng php Ziehl- Neelsen.
thnh m(amas), thnh cm (globi), thi gian th h 14 ngy, sng ngoi c th c 7 ngy
(theo Rees 1974), un si git cBH, tim truyn cho sc vt c nhng kh, cha nui cy
c trn mi trng nhn to.
2.2. L bnh ly, (thuyt di truyn b bc b), l bnh ly nhng ly t, t l ly gia v chng
l 3-6%, ly chm, bnh di 2-3 nm, ly kh.
2.3. ng ly : vi khun xm nhp ch yu qua da b xy st, bnh nhn thng thi vi khun
ch yu qua thng tn mi, hng giai on mun, ch yu l bnh nhn th phong u(th L
)v th phong trung gian (th B).
3.1. Thi k bnh : trung bnh 2-3 nm ( 6 thng n 32 nm), cha xc nh c chnh xc.
3.2. Triu chng sm : st nh, bun ng, cm gic vng mng nhn, t c gi tr, kh pht
hin.
l tn ti lu v gim , mt cm gic.
cp,u phong hoc mt cm gic au hai cng bn tay, cng bn chn, pht hin bng chm
+ Vim, sng mt s dy thn kinh nh dy thn kinh tr, cnng, hng khoeo ngoi,dy thn
kinh sng nh hoc sng to ln nhn nh chui ht.
+ Teo c u chi,, teo c giun, c lin ct bn tay, bn chn, c th c c cng chn, cng
tay.Lit thn kinh hng khoeo ngai dn n i lt,i ct cn.Lit thn kinh tr gy vut tr.
Lot g thng bn chn ni t nn do ri lon thn kinh dinh dng, do sang chn khng
bit au, lot su dai dng, kh lnh.
3.3.6. Lon chng bi tit: da kh hoc m qu.It tit m hi ,Da m do ri lon ni tit
+ Vim tinh hon, vim xng, gan, lch to, c th c tn thng ton th cc c quan v l
4.1.1. Theo hi ngh chng phong quc t ( 1953) Madrit, bnh phong c chia lm cc th
sau y:
+ Th T: tc th c.
+ Th B: tc th trung gian.
th nh sau :
Vi trng m tnh hoc dng m tnh Dng tnh Dng tnh mnh
tnh nh
Phn ng m hoc dng tnh Dng tnh m tnh hoc dng m tnh
Mitsuda mnh tnh nh
tin li cho vic p dng a ho tr liu, chia bnh phong ra lm 2 nhm, nhm t vi khun
tr ring.
+ Nhm t vi khun (PB), nhm ny vi khun m tnh, thng l nhng bnh nhn th I, T.
+ Nhm nhiu vi khun (MB), t 1- 6 (+), nhm ny thng l nhng bnh nhn thuc th B,L.
4.3. Bng phn loi bnh phong theo c ch min dch hc ca Ridley v Jopling ( 1966):
+ Bnh phong c phn thnh nhiu th, nm gia 2 cc TT( th phong c, min dch trung
gian t bo mnh)v LL( phong u CMI yu)l cc th l BT phong c trung gian, BB phong
trung gian, BL phong th trung gian- U,LLS phong u di cc,phong u cc LLp.
S minh ho nh sau:
au, vim dy thn kinh, lit ,teo c, mt cm gic d b bng, xy xt nhim khun, lot gic
mc gy m lo, cn bc pht phn ng phong.
6. Chn on da vo cc cn c sau:
+ C m thay i mu sc da km theo mt cm gic au,khng phn bit c nng lnh.
+ Teo c u chi.
mc mi gi l kch pht rch da ( Slit skin smear) cch lm nh sau : st khun vng da tn
thng nghi ng, cng da nh, dng dao sc rch nh 1 ng di khong 0,5 - 0,7 mm su
n chn b, dng li dao gt nh lp mng t chc pht ln phin knh, c nh, nhum ziehl
c knh hin vi tm trc khun Hansen, bng vt thng li.
Phn ng Mitxuda gip tin lng th c,th u.nh gi tin lng th bnh thng (+) tnh
trong phong c, (-) tnh trong th phong u.
Bnh nhn n nhn tin b bnh phong nh mt th chong, tuyt vng, au kh v vy phi
thng bo kho lo, t t trn quan im y hc hin i v ngh thut to cho bnh nhn mt
hy vng , quyt tm tin tng l c th cha khi bnh c.
Hansen.
7. iu tr d phng.
7.1. ng li chung.
+ Mc ch iu tr l nhm cha khi bnh cho bnh nhn nhng quan trng l trnh tn ph,
hn ch ly lan.
+ Ct t ly lan bng rifampicine. Dng rifampicin sau5-27 ngy l bnh nhn ht ly lan cho
ngi khc,tuy cn phi tip tc iu tr bnh.
+ ng li chng phong ca Vit Nam l " iu tr ti gia nh", thanh ton bnh phong tng
vng.
+ Phng chng tn ph, phc hi chc nng bng chm sc hng dn cch tp luyn chm
sc da trnh tn ph, iu tr sm bng vt l tr liu, chng trnh giy dp cho bnh nhn
phong.
+ Cng tc tuyn truyn nng cao hiu bit trong nhn dn v bnh phong, xo b thnh kin
vi bnh phong, cng tc qun l h s cha bnh.
Thi gian 24 thng hoc n khi xt nghim vi khun m tnh BI -= 0, sau ngng thuc theo
di 5 nm.
- t vi khun (PB).
DDS Dapson (Diamino diphenyl sulfon) r tin, c tc dng dit khun, dng ng ung, d s
dng. Rifampicin ( Rimactan ,rifadin) dit vi khun nhanh, ct t ly lan nhanh chng.
Ethionamit v prothionamit.
+ Vt l tr liu.
Phc hi chc nng , chng tn ph, iu tr chnh hnh v ngoi khoa, no phu thut g,
chuyn gn iu tr lit dy thn kinh .
Chng trnh giy dp ng loi giy dp ring thch hp vi tng bnh nhn trnh tn ph.
Hng dn bnh nhn phng chng tn ph, trnh sy xt nhim khun vng mt cm gic, d
7.4. D phng.
L bnh ri lon vn mch tay, chn, pht trin sau khi b lnh lm co nhiu ng mch nh.
1. Lm sng :
Mt hoc nhiu ngn tay t nhin thy trng vng, rn, lnh. Hin tng thiu mu ny lan dn
ln gc chi. c bit ngn ci t b nh h ng. Tun hon ngng t ngt s km theo cm
gic kin b, au but, cng tay v vng v. Cc u chi hi gim cm gic au v chi cng
Cc ngn c mu tr li dn dn xanh tm, c khi thnh en, cng lan ln vng tr c kia c
hin tng ngt. n tay vo c vt mt mu, khi th ra thy nu tr li. u chi lnh, cm gic
tng thm hoc au d di. Nu d cao tay hoc ngm nc m lm gim bt thm tm.
Thm tm u chi trong mt thi gian ri cng gim , cn ngn nu trnh c lnh.
2. Tin trin :
Ri lon dinh dng nng nht l hoi t i xng cc u chi. u chi thm tm en, gii hn
r, khu tr xung quanh v di mng. Xut hin nhng bng nc nh trong c cha nc lm
m v ra li vt trt, bng n c c th kh, khng lot. Nhng vt lot qua i hoc dai
- Hoi t u chi c th c nh ng him, tip theo sau vt lot nhiu ln, hoi t pht trin v
tin trin nhanh. Hoi t c th mt phn, mt t hoc c ngn, nhiu ngn.
- Hin tng co mch ngoi bin : l hin tng sinh l do lnh, xy ra r rt mt s ngi.
Tm ti u chi th ng xuyn, khng au.
to hoc nh mt v hai bn. Pht hin c khi thm d ng mch hoc chp ng mch.
Bin php thm d: ngm tay trong nc lnh < 15 C l bin php n gin nht t thy
xut hin cc triu chng trn.
- o huyt p.
4. Cn nguyn :
5. iu tr :
Rt kh tr mt s trng hp nguyn nhn r v loi tr c nguyn nhn khng gy bnh.
Ct b mt t sng c, bc tch m ri thn kinh xung quanh mch mu, cn bng ni tit,
iu tr tuy vy cng khng khi d dng v hon ton c.
- Phu thut .
1881 Pasteur thnh cng trong ch vacxin phng bnh than cho ng vt.
1. Vi khun than hnh trc khun, to hai u v vung. Kch th c 1-3 x 4- 10 micromet, xp
tng con ring r hay thnh chui di ( Gram dng). Tn ti lu ngoi cnh hay mi tr ng
nui cy. Vi khun khng di ng chng to v v v l yu t c lc ca vi khun .
1.1. khng :
si sau 60 pht, sc nng kh 140 C sau 3 gi, nhit t 120 C sau 15 pht.
1. 2. Kh nng gy bnh :
1. 2.1. c lc :
1. 2. 3 .Gy bnh cho ng vt: bnh than (bnh nhit than) l bnh ca cc loi vt n c: cu
hay gp nht, sau n tru , b, nga, d. Cc sc vt cht th ng do b nhim khun
Pakistan n , I Ran, Trung , Mng c, Nam Phi, bnh ny gp nhiu hn. Australia,
lao ng chn tay, sn xut hng tiu th cng nghip. S ly truyn c th qua cc chn th
ng da. Ngoi ra qua ng tiu ho hoc qua ht th khng kh c cc nha bo vi khun .
Vi khun Anthracis gy ra thm nhim t chc, hoi t, xut huyt v biu hin bng ph cc
phng n c.
Triu chng chung xut hin sau 3-4 ngy c mn m da, khi da tn th ng lot hoc hoi
t th ton trng suy sp, st cao, m sng, nhim trng huyt v thm ch dn ti t vong. Nu
3- Chn on :
- Bnh phm Ly m ch lot, mu, m, phn, cc mu vt phm khc : da, lng, x ng
sa...
- Ph ng php soi knh hin vi : Lm tiu bn nhum Gram pht hin hnh th, xem kh nng
to bo t, to v.
Mi tr ng thch mu 5 %.
Mi tr ng thch thng.
Sau 18- 24 gi t m 37o C, xem tnh cht mc vi khun . Tch cc khun lc nghi ng sang
mi tr ng canh thang v sau th cc tnh cht sinh ho hc.
- Song song tin hnh tim bnh phm d i da chut nht trng hay chut lang, chut s cht
sau 1-2 ngy, m chut ly ph tng lm tiu bn v nui cy phn lp thun khit.
- Cc ph ng php khc :
Cc phn ng chn on nhanh: min dch, hunh quang, phn ng ht chai (penicilin lm
bin hnh vi khun than) hoc chn on bng phagie c hiu.
5- iu tr :
Tim bp tht penicilin 600.000 UI trong 7- 10 ngy.
Hoc Tetraxilin 0,50 g x 5 vin 1 ngy nu c tnh trng nhim c nn dng cocticit , tim c
tc dng .
1. i c ng.
2. Cn nguyn .
Bnh zona gy nn bi virus thu u VZV ( varicellac zoster virus), loi virus h ng da thn
kinh. Bnh thu u xut hin ng i b nhim VZV ln u, bnh zna xut hin ng i
tng b nhim VZV ( VZV tn ti trong r hch thn kinh ), ti hot khi c iu kin thun li
nh chn thng tinh thn hoc th cht, c thai, iu tr phng x, suy gim min dch...
Nhiu tc gi cho rng zna l hin t ng ti hot ca VZV tim n.
3. Lm sng.
4. Cc th lm sng.
+ Zna lin s n v ngc bng th ng 1/2 ng i c khi lan xung mt bn cnh tay ( ngc,
cnh tay).
+ i khi gp zna hng, bng, sinh dc, bn, x ng cng, ngi, i, cnh tay...
mng tip hp gy chy n c mt n vim gic mc, vim mng mt, dn dn lot gic mc,
ri lon ng t, teo gai... Zna ny rt au c th li so quanh hc mt dai dng.
hng.
Zna hch gi ( RamsayHant) c tn th ng vnh tai, km theo ri lon cm gic 2/3 tr c l
i, ri lon nghe, i khi lit mt mt bn, nhc v au nh ng thong qua.
6. Bin chng : th ng gp ri lon cm gic , biu hin au dy thn kinh sau khi tn th ng
ngoi da khi ( khong 50% bnh nhn trn 50 tui b au vim dy thn kinh ).
7. iu tr .
Tu thuc vo giai on, mc d th trng ng i bnh m dng thuc cho thch hp.
+ Ti ch :
M khng sinh....
- Gim au, khng vim, an thn nh seduxen, nhm Diazepam c bit Neurontin (
gabapentin).
1. i cng v nm candidas.
Nhng loi candida thng tp sinh. Nhng trong iu kin thun li th gy bnh ( gy bnh c
hi ).
+ Men chnh cng: sinh sn bng nang m (ascus) trong in hnh l nm men
saccharomyces.
+ Trong phin t chc ( sinh thit b phn mc bnh) cng c hnh si min gi v hnh t
+ Trn da nu thng thy nhiu t bo nm ny chi v si " min gi" cng c coi l dng
tnh. V candida albicans thng khng thy sng tp sinh trn da lnh.
1.3. Gii thiu mt s t l : trong 6 nm t 1960- 1966 ( BV Past) ly 3000 bnh phm cy
c 640 chng candida. Phn b nh sau :
C. krusei 50 ( 48%).
+ Yu t ni lai:
- Bnh nhim trng cp tnh hay mn tnh.
- S dng cocticoid ko di .
+ Yu t ngoi lai.
- Ngi hay tip xc vi ngun nc, hoa tri, thc phm , cng nhn sn xut bia, th git...
cocticoit di ngy.
3.1.2. Nt mp do Candida.
Mp , nt v lot trt, hay km theo ta trong ming v c th lan ra c mt. Thng hay
phi hp vi t cu gy vim mi (Cilite).
v ngn tay, k ngn chn. Thng tn l nhng vt ,ranh gii r, hi g cao, c vy, c khi
Thng tn bt u thng l vim quanh mng, c khi c m c khi khng. V sau mng dy
mng cng c nhng mng vy lm cho kh chn on phn bit, i khi c dch m gc
mng.
Tn thng c th lan ra c bn, nht l nhng ngi b bnh i ng. Bnh rt dai dng,
no y, li pht trin ln. Cc triu chng ln sng thng khng ph thuc vo s lng nm
tm thy trong m o.
thng nga.
3.2.2. Hnh thi u ht (granulomateuse): Thng bt u l mt nt mp, ta, sau lan xung
quanh mng ri vo mng lan c ln da u, c khi c ngi v chi di. Loi ny c mt phn
ng vim lan su xung trung b, to thnh nhng u sn si nh ln nh mn cm rt ln 4-8
mm ng knh, trn c vy. Cy ra y c nhng t chc ht chy mu d dng.
Nhng p xe di da lan to ln c da u.
4. Nm candida ph tng.
4.1. Nm candida ph qun ( bronchique) : thng gp nhng ngi hay ung ch nhiu
n v Ceylan, hoc nng dn p la ht phi bu.
mu.
+ Nghe v X quang c th thy nhng tn thng ging vim phi mt hoc c hai ph
trng.
4.3. Nhim nm candida a- mi- dan: hnh nhn c nhng nt trng nh ta.
4.4. Nhim nm candida ng tiu ho: thng xy ra sau khi dng khng sinh lu di.
+ Candida nim mc ming, li th ra, sc ming bng dung dch natriccbonat hoc chm
hoc fluconazol.
nystatin, nizoral, canesten. Nu tn thng rng th ngoi bi ti ch phi ung thuc chng
nm thuc nhm imidazol nh ketoconazol, itraconazol, fluconazol.
+ Candida h thng hay u ht do candida c th truyn tnh mch chm amphotericin B 0,25-
1,0 mg/ kg th trng/ ngy hoc ung thuc chng nm nhm polyen hay nhm imidazol.
61. U TRNG SN LN DI DA
ti 55 nghn trng,nhng t gi cui thng rng thnh tng on 5,6 t lin nhau theo
phn ra ngoi bnh thng. Vt ch chnh ca sn l ngi, cn vt ch ph l ln. Ln n phi
t sn hoc trng sn, trng sn qua d dy n rut ln. u trng chui qua thnh rut vo h
thng tun hon v i khp c th ln. Sau 24-72 gi k t khi n phi u trng s c tr cc
m lin kt hoc cc c, sau 2 thng u trng to thnh mt nang c v bc ngoi (kch thc
17- 20 x 7- 10 mm), cn c gi l go ln (cysticereus cellulosae), trong nang c dch mu
say xe, ph n c thai hoc st cao... b nn o , nhng t sn gi rng rut non theo nhu
ng ngc chiu ln d dy, di tc dng ca dch tiu ho trng t cc t gi c gii
phng ra xung t trng, hng nghn u trng thot ra khi trng v chui qua thnh rut vo h
tun hon i khp c th, vo cc c, cc m, pht trin thnh nang u trng sn (cysticereus
cellulosae). Ngi c nang u trng sn cn gi l ngi go.
v ln di da, mu da trn bnh thng. U nang sn thng ni mt trong cnh tay nhng
c th ni bt k v tr no v c tnh cch i xng. Rt him khi cc u nm bn cnh dy
thn kinh v gy au dy thn kinh hoc chn p lm ba gy ph voi. U nang sn sau nhiu
+ mt: nang u trng c th nm trong hc mt, mi mt, trong kt mc, thu tinh th, tin
+ c tim: c th lm tim p nhanh, ting tim b bin i, bnh nhn b ngt xu.
4 Xt nghim:
+ X quang, chp no tht hoc soi y mt pht hin thy u nang sn hoc u trng sn ln.
+ Cc phng php chn on min dch hc cng c gi tr chn on, tuy nhin thng c
phn ng cho vi cc loi sn dy khc.
7. iu tr v d phng:
+ Ht b , ht cau.
+ Quinacrin ngi ln ung t 0,9- 1,2 gr chia liu nh. Mt ngy trc khi ung cn dng
thuc nhun trng lm gim cht nhy bm quanh thn sn. Sau khi ung thuc 1 gi phi
dng thuc ty. Nu dng thuc ty chm hn th quinacrin s ngm vo mu gy c.
cao. Bui sng nhai tng vin mt, nhai tht k, nhai 10 pht ung vi mt t nc, Trng v
cc t sn b dp nt v o thi ra ngoi.
chng ph n no.
+ C th phu thut khi tht cn thit v yu t thm m hoc cc u nang chn p cc dy thn
kinh.
7.4. D phng:
trnh bnh sn ln ng tiu ho cn qun l phn tt, khng n tht ln sng hoc cha
nu chn. Nu c bnh sn ln ng tiu ho th cn tch cc iu tr d phng bnh u
nang sn ln di da.
My ay mn chim 25 % s m ay.
1. Cn nguyn :
Ph mch v my ay c xp loi trung gian IgE, trung gian b th, lin quan kch thch vt l
( lnh, nh nng, p xut ) hoc c ng ( Idiosyncrasie).
1.1.2. My ay vt l :
- My ay do nh sng mt tri ph 290 - 500 nm, histamin l mt trong cc trung gian ho hc.
- Ph mch : p sut , rung chn ng, tin s s ng ln sau chn ng, khng histamin khng
hiu lc, corticoids th c ch.
1.1.5. Ph mch di truyn : ri lon Autosome tri nghim trng, ph mch mt, c lc ph hu
hng, au bng do ph mch thnh rut, bt thng h b th, gim cht c ch C1
esterase ( 85%) hoc cht c ch lon chc nng ( 15 %), C 4 thp ph mch do hnh thnh
Bradykinin.
- Trong m ay trung gian b th, b th c hot ho bi phc hp min dch lm gii phng
Anaphylatoxins gy nn tn ht t bo Mast.
bo.
- S khng dung np Salicylat, thc n, cc cht bo qun thc n nh benzoic acid, sodium
benzoat cng nh mt s thuc nhum azo gm tartrazin v cht vng hong hn cho l
trung gian nhng bt th ng ca con ng arachidonic.
c nhn dng l IgG. N gii phng histamine t c hai loi t bo a kim trong mu v t bo
- Trong ph mch di truyn cht c ch esterase gim hoc lon chc nng dn n tng hnh
thnh kinin. Hi chng m ay, ph mch tng bch cu i toan c th l bch cu i toan mu
tng v gim cng vi ph mch v m ay. C nhng bin i hnh thi trong bch cu i toan
gm ph hu v gii phng cc cht bn trong n vo chn b, mt s protein c s ln c
phn b tip theo s gii phng t bch cu i toan trong di collagen v t bo Mast trong
chn b thy b tn ht.
1.2.1.
pht, lin quan xc ng thn kinh lm trm trng bnh, khng dung np vi salicylate
benzoate, m ay mn th ng gp ng i ln, n nhiu hn nam.
2. Tin s bnh .
kh ( trong m ay Cholinergic ).
Triu chng ton thn : st trong bnh huyt thanh v trong hi chng m ay - ph mch, tng
eosinophil trong ph mch, ging khn, th rt, kh th.
Cc c quan : au khp ( bnh huyt thanh, vim mao mch hoi t, vim gan).
3. Khm thc th :
Cc tn th ng da
- Cc kiu .
- Hnh dng bu dc , hnh cung, hnh vng, a vong, kiu hnh c pt v kiu hnh dng k l.
Khm ton thn loi tr c bnh m ay mn (SLE, vim mao mch hoi t, lymphoma)
- T chc bnh l da : ph chn b v m d i da, gin tiu tnh mch nhng khng c bng
chng h hi mao mch v nhn, hng cu xuyn mch. T bo Mast tn ht. Vim quanh
- Huyt thanh hc :
nh gi h thng b th.
- Huyt hc : mu lng tng trong m ay dai dng ( vim mao mch hoi t Necrotizing
vasculitis), gim b th mu, tng bch cu i toan nht thi trong m ay phn ng vi thc
n, k sinh trng v thuc. Trong hi chng m ay - ph mch tng cao bch cu i toan.
6. Chn on :
- Trong m ay trung gian b th, b th c hot ho bi phc hp min dch lm gii phng
Anaphylatoxins gy nn tn ht t bo Mast.
- S khng dung np Salicylat, thc n, cc cht bo qun thc n nh benzoic acid, sodium
benzoat cng nh mt s thuc nhum azo gm tartrazin v cht vng hong hn cho l trung
gian nhng bt thng ca con ng arachidonic.
c nhn dng l IgG. N gii phng histamine t c hai loi t bo a kim trong mu v t bo
Mast da ( Hide M et al. N Engl J Med 1993 328. 1599). y l mt t khng th n tc ng
chc nng hoc t khng th khng FC G RE a c nhn bit 48 % mu huyt thanh bnh
nhn m ay mn tnh v s t ng quan d ng tnh gia hot ho bnh c chng minh.
Nhng t khng th ny c th gii thch v sao iu tr bng huyt t ng tinh khit, globulin
min dch tnh mch hoc cyclosporin lm bnh. Mt s m ay mn tnh c du hiu ca
bnh t min t bo Mast c coi l c s kt hp m ay mn tnh vi bnh tuyn gip t
min.
- Trong ph mch di truyn cht c ch esterase gim hoc lon chc nng dn n tng hnh
thnh kinin. Hi chng m ay, ph mch tng bch cu i toan c th l bch cu i toan mu
tng v gim cng vi ph mch v m ay. C nhng bin i hnh thi trong bch cu i toan
gm ph hu v gii phng cc cht bn trong n vo chn b, mt s protein c s ln c
phn b tip theo s gii phng t bch cu i toan trong di collagen v t bo Mast trong
chn b thy b tn ht.
8. X tr iu tr .
Danozol tr liu di ngy cho ph mch di truyn huyt t ng t i ton b hoc cht c ch
nhn
hoc sn m ay, sn ph
M ay mn tnh 20-50
hng hoc ti nht, thng
t pht
hnh vng c nga. C
vng 30 pht.
63. BAN M AY
- Tn thng c bn
L sn ph (sn m ay) : mu hng hay trng nh mu da, g cao, l chn lng dn rng, kch
thc sn vi mm 1-2 cch mng.
Xut hin t ngt,; bin i nhanh chng trong vng mt vi gii- mt vi ngy, khng li vt
Tin trin tng t vi ngy, c khi ti pht dai dng hng thng.
- Cn nguyn :
+ Ho cht
- iu tr:
- Ti ch : Bi h nc, du km oxide km
+ M Corticoid: Flucinar.
- Ton thn:
+ Vitamin C.
1. i cng : l mt bnh da mt sc t mn tnh, lnh tnh, khng ly, nguyn nhn rt phc
tp, iu tr cn nhiu kh khn lm nh hng v tm l bnh nhn khi tip xc vi cng ng
x hi.
Bnh chim t 1- 4% dn s, xut hin mi la tui ( s sinh, tui tr hoc ngi cao tui),
c 2 gii (t l nam = n) v mi chng tc .
2. Cn nguyn c ch bnh sinh :
3. Lm sng :
hoc rt nhanh), c gii hn r, khuynh hng pht trin ra ngoi vi v lin kt vi nhau. Hnh
dng tn thng l hnh trn, hnh vng trn, rt him biu hin thnh vch ( du hiu
Koebner), ranh gii tn thng c vin sc t. Lng tc vng da tn thng thng cng b
mt sc t. Nhim sc quanh nang lng trong dt trng c th l do nhim sc cn st li
hoc l nhim sc c ti li trong qu trnh iu tr. C th gp phn ng vim trong bnh
bch bin, tn thng tr nn rt, nga v hng . Bnh tin trin lan rng t t hoc xut
Bnh nhn khng c triu chng ch quan g c bit (khng mt cm gic au, nng, lnh).
- Th lan to (Generalized type) tn thng phn b rng ri lin kt vi nhau to thnh hnh
- Th u chi hoc mt ( Acral or Acro- facial type) tn thng khu tr u chi nh mu ngn
4 . Tin trin : bnh xut hin t ngt sau mt chn thng , xc cm mnh hoc sau mt t
phi nng v tin trin rt tht thng ( xu hng tng v ma h, c th n nh hng
nm hoc vnh vin, rt him c trng hp t khi ).
+ Chn on quyt nh :
- Triu chng ch quan : khng b ri lon (c th khi phi nng tn thng hi hng ln, rt v
nga nh).
- Phong bt nh.
- Lang ben.
+ Gii thch cho bnh nhn khng mc cm vi bnh tt, chng t ti ngi tip xc , dng cc m
phm xo tn thng khi cn giao tip.
+ Dng meladinin 10 mg .
Ung 2 vin/ 1ln/ ngy , sau ung 5- 10 pht cn phi nng hoc chy tia t ngoi
Dung dch meladinin bi vo tn thng, sau bi 3-5 pht cng phi nng hoc kt hp iu tr
tia t ngoi.
+ Dng dung dch melagenina bi vo tn thng, sau khi bi 3-5 pht cng nn phi nng.
1. i cng : l mt bnh him do Bowen m t t 1912 coi nh mt lon sng tin ung th.
2. Triu chng lm sng : bnh gp ngi trung nin hoc ngi cao tui, bt c vng
no trn da hoc nim mc (sinh dc v ming) . Tn thng trn da l nhng m hnh a
ng n c hoc hnh cm 10- 20 m. Cc m mu nu sm hoc hng hi g cao,
phng, nh nh bo tm hoc thnh mng rng, b vng cung kh r. Cc m tn thng cn
c c im lm trung tm , xung quanh x x c gai nh ht cm, trn ph vy da v vy tit.
Bnh Bowen tin trin qua 2 giai on: giai on u 3- 10 nm tn thng tng i n nh.
+ Chn on phn bit : vi bnh vy nn, lupt , ht cm da du, giang mai III, lao da dng
ht cm, liken ht cm...
Bnh c tin lng tt ngi tr tui, tin trin tng t, tht thng, cc tn thng li cc
dt thm mu ri dn dn mt. Khi bnh nhn trn 60 tui, tin lng d dt hn hay st, gy ,
mt ng v thm ch t vong.
bnh nhn DH c mt t l cao 85- 90% HLA- B8 v HLA- DRW3. 2.2. Yu t khng th
(KT) v b th.
Bng test min dch hunh quang trc tip, lng ng IgA thnh ht 85- 90% bnh nhn v
to thnh ng( thnh vch 10- 15%) bnh nhn DH, cng vi lng ng C3 xp xp
thnh tng ht lp ng b.
2. 4. Vai tr ca gluten.
ph bin bnh nhn DH. Gluten l mt protin c trong ng cc (loi tr la v ng). Trong
thnh phn ca gluten c gliadin. Gliadin lin kt vi reticulin. Chnh reticulin l thnh phn
quan trng vng mng y, n ng mt vai tr lm tng s bm dnh ca mng y. Gliadin
kt hp vi cht ngoi t bo lm tng nht ca m. Trong DH, tng nht ngoi t bo
s kt hp vi s khuych tn ca dch t chc nh b v dn n hnh thnh mn nc.
Nm 1966 Marks , l ngi u tin m t bnh l d dy- rut khng triu chng bnh nhn
DH. Mt vi tc gi khc cn thy c s teo nhung mao rut non l th pht i vi s nhy
u c ri lon chc nng rut non. Nhng bnh rut non bnh nhn DH thng nh hn
bnh CD.
3. Triu chng lm sng:
bnh nhn st nh hoc khng st, mt mi, st cn, km n khng ng k. Trn cc vng da
sp tn thng thng c du hiu bo trc m in hnh l nga, sau l rt bng hoc
au.
V tr tn thng ch yu l da, mang tnh cht i xng, mt gp cng chn, cng tay, cnh
tay, k tip l mng, k mng, i, sau l lng v bng, him khi c tn thng k
nch, vng xng cng. Tn thng nim mc ming ch pht hin c 4,6% s bnh
nhn DH.
Tn thng lc khi pht l cc ban , mn nc, sn, sau dn dn tr thnh bng nc, sp
Bnh tin trin thnh tng t, c lc tng lc gim, c lc tm n nh nhng sau li ti pht,
c trng hp bnh ko di sut i nhng bnh nhn vn sinh hot lao ng gn nh bnh
4.1. Xt nghim mu: c th c bch cu i toan tng > 10% (thm ch t 20- 90%).
4.2. Test KI
Test c tin hnh vi iodua kali (KI) bng ng ung, liu duy nht 1 gam, hoc bng
cch bi ti ch m KI 50% trong vaseline ln da thng. Phn ng xut hin sau 24- 48 gi
di dng ban nga hoc bng nc nga.
4.3. T bo Tzanck.
y l test c gi tr nht trong chn on bnh DH. T l dng tnh 85- 90% trng hp. Test
Hnh nh in hnh l bng nc di lp thng b. Khng c hin tng tiu gai. Dch bng
nc mu vng chanh. Thm nhim bch cu trung tnh v bch cu i toan chim u th.
trung b c s thm nhim xung quanh mch mu bi t bo lymph, bch cu trung tnh, bch
cu i toan. Hnh nh vi p xe nh nh b.
5. Chn on:
+ Lm sng (in hnh vi 4 triu chng ): c nga da trc khi xut hin tn thng , ban
, sn, mn nc, bng nc. Tn thng nim mc rt him. Du hiu Nikolsky thng m
tnh.
+ Cn lm sng: bch cu i toan tng trong mu.Test KI dng tnh. T bo Tzack m tnh.
Xt nghim m bnh hc l chc chn nht. Test min dch hunh quang trc tip dng tnh
ngay c trong thi k bnh n nh.
chanh...
+ My ay: tn thng l ban , sn, ph, thng c nga nhng c bit xut hin nhanh v
mt i nhanh.
+ Ngoi ra cn phn bit vi bnh zona, sn nga th bng nc, ly thng b bng nc bm
sinh.
6. iu tr v d phng.
+ Ton thn:
- Corticoid 30- 40 mg/ ngy , sau h liu dn trong 4- 8 tun, ch dng cho cc trng hp
nng.
+ c bit ch : ng vin tinh thn t tng bnh nhn, b sung dinh dng, chm sc ti
ch, gi v sinh rng ming, nng cao th trng chung cho bnh nhn.
1.1. Eczema l bnh ngoi da ph bin, ngy nay v trong t ng lai do yu cu cng nghip
ho, s dng nhiu ho cht Eczema ngh nghip s ngy cng tng ln.
1.2. C th nh ngha Eczema l mt trng thi vim lp nng ca da cp tnh hay mn tnh,
tin trin tng t hay ti pht, lm sng biu hin bng m mng da, mn n c v nga,
nguyn nhn phc tp ni gii, ngoi gii nh ng bao gi cng c vai tr " th a d ng", v
m hc c hin t ng xp bo ( Spongiosis).
2. Nguyn nhn .
cht dng trong cng nghip, trong gia nh (cao su, kn, crm, xi mng, sn...)
Mt s bnh ngoi da gy nga ( nm, gh...) do ch xt, bi thuc linh tinh... c th tr thnh
eczema th pht.
- Ri lon chc phn ni tng, ri lon thn kinh, ri lon ni tit c th l nguyn nhn trc
tip hoc gin tip gy eczema.
2.3. D nguyn nhn ni gii hay ngoi gii cng u c lin quan n phn ng c bit ca
c th dn n phn ng d ng ,bnh nhn c " th a d ng ".
3. Triu chng .
3.1. V tr :
c tnh cht bt k ,vng da no cng c th b eczema, tuy nhin tu theo tng th lm sng
hay v tr no ( s trnh by phn th lm sng ).
3.2.1. Giai an da: bnh bt u bng trn da xut hin vt hoc m , hi n, cm nh,
ranh gii khng r, rt nga - trn nn xung huyt nhn k thy c nhng sn trn lm tm
nh ht k ( thc cht l nhng mn nc ang t di n ln ) y l phn ng u tin ca
biu b.
- Nng, t v.
- n t d i ln ht lp ny n lp khc .
3.3. Giai an ln da non : giai on ny m tn th ng gim vim, gim xung huyt , gim
chy dch, cc vt cht kh, ng vy, ln da non thnh mt lp da nhn bng nh v hnh,
Eczema tin trin lu ngy da cng ngy cng sm mu, tng nhim cm, b mt x x th rp ,
Chia thnh 4 giai on ca eczema d hiu tin trin cu mt eczema nh ng trn thc t
cc giai on khng thc phn chia r rt nh vy m thng xen k nhau, lng vo nhau . V
d trn m tn th ng c vng l giai on chy dch, c vng bt u ln da non , lc
phi nh gi xem tn thng giai on no chim u th m chn on giai on cp, bn
cp, hay mn lichen ho. sang giai on sau c khi v mt nguyn nhn no ( ch xt,
bi thuc khng ph hp) li tr li giai on trc.
- Nga l triu chng xuyn sut, xut hin sm nht tn ti dai dng, ngi ta coi bnh
Tin trin : mn tnh hay ti pht, nhiu t vng bnh, xen k cc giai on tm .
4. Cc th lm sng :
kh, dy cm v c vy da.
- Ngng tip xc bnh thuyn gim, tip xc li vi d ng nguyn bnh ti pht hoc nng ln.
test p da, test con tem ( Patch test) nh ng khng lm khi bnh ang vng hay ang iu tr
corticoids.
- Eczema tip xc c c ch min dch thuc tp IV tng mn cm loi hnh chm c vai tr
lymph T khc vi vim da tip xc khng d ng ( nonallergic) thng gi l vim da tip xc
kch ng ( irritant contact dermatitis) khng c c ch min dch d ng, th ng do tip xc cc
cht ho hc c nng cao ( nh axid v kim mnh) v hu nh ai tip xc u b vng
da tip xc .
iu tr :
- M corticoids ti ch.
- Corticoids ung khi bnh lan rng hay tn thng mt, sinh dc, ung vo bui sng.
bnh nhn c tin s gia nh b hen, vim mi d ng, st ma c kh ( hay fever) hoc
eczema. Khong 10 % tr em c mt vi dng biu hin ca vim da c a
C s hnh thnh v tng IgE cn gi l vim da tng IgE, c mt phn ng tng mn cm do
gii phng cht hot mnh t t bo Mastocytes hoc Basophils.
IgE tng cao 80 % s bnh nhn AD v cng cao nu AD cng nng , mc IgE bnh nhn
bch cu suy yu, suy yu chuyn dng lympho ( TTL gim ) . Mt khc suy gim s l
ng TS tc l t bo lympho mang th th H2, chnh cc t bo ny c chc nng sn xut ra
mt yu t c ch sn xut IgE do histamin pht ng, IgE c sn xut tng cao do thiu
yu t ny. Ngoi ra IgE tng cao cn do trong bnh AD c tng cao AMP - Phosphodiesterase
trong t bo B/ hoc t bo T gip ( T h tr) lm cho tng hp IgE tng cao.
- Trong bnh AD min dch trung gian t bo b suy gim gim st tnh phn ng trong test da
chm nh Tuberculine , Candidine...
- C s tng cao hot tnh ca Nucleotid- Phosphodiesterase lm thu phn nhanh chng cht
- Tin trin mn tnh- cc t v ng bnh xen k thi k thuyn gim , c khi chuyn thnh hen
hoc st ma c kh.
- Cc yu t lm trm trng bnh l do d nguyn hay do thc n, xc ng cng thng thn
kinh, ri lon kinh nguyt, bnh l tuyn gip, nhim t cu c bit l t cu vng
Staphylococcus aureus, cn ch mt s cht len d lm tng bnh.
+ Vim da : dt km sn mn nc.
+ Hn c tru.
Bnh hay gp tui u th t 2 thng n 2 tui, tr em, thanh thiu nin v c ngi ln.
3 thng tui, ban u m, trn ( hnh mng nga) , quanh ming, u , sau c th b c, mt
dui, thn mnh, bn. Tn th ng l dt , c nhiu mn nc trn b mt, trt, chy dch
mnh, nhim khun th pht c m, vy tit.
4. 2.2. Thi k tr em ( child type atopic dermatitis): tr em ( childhood) hoc thanh thiu nin (
- Bi m glucocorticoids.
- Corticoids ng ton thn ( ung) nn hn ch dng, ch dng cho giai on vng bnh
v dng tng t ngn.
epidermophyton.
PUVA kh hiu qu .
Chiu UV
5. iu tr :
5.1. iu tr chung :
- Vi eczema ang trong giai on cp tnh cn ngh ngi, hn ch cht kch thch ( c ph, r
u...)
- Cho thuc gii cm, chng nga, chng d ng: khng histamin tng hp .
nu khng c chng ch nh
5.2. iu tr ti ch :
- i vi eczema cp tnh chy nc, lot trt, dng cc thuc du da, st khun, chng nga,
ro nc nh p gc dung dch thuc tm pha long 1/ 4000, nc mui sinh l 9 %, Nitrat bc
0,25 %, Rivanol 1 %o, dung dch Yarish trong 5- 7 ngy u sau bi thuc mu dung dch
tm Metin 1 % , dung dch Milian, kt hp h nc.
- Khi tn th ng kh cho bi tip du km cream, m corticoid + khng sinh ( cream Synalar,
neomycin, cream celestoderm -neomycin....)
c lot. Bnh din bin nhiu nm (10, 20, 30) nm c khi c i, c lc rm r, c nhng thi
k ngm ngm khng c triu chng g lm cho ngi bnh lm tng l khi v th ly
truyn cho th h sau.
dn tc.
Chu u ngi ta cho rng bnh lan truyn do Christopho Colombo cng 44 thu th mang
bnh t Haiti v Ty Ban Nha v sau do bnh lan thnh dch Chu u vo u th k 16.
Vit Nam bnh xut hin thi k no cng ch a xc nh r. C thuyt cho rng bnh c t lc
lnh ca Gia Long vin chinh sang Xim La (Thi Lan) mang bnh v (th k 18) v vy mi c
tn l bnh tim la.
Gn y ngi ta cho bnh giang mai l mt trong nhm bnh xon khun gy nn :
- Bnh Pian (gh cc): nguyn nhn do T.Pertenu . Bnh ny gp Ty Nguyn- Vit Nam v
2. Mm bnh:
- Di ng qua li nh mt qu lc ng h.
- Di ng l n sng.
mi tr ng m t c 3 loi di ng ny c th tn ti v ko di n 2 ngy .
Xon khun giang mai l 1 loi vi khun yu, ra ngoi c th n khng sng qu c vi ting
Nhng nm gn y bnh giang mai tng nhiu nc. Bnh tng r rt cc n c nhit
i v cc n c pht trin.
Hnh thi lm sng c khc nhau tu theo ging ngi. Th d: ngi da en thng hay c
biu hin vim nhiu hch trong giang mai sm hoc hay c sn hnh nhn, mn m, vim x
ng khp, vim mng mt hoc trong giang mai mun th hay gp bin chng tim mch. Ngc
li giang mai thn kinh, ( tabes) lit ton thn li rt him gp ngi da en.
Vit Nam tr c nm 1945 v trong thi k Php tm chim cho n nm 1954, bnh giang
mai ng hng th 2 sau lu. Phn nhiu bnh nhn t cha hoc n thy thuc t nhn nn
s liu khng chnh xc.
nm 1954.
T 1965-1975 l thi k chin tranh, trt t v np sng b o ln, tm l sinh hot khng
bnh thng, y t kh khn, cc bnh hoa liu tng ln min Bc v c bit n nm 1975
T 1975 n 1990, mi nm ngnh da liu iu tr cho khong 10-20.000 bnh nhn giang mai.
Ngun bnh: l ngi mc bnh giang mai k c giang mai kn, giang mai.
ng ly truyn: l ng trc tip tip xc gia ngi bnh v ng i lnh hoc gin tip
qua vt. Ta c th khi qut c 3 ng chnh sau:
Theo c in bnh giang mai tin trin lm 3 thi k : giang mai 1, giang mai 2, giang mai 3.
Giang mai mi v ly
Gia thi k 1 v 2 c giai on khng c triu chng lm sng v gia thi k 2 s pht n
thi k 2 ti pht ( giang mai ti hi) cng c giai on khng triu chng lm sng gi l giang
mai 2 kn sm.
Gia thi k giang mai 2 ti hi c giai on khng triu chng lm sng gi l kn mun sau
n giang mai 3.
Thai nhi b ly t m khi cn nm trong t cung nn khi ra mc bnh, d i nhiu hnh thi
khc nhau.
- Di chng ca giang mai bm sinh:cc th ng tn giang mai thai nhi thnh so v khi b
rt mnh (nhiu xon khun ti cc tn thng, bnh nhn khng c cm gic ch quan vn
Giai on ny xut hin sau khi bnh 3-4 tun hoc 3 thng v ko di 1-2 thng vi cc triu
chng sau:
4.4.1.Trt pht ngay ch xon khun t nhp vo c th, n ng khu tr quy u, rnh
quy u, nhng cng c th ming so, hm, bu, vng xng mu trc trng quanh
hu mn i vi ngi c quan h ng gii.
c im ca trt l:
- Vt trt nng hnh trn hay bu dc bng phng vi mt da, mu t i, khng c m, khng
c vy th ng n c.
- Nn rn nh mnh ba.
1/3 s bnh nhn c nhiu trt lot, 25% c lot gy au v khng c nn rn nh c in. C
th trt bi nhim, trt hoi t hoc trt khng l.
25% bnh nhn giang mai khng c lot m biu hin l th ng tn ca thi k 2. Trong thi
k bnh do dng penicilline lm cho lot xut hin chm hoc khng xut hin.
n ng i khi chancre khu tr niu o hi su trong ming so, ch thy t tit dch nhy
v rn chc. hm dng vt lot trng gingnh mt vt nt hnh raquette (vt). Nu trong
bao quy u s gy ph n nhiu lm cho d ng vt hnh chung, vt (raquette).
nhim v au but. Cc khu tr khc ngoi sinh dc nh mi, nm v, ngn tay u c au.
Lot t khi sau 5-6 tun, th ng ch li so nng v mng. Nu c iu tr xon khun
ht sau 24 - 40 gi v th ng tn lnh nhanh chng.
4.4.2. Vi ngy sau khi c trt, cc hch vng ln cn thng vim to thnh 1 chm gm nhiu
hch trong c 1 hch to c gi l hch cha. Bt u hch 1 bn, sau c th c 2 bn.
Hch c cc tinh cht nh sau:
-Rn.
-Di ng.
-Khng lm m.
u c xon khun.
Giang mai thi k 2 xut hin: trung bnh khong 6-8 tun sau khi c lot. Cc thng tn
nim mc xut hin rm r v lan to trong khi 1/3 s tr ng hp chancre giang mai vn tn
ti ch a mt ht.
Ng i ta chia giang mai thi k 2 thnh: giang mai thi k 2 s pht v giang mai thi k 2 ti
pht.
m, mn m.
- Cc th ng tn giang mai 2 ti pht th ng thnh hnh vng cung, hnh nhn v khng i
xng.
- Nhng biu hin ton thn: vim mng mt, vim gan, vim hng khn ting, vim mng x
ng, au rc x ng i v m, vim thn, biu hin thn kinh.
Cc thng tn ca giang mai 2 tin trin thnh tng t trong vng 2 nm u, cng v sau th
ng tn cng n su xung v khu tr li.
Thi k ny c th chia lm 2 giai on: khong 2-6 thng sau khi xut hin cc th ng tn ca
thi k ny bnh khng ly lan na, bnh nhn tng khi tuy nhin vn ly lan cho thai nhi
Giai on giang mai kn mun c th ko di nhiu nm,thm ch sut i bnh nhn khng c
triu chng g. Tuy nhin 1/3 s bnh nhn ny sang nm th 3 tr i s thy cc triu chng
ca giang mai 3.
Thng t khu tr vo da, nim mc, c bp, khp, mt, h tiu ho, gan, ni tit. Th ng tn
ch yu l:
- Cc c s lng t, khu tr 1 vng, khng i xng hay gp phn trn lng cc chi. C ni
cao trn my da, trn, trn, thm nhim, khng au, ng knh di 1cm, hnh nhn, hnh
cung, hoc vng vo, lnh gia, pht trin ra xung quanh, c khi c vy nh vy nn.
+ Giai on cng: 1 khi rn, trn, ranh gii r di da, b mt da vn bnh thng.
Chim khong 10% cc bnh nhn giang mai khng c iu tr. Thng xut hin mun
khong 10-40 nm sau khi b bnh.
thng. Khi ng mch gin rng th pht hin bng chiu X quang.
- Tr ng lc c gim
- Ri lon cm gic su (khng ng c khi nhm mt)
Bi lit ton thn, cc ri lon tm thn. Xy ra khong 10-25 nm sau khi b bnh v chim
Trong thi k thai nghn giang mai c nhng c im: lot giang mai khu tr mi nh thng
c kch thc to hn bnh thung, ngc li cc triu chng khc ca giang mai 2 thng
khng r rt nn rt kh chn on.
S ly truyn bnh giang mai t m sang thai nhi khng xy ra trong 3 thng u ca thi k
thai nghn m xy ra t thng th 4, th 5 tr i (tun th 16, 18, 19 ca thai ).
Tu theo mc nhim bnh nhiu hay t m c nhng biu hin khc nhau.
Nu nhim nh hn na th ra c th bnh thng nhng va ngy sau hoc trong vng 6-8
tun thy xut hin thng tn giang mai mang tnh cht ca thi k 2 nh bng nc lng bn
tay, chn, nt mp quanh l mi, chy nc mi ln mu hoc vim x ng sn, au cc u
chi, gi lit Patrot. Hoc tr ra gy g nhn nheo nh ng gi, bng to, gan lch to.
Cc triu chng ca giang mai c th xut hin mun hn lc 3-4 hoc 5-6 tui. l giang mai
bm sinh mun. Cc triu chng giang mai bm sinh mun thng mang tnh cht ca giang
mai 3.
C th khng c biu hin lm sng m chn on phi da vo phn ng huyt thanh (giang
mai kn).
- Vim mng mt k (Interstitial keratitis) hay xut hin lc dy th, bt u bng cc triu chng
nhc mt, s nh sng 1 bn v sau c 2 bn. C th dn n m.
5.1. Tm vi khun:
Ly bnh phm trn vt trt, vt lot hay trn sn, mng nim mc, chc trong hch.
Soi trc tip trn knh hin vi nn en, xon khun nhn thy di dng l xo di ng.
+ Phn ng khng th xon khun hunh quang. FTA (Fluorescent treponemal antibody)
Tpeponemal Antiboly Test v FTA abs (Fluorescent treponemal antibody absorption test n
gin hn TPI nh ng c hiu hn nn c s dng rng ri khng nh chn on.
6. iu tr:
Ph ng php tr liu bng Asen, Bismut, thu ngn tt nh ng bt tin, phi ko di trong 4 nm,
t bnh nhn theo ui cho ht t iu tr. Hn na s iu tr ny c nhiu tai bin nng c
th a n t vong.
- Giang mai mi xon khun pht trin nhiu th tc dng ca penicillin cng tng.
- Giang mai mum xon khun t pht trin th tc dng cng km v vy cn ko di thi gian
iu tr.
- gi nng thng xuyn ko di, ngi ta hay dng cc loi penicillin chm tiu
Nu dng Benzyl penicilline tinh th ho tan trong nc th sau 20 pht c th thi ra ngoi
50% s lng v vy phi tim cch 2- 3 gi 1 pht th tc dng mi tt.
Cc phc iu tr
- Hp tc nhiu ngnh gio dc nam n thanh nin sng lnh mnh - Bo v thun phong
m tc ca dn tc.
-Chng nn mi dm gi im.
- Ci to gi im.
- Xy dng qui ch c i xin (cn kim tra sc kho trc khi cho ng k kt hn).
-T chc lng ghp cc hot ng phng chng bnh vo hot ng ca mng li a khoa.
69. BNH LU
(Gonorrhoea )
1. i cng.
+ L mt bnh nhim khun ly truyn qua ng tnh dc, tng i ph bin ( chim 3-15%
trong tng s cc bnh LTQTD), cn nguyn do vi khun Neisseria gonorrhoeae , triu
chng lu cp in hnh l i but, i ra m, nhng phn ln li gp l lu mn tnh vi cc
triu chng khng in hnh, bnh c th li nhiu bin chng cho bnh nhn.
+ Mt vi yu t dch t:
Tui ca bnh nhn: gp mi la tui t s sinh n ngi cao tui, nhng thng thng la
tui tr hot ng tnh dc mnh, nam v n u c th b bnh, n gii t l bnh lu khng
c triu chng nhiu hn nam. Ngi bnh l ngun duy nht ca bnh lu ( ly truyn qua
hot ng tnh dc ng gii hoc khc gii, ly t m sang con trong giai on chuyn d v
).
+ Tnh hnh khng khng sinh ca vi khun lu: cho n nay cc khng sinh sau y cn c tc
+ bnh: l 3- 5 ngy sau khi quan h tnh dc vi ngi b bnh lu ( 90% trng hp).
+ Lm sng :
- Vim niu o trc cp tnh: gp trn 90% cc trng hp. Triu chng lm sng sm nht
l c cm gic nga nhiu hoc t ming so, h thuyn, cc mp ca ming so tr nn ty
. Lu cu pht trin nim mc niu o trc gy vim xut tit. Cht nhy chy ra km
theo cm gic i nng, but nh. Sau chy m mu trng c hoc vng c. Cm gic
nng but tng ln r, c khi i rt but lm bnh nhn phi i tng git, th nghim nc
tiu 2 cc th ch c cc nc tiu th nht c.
- Vim niu o ton b : khi bnh khng c iu tr kp thi v y , sau 10- 15 ngy,
bnh nhn b i dt, i kh, c th i ra vi git mu cui bi, m chy ra nhiu, hch bn c
th sng au, hay b cng dng v au rt khi dng vt cng ln. Th nghim nc tiu 2
cc th c 2 cc u c
cc tn thng sau:
+ Bin chng xa hn :
2.2. n gii .
+ Lm sng :
- Rt him khi c triu chng lm sng cp tnh. Biu hin lm sng bng i dt, au sau khi
giao hp, au vng xng chu. Khm thy vim niu o, vim c t cung c m, vim m h,
m o, c khi vim tuyn Bartholin, vim niu o v tuyn Skne.
gic nng hay rt khi i tiu, l niu o bnh thng, n vo niu o c m chy ra ( khm
- Vim phn ph (vi trng): vim lan t m o, c t cung ln. Him khi theo ng mu.
3. Chn on khc :
- Do nm Candida.
+ Lu pht hin cc bnh LTQTD khc nh giang mai, nhim HIV/AIDS, xt nghim kim
4. Chn on .
4. 1. Chn on lm sng da vo .
+ Chn on xt nghim :
- Phng php xt nghim trc tip: nhum bnh phm, soi thy vi khun lu bt mu gram (-)
nm trong v ngoi bch cu a nhn.
Mi trng thch hp nht l mi trng chn lc thayer- martin (TM) hoc thch scola, nhit
5. iu tr v d phng.
5.1.Nguyn tc chung.
vi khun a phng .
+ Bnh nhn cn phi ngh ngi, trnh i xe p, i nga, chy nhy gy sang chn b phn
sinh dc - tit niu.
Ceftriaxone 1 gram / 1 ngy tim bp x 3- 7 ngy. Sau dng Doxycyclin 100 mg x 2 vin/
ngy x 7 ngy.
Cc trng hp nng hn (bin chng vim mng no, vim ni tm mc do lu) cn dng liu
lng trn nhng phi ko di n 4 tun l.
DO BORRELIA.
1. i cng:
Bnh Lyme l mt bnh ly truyn t ng vt sang ngi (do ve t), tc nhn gy bnh l
do xon khun Borrelia burgdorferi (B.b) .Bnh gy thng tn ch yu da, h thn kinh, tim
v khp.
Taylor (1876), Buchwald (1883) ri Pick (1894) m t l bnh teo da khng r nguyn nhn,
sau Kaposi (1897) gi l vim da teo. Herxheimer v Hartmann (1902) gi l vim da vin
Bnh ny trc y hay gp vng trung u v Alsacl (Php); gn y hay gp Lyme bang
Connecticut (M) bnh c mang tn l bnh Lyme.
+ Tc nhn gy bnh
- Xon khun Borelia burgdorferi di t 10- 30 mm, rng t 0,2- 0,25 mm. Khc vi T. pallidum
l: B. burgdorferi c th nui cy c mi trng nhn to, chu k sinh sn (khi nhit
30- 34 C) l 7- 20 gi. Mm bnh c th tm thy trong mu, da, dch no tu, mt, dch khp
Bnh Lyme c th chia thnh 3 thi k lm sng nhng cc thi k c khi khng tch bit r
rng m c th chng ln nhau.
+ Thi k 1 ( xut hin sau khi nhim B.b t vi tun- vi thng ): ban di chuyn l mt loi
+ Thi k 2: vi tun hoc vi thng sau khi b nhim khun. Biu hin thn kinh c th l vim
mng no- r thn kinh , vim dy thn kinh s no (ch yu l dy thn kinh mt), vim m
ri thn kinh, vim nhiu dy thn kinh n c v him hn l vim no tu v vim mch mu
no. Hi chng Bannwarth l biu hin thn kinh hay gp nht ( chu u) c c trng bi
tng lymph bo trong dch no tu v au r dy thn kinh. Vim mng no thng c
th c v r nht l tr em.
Tn thng tim l bloc nh tht nht thi cc mc khc nhau, ri lon nhp, vim c- mng
tim, suy tim. U lymph biu hin bng thm nhim da ging nh u, cc, mu - xanh xanh hay
thy di tai hoc nm v. au khp ( gp cc thng u ca bnh ) v au c chng t c
tn thng c- xng. Mt s du hiu khc ca thi k 2 c th gp l tn thng mt (vim
mng tip hp, vim mng mt mi, vim mng mch, vim th gic thn kinh vi ph n gai
th, vim ton mt), gan to, vim gan v him hn l ho khan v sng tinh hon.
+ Thi k 3: tn thng xut hin chm hng thng, hng nm sau khi nhim B.b . M,
khong 60% bnh nhn khng c iu tr b vim nhiu hoc mt khp, cc khp ln nh gi
thng hay b nht. Bnh nhn Chu u hay gp th ACA (acrodematite chronique
atrophiante: vim da vin on mn tnh teo, cn gi l bnh Pick- Herxheimer). ACA gy tn
+ Xt nghim .
Cy B. burgdorferi kh thc hin. Thng s dng huyt thanh chn on. Trong tiu bn sinh
thit c th pht hin xon khun bng phng php nhum bc v k thut min dch- t chc.
C th s dng ELISA hoc IFA (min dch hunh quang gin tip) hoc Western blot. Kt qu
6. iu tr:
+ Ngi ln:
+ Tr em (< 8 tui)
Amoxilline hoc Penicilline 250 mg x 3 ln trong ngy hoc 20 mg/kg/ngy. Chia nhiu ln x
10- 30 ngy.
6.4. D phng : nhng ngi cng nhn lm nghip, chn nui gia sc trn ng c cn lu
phng trnh ve t gy nhim bnh.
71. BAN NHIM SC C NH TI
PHT
Th.S Nguyn T
1. nh ngha.
mt s v tr (c th thm v tr mi), thng xut hin vi gi sau khi ung thuc, s xut hin
tn thng th ng c bo tr c bi cm gic nng bng v cng v tr m sau s mc
tn th ng.
+ Nguyn nhn thng gp nht ca BNSC l do cc nhm thuc : cm st, khng sinh,
sulfamid, an thn v gim au.
hc gn gi.
3. Lm sng.
3.1. V tr :
Bt k v tr no, nh ng hay gp b phn sinh dc, quanh ming, quanh mt, c th gp
bn tay, thn mnh, mt...
3.2. Tn th ng:
L vt (m mng) da, hnh trn hoc bu dc, ng knh 1 n vi cm, hi n, ranh gii
r rt, mu chi, sm, tm, c n cm lm vt g cao hn. C khi trn b mt c bng
n c v trt ra. Khi khi li dt mu thm, nu, tm en do nhim sc t sau vim, tn ti vi
thng n vi nm.
Hay ti pht, do bnh nhn nhng ln u khng bit l bnh do d ng thuc, nn li dng
thuc lm bnh ti pht, sau khi ung thuc 30 pht n 8 gi s xut hin tn th ng, tn th
ng ko di nu vn dng thuc, sau khi ngng thuc vi ngy n vi tun th tn thng
bin mt. Cng ti pht nhiu ln tn th ng nhim sc cng nhiu v tn ti lu (mu thm
en).
Th ng khng c triu chng ton thn, him ca gp st, nhc u, ri lon tiu ha.
3.5. C th c mt s th lm sng khc nhau nh :
Th ng khi sau vi tun sau khi ngng thuc, ti pht xy ra vi gi sau khi ung thuc, vt
nhim sc sau vim tn ti lu vi thng, hng nm, cng ti pht nhiu ln th tn thng cng
thm en.
4. Chn on.
+ V tr s l ng tn th ng.
+ Ban a dng.
+ Hi chng Stevens-Johnson.
+ Ton thn dng khng histamine tng hp, corticoid, vitamin C, clorua canxi tim tnh mch
chm.
Phng bnh:
Thn trng trong vic dng mt s thuc gy bnh nh ni trn, nht l nhm thuc cm
st, khng sinh, sulfamid, thuc ng.
Nhn din v ngng dng thuc gy bnh ; nu b mt ln th khuyn bnh nhn khng dng
li thuc , cc dng khc ca thuc cng c th gy phn ng cho.
TRACHOMATIS
2- Cn nguyn .
- C. trachomatis l nhng vi khun k sinh bt buc trong t bo gy nn hai loi bnh .
+ Bnh au mt ht ( Trachoma).
+ Bnh vim nhim ng sinh dc, niu o, bnh ht soi ly theo ng tnh dc.
- C. trachomatis c kch thc 0,3 - 0,4 mm, c vch t bo . Cc loi C.trachomatis c khng
nguyn chung l cht lipopolisaccarit . Loi vi khun ny c chia thnh 15 serotyp, trong
gy bnh sinh dc , tit niu do serotyp D- K , gy bnh ht soi do L1, L2, L3.
- Sc chu ng : d cht bi nhit nng ( 60 C trong 10 pht) chu c lnh trong nhiu
nm nhit m 50 C. Cc dung dch st trng thng thng u git cht vi khun trong
thi gian ngn . Tuy nhin chng c th tn ti trong nhit kh, hanh ( trong khn mt, qun
o ) mt thi gian.
3- Ngun bnh .
- Nhiu ngi kho mnh c th mang C.trachomatis vi t l nht nh : nam gii 1-7 %, n gii
5- 20 %. ph n no thai t l nhim t 15- 18 %.
4- ng truyn bnh .
- Con trong giai on s sinh b mc bnh hoc h hp do ly truyn trc tip t cc dch m
- Hi chng Reitr: vim kt mc, vim a khp. Nhng bnh nhn b hi chng Reitr c mt
khng nguyn c hiu ( HLA- B27) c yu t di truyn i vi bnh . Kt lun dn n suy
- Vim c t cung : triu chng lm sng biu hin bng cc vim c t cung chy m, ph,
km l tuyn c t cung. Tuy nhin vn thng c nhng trng hp khng c triu chng lm
tnh do nhim chlamydia trong s bnh nhn n khm vim phn ph.
+ Ngi ta cng thy c s t ng quan gia thai nhi cht v cht ca tr s sinh vi nhng ng
i m mang thai, b nhim C.Trachomatis.
5.3. Tr s sinh .
tnh cht kinh din, lan to, ho thnh cn nh ho g nhng khng c ting ging nh ting g
gy th th vo. Km theo c tng hiu gi ca nhng globulin min dch v bch cu tng .
6- Chn on .
- Chn on huyt thanh phng php min dch hunh quang ( dng tnh 90-99%).
- Chn on bng phng php min dch enzym ELISA pht hin khng th IgG khng
C.Trachomatis ( nhy 80- 95%).
7- iu tr .
- Hoc Tetracylin 500 mg, ung mi ngy 4 ln, trong 7 ngy ( khng dng cho ph n mang
thai ).
8 - Phng bnh .
- Ch a c vacxin d phng.
1. i c ng.
L mt bnh ngoi da th ng gp, bnh xut hin bt k v tr no trn c th, hay gp nht
l quanh mi, l mi, m v vng sinh dc, tng sinh mn( nam gii thn d ng vt, n gii
mi b), c bit th hu hng . Ecpet l mt bnh lnh tnh nh ng hay ti pht v th ng xut
hin sau nhng t sang chn v c th nh nhim khun , nhim c nng, sau tim chng,
dng huyt thanh... c bit nhng ng i c suy gim min dch nht l bnh nhn nhim
HIV/ AIDS.
2. Cn nguyn.
3. Lm sng.
c th km st v triu chng ton thn nht l ecpt hng hu ( ecpt vim hng). Nhng
triu chng ton thn c khi l do bnh nhim khun ( cu khun ph, mng no, xon khun)
khi ng ecpt.
bnh nhn nhim HIV/ AIDS ,ecpet c bnh cnh lm sng trm trng nh lot trt rng
vng hu mn, sinh dc, nim mc ming... c th c tn th ng no, mng no , 40% gy t
vong.
4. Cn lm sng :
- Xt nghim tm khng th bng min dch hunh quang trc tip cho kt qu nhanh v nhy;
nui cy tm virus.
5. iu tr.
Trong iu tr ch loi tr nhng yu t thun li v nng cao sc khng c th, kch thch
min dch. Ton thn dng khng virus tr c mt v ung phng ti pht nh : Acyclovir 0,2
(08) x 5 vin / ngy . Chng ti pht: Acyclovir 0,4 x 2 vin/ ngy.
NC BM SINH
1.1. i c ng .
- Bnh di truyn theo tri, n v u.thng pht sinh t lc hoc trong cc thng u .
1.2. Lm sng .
- Cc phng nc bao gi cng xut hin sau sang chn v khu tr cc vng h ( lng bn
tay : nm cht mt vt g - lng bn chn : sc nng ca c th - l hai ch hay c phng nc
nht ).
- Mc sang chn nng nh ty tng ng i v thi gian xut hin phng nc thay i
t vi pht n 24 gi.
1.3. T chc bnh l : phng nc nng, trong lp gai hoc d i lp sng, khng c th ng tn
t chc chun gin.
1. 4. Tin trin .
1.5. iu tr .
- Khng kt qu.
- Th ng rt kh iu tr .
- C ca vi corticoid.
sc .
- Ti ch : MnO 4K.
2.1. i c ng .
2. 2. Lm sng .
khp, b da, mch mu d v ) da rt mng, teo fripc, nhn, mu hng tim tm- Trn da kiu "
v hnh" ny c nhng so trn hoc khng u r hoc khng r. Teo ca cc vng ny c l
- ngn tay, mt l ng bn tay v bn chn, mt dui cc khp rt hay xut hin cc u nang
th ng b nh, trng , cng, ging nh cc ht nang k ( Milium) hay thy cc u nang ny trn
cc vt teo.
- Nim mc nht l nim mc ming, i khi gy kh b ( tr nh ) v nut kh. i khi c
ming v l i b lot rng .
- D dng khc c th c : mng dy, mng thnh vut, mng nh n khng mng. u ngn
i khi nh li, teo, gi x cng b xm vin on - th ng c km da c, dy sng ( chai
chn, dy sng lng bn tay, bn chn, dy sng chn lng, dy trng nim mc ). Thm mu
da, d dng rng, lng mc nhiu hoc rng lng tc, ri lon tit m hi. Nhng khuyt tt v
c to c th v ni tit khng phi him - ri lon tm thn cng hay gp : chm pht trin tri
thc ( retards intellectuels ) v bt thng ca in no nhng ngi anh em vi ngi
bnh tuy khng c tiu th ng b phng nc - ( lon phi sinh thn kinh - ngoi b - c th do
ri lon h no trung gian - tuyn diencphalo- hypophysaire ).
trng .
- Th dt : him .
- Th nng hoc c tnh ( th cht ngi Heinrichsbauer) : suy yu, nhiu lon hnh, cht trong
vi thng hoc vi nm u - lot to rng, hoi t - di truyn theo ln - ( theo Touraine 59 %
cht trong t cung hoc vi ngy hoc thng u ).
- Tiu thng b phng nc n gin : di truyng tri n chi c phng nc do sang chn ,
th ng, h lng th ng pht trin. Trng thi th lc v tm thn bnh thng ( trong th ny
c th xp th vt trng - dng sn ).
3. T chc bnh l :
4. Cn nguyn :
5. Chn on .
Chn on phn bit vi bnh phng n c khng di truyn th ng xut hin mun hn.
6. iu tr .
QUA NG TNH DC
+ Tnh n 2002 con s mc bnh LTQTD tng gp 10,6 ln (153/17 ) so vi nm 1976 bao
gm cc bnh lu, giang mai , chlamydia, nhim HIV/ ADIS ( ca nhim HIV u tin 12/90,
ca AIDS u tin 1/93; tnh n 8/2003 ton quc c 70.780 ca nhim HIV, 10.840 bnh nhn
- Vit Nam ang nm trong vng trung tm, c t l mc bnh cao ca khu vc v trn th gii.
+ Cc tc nhn gy bnh:
- Siu vi khun : virus ecpet alpha 1 hoc 2, virut ecpet beta 5 ( cytomegalovirus), virut vim
gan B, pox virut ( u mm ly), virut zosterr( zona), HIV...
- Cc k sinh trng; gh , rn mu
+ d dy v rut:
- Vim gan do virut, vim gan B, virut ecpet 5, xon khun nht.
+ nhiu h c quan ; do xon khun nht ( giang mai bm sinh, giang mai 2,3), do HTLV1 gy
u lymph t bo T, do virus, HTLV3 tc HIV gy bnh AIDS.
Cc biu hin lm sng lm khi rt t, kn o nht l n gii,lm cho ngi bnh b qua,
khng ch giai on mi mc.
+ V sinh do vim tc vi trng ( n), ng dn tinh vim tinh hon, mo tinh hon ( nam).
+ Tr s sinh: nhim khun mt ( lu mt), nhim khun ton th ( giang mai bm sinh), hu
sinh v dng.
+ Trong thc t , nhng nc hoc nhng vng c lu hnh cao v bnh LTQTD cng
ng thi c lu hnh cao v HIV/AIDS.
- Bnh nhn ngi n cc c s y t nh nc, s " b l" vi gia nh, bn b, c quan cng
tc, li phi tun th gi gic hoc ch i v tr tin khm bnh, xt nghim v.v... ( vin ph).
- Bnh nhn thng n thy thuc t, va nhanh chng, va kn o, t ngi bit, li c
ngh l c " thuc tt" ( c ch th trng).
- Mt s thy lang,thy thuc " gia truyn" cng nhn cha cc bnh LTQTD, thng khi ch
hi s qua ( khng khm) ri bc thuc lm cho bnh nhn cm thy thun tin thoi mi nn
n cha tr.
- Bnh nhn da vo sch , bo ,t i mua thuc cha tr, trong khi nhiu dc s hoc nh
thuc, mt mt do thiu kin thc, mt khc do nng v kinh doanh, nn ch bn thuc theo yu
cu ch khng hng dn chuyn mn ng n cho ngi bnh.
- Kh nhiu bnh nhn khng bit mnh c bnh i cha tr, c bit i vi cc trng hp
bnh khng c triu chng rm r, cp tnh. V d: bnh lu n gii.
5.2. Lm ngng tin trin, cha khi bnh v trnh bin chng.
5.3. Theo di, iu tr cho ngi tip xc, bn tnh ca bnh nhn.
5.4. Gio dc bnh nhn v bn tnh ca h v np sng lnh mnh, tnh dc an ton
phng ti nhim.
5.5. Chng k th i vi bnh nhn b bnh LTQTD c bit l bnh nhn nhim HIV/AIDS.
+ Ti sao li k th.
- Bnh nhn b bnh LTQTD v nhim HIV/AIDS gn lin vi i tng nghin ma tu, mi
dm ( l cc thnh phn m c x hi c mc cm).
- Do cc chnh sch, cch tuyn truyn thi qu gy hu qu ngc li vi mc ch.
+ Hu qu ca vic k th.
vi ngi bnh, h l ngi cng dn, l ngi bnh vn cn y quyn li ca ngi cng
dn.
- Bn thn bnh nhn khng cn hy vng trong cuc sng, h b tch ri khi cng ng, t
c cc hnh ng tiu cc khng li thot.
5.6. Xy dng c s v cng thc hay phc chn on v iu tr hu hin nhanh chng,
d dng chp nhn, thun tin cho bnh nhn, vi tn km ti thiu v c th thc hin cc
1. Cn nguyn :
hng, thc qun... Mt khc mm bnh c th thng tr rng su, cao rng hay rng gi, khi
c iu kin thun li ( nh rng) bnh xut hin.
chm, dai dng, khng iu t kp thi bnh ngy cng lan rng, n su xung n tn xng c
th pht hin bng X quang, lan vo ph tng, c bit khng c hch.
xut hin cc l d chy dch trong c ln cc " ht nm " nh, mu vng. Pht hin bnh c th
chp X quang, tn thng thng na di ca ph, rn phi, i khi c trn dch mng
phi.
Bnh nm ng tiu ho: mm bnh xm nhp qua ng tiu ho. Actinomyces hay tp
trung vng t nhu ng nh manh trng, rut tha, d gy vim nhng c quan ny.
3. Xt nghim :
Soi trc tip : bnh phm l dch t l d, dch nim mc ninghi nhim nm, soi trong KOH
20% hay nhum gam. Thy cc " ht nm " gm nhiu si mnh, nh chng cht nh r cy,
xung quanh c cc si to ra nh cc tia. ng knh knh cc si thng nh di 1 mm,
Nui cy : bnh phm c th nui cy trn mi trng BHI, mi trng Bouillon, mi trng
M hc: c th sinh thit khi nghi nhim nm cc c quan, nhum PAS hay hematoxylin-
eosin s quan st thy nm.
4. Chn on phn bit : cn chn on phn bit vi ct tu vim xng hm, lao, vim rut
tha, u c tnh.
5. iu tr :
C th dng cc loi khng sinh nh penixilin hng triu n v trong 30- 50 ngy. C th kt
hp dng metronidazol 0,25 x 3 vin/ ngy hng thng. C th kt hp phu thut v chiu tia
rn ghen. Trong iu tr c in thng dng kaliiodua ung 6-12 gam/ ngy hoc kt hp
sulfamid vi khng sinh.
NGOI DA
PGS Nguyn ngc Thy
Vi ngnh Da liu th phng chm trn cn c ngha c bit, v phn ln bnh ngoi da l
bnh ca qun chng, rt ph bin trong nhn dn. Trong qun i th bnh ngoi da hay gp
chin s,do bnh c lin quan n iu kin mi trng sinh hotcng tc ca b i.
Tri qua hng nghn nm lch s, nn ng cha ta tch lu c nhiu kinh nghim v iu
tr,v phng bnh ngoi da bng thuc dn tc rt c hiu qu, m ngy nay chng ta cn
phi hc tp, tha k, khai thc pht huy nhng kinh nghim, nhng bi thuc qu nhm
a s ngi mc bnh ngoi da sng vng nng thn, rng ni, vng su vng xa v cng
chnh nhng ni sn c kho tng cc cy thuc, dc liu rt phong ph. V vy nu bit
khai thc c s p dng rng ri trong nhn dn thc hin " hu cn ti ch" gp phn cho
cng tciu tr kp thi v mang li c li ch v kinh t.
Trong cng tc iu tr bnh ngoi da th vic cung cp thuc men thuc men cn nhiu tn
km, v phn ln l thuc nhp ngoi. Do vic khai thc ngun cy thuc dn gian s c hiu
qu kinh t ph hp vi quan im qun chng nhn dn.
+ An ton trong iu tr: thuc dng phi an ton, t c hi vi cc c quan ni tng, khng gy
+ Khoa hc: khi s dng phi ng cy thuc, dng ng b phn, thu hi ch bin, sn xut
phi ph hp vi qui trnh, ng thi phi chng cc phng php c tnh cch me tn d oan
hay phng thc iu tr khng khoa hc, khng m bo v sinh. Tuy nhin bc u khng
kim a phng no cng c, d ch bin, s dng n gin , r tin nhng hiu qu.
Mt s bi thuc.
bi vo ch chc.
1.4. Thuc dn: l bn ( xch ng nm hoc bch ng n) un ra sch ri luc hoc hp cho
chn dn ln chc chc lot ngy 2 ln thi gian 1-2 tun.
2. iu tr eczema (chm).
hng ngy.
2.3. Thuc bi : v nc nc 40 gam, ngh vng 20 gam, qu k 20 gam, ba v phi kh, tn bt
trn ln vi du vng hoc du lc ri bi hng ngy.
2.4. H thnh i:
Bt thanh i 40 gam, bt hong lin 1 gam, thch cao 20 gam , du lc 60 gam, trn u
ngy bi 2 ln.
2.5. Thuc dng trong : kim ngn hoa, k du nga 15 gam, t mc 10 gam, v nc nc 12
3. iu tr t a.
3.2. l bch hoa x 1 nm gi nt, luc chn, p v bng li trc khi i ng, sng dy b thuc
3.3. Vi bt trn l ngi cu ri t xng khi hoc xng khi hng trut v bt l lt.
4. iu tr gh.
+ Thuc bi :
vo ch gh.
- L tru khng 50 gam, dim sinh 100 gam, m ln 140 gam, nu chy ra trn u vi nc
ct l tru khng( l tru khng c gi nt vt ly nc) v bt dim sinh, trn cho nhuyn,
bi gh bui ti.
5. iu tr vy nn .
+ Nc sc ht u miu 10% ngy ung 1 ln.
6. iu tr bch bin.
Dng ph c ch 10- 15 gam sc ung ngy 1 ln vi thi gian 30- 60 ngy, ng thi bi dung
7. iu tr ht cm.
+ ivi ht cm dt th hng ngy lau bng nc vi nh sau st k ni kim thi gian 20-30
ngy.
7. iu tr d ng do sn.
8. iu tr nm da.
Ngm trong 1-2 tun, sau lc qua bng, ly dch bi ngy 2 ln vo tn thng nm hc lo,
lang ben.
Chanh 1 qu.
thng nm.
+ Cn ht mung tru:
Kh chua 40 gam.
L tru khng 10 l.
Ring gi nh 30 gam.
NHIM HVI/AIDS
Cc bnh ly truyn qua ng tnh dc (LTQTD) kinh in gm c : lu, giang mai, h cam,
ht xoi (nicolas favre),u ht bn ( granuloma inguinale).
Cho n nay ngi ta b sung thm n hai chc bnh LTQTD , trong c mt bnh rt
quan trng l him ho ca loi ng i, l nhim HIV/ AIDS.
a s cc bnh LTQTD iu tr khi c, tr nhim HIV/ AIDS. Hin nay bnh AIDS vn
ch a c thuc iu tr mt cch c hiu qu.
Mt s bnh LTQTD nh giang mai, nhim HIV/ AIDS thc cht l ly truyn trc tip qua
ng mu, m hot ng tnh dc ch l mt cch cho virus , vi khun truyn t mu ng i
bnh sang mu ng i lnh.
+ Tinh dch
+ Dch tit m o
+ Mu .
+ Sa m
+ Ni hp 120 20 pht
+ N c si 20 pht
+ Hypochloride Natri 0, 5 % 10 - 30 pht
+ Glutaraldehyde 2% 10 - 30 pht.
+ Formalin 1 % 10 - 30 pht
+ Cn 70% 10 - 30 pht
+ Trong quan h tnh dc ngi ph n c nguy c ly nhim HIV/ AIDS cao hn nam gii.
nhim HIV.
+ Nhn vin massage ( massage mt, ton thn, chn), nhn vin tm qut.
+ Nhn vin y t : khm bnh, tim thuc, thay bng, lm tiu th thut chy mu, m, xt
nghim, nh rng ...
da.
5. Cc bin php phng trnh bnh LTQTD v nhim HIV/ AIDS trong lc l ng v trang .
5.1.Tuyn truyn gio dc: phi gio dc mi qun nhn hiu c tnh cht nguy him khi
nhim STD v HIV. Hiu c cc bin php phng bnh.
+ Dng nhiu hnh thc gio dc nh : ln lp, ni chuyn, thng tin trn i truyn thanh,
+ T chc cc hnh thc vui chi gii tr lnh mnh ti n v: ca ht, th dc th thao, c
bo, nghe i, xem ti vi. gim bt cng thng, bun t n v .
Th no l tnh dc an ton.
+ Khi quan h tnh dc phi eo bao cao su tr c khi c bt c tip xc no nh qua ming,
m o, hu mn.
+ C th dng bin php t khoi cm ( orgasm) m khng giao hp, hoc thc hin "
outercourse"
+ Cn phi bo v i bn tay trong tr ng hp c cc vt t tay, cc vt trt, v dch tit m
o c cha HIV.
-+Khng dng chung kim xm mnh, kim x l tai...m cha c kh trng ng quy cch.
5.5. Phi kim tra HIV tr c khi cho mu , tr c khi cho tng(tuy nhin giai on ca s
khng pht hin ra c nhim HIV hay khng ).
+ Kh trng tt cc dng c y t .
5.7. i vi nhn vin massege, th ct tc, nhn vin lm thm m nn ngh vic khi i bn
6- Mt s ch khc :
+ Phng bnh thng qua gio dc y t trong cng ng nhanh chng hn.
+ Chn on c hi chng thc ra cng khng phi l n gin cho cc thy thuc c s
Phc iu tr lu v Chlamydia:
+ Ciprofloxacin 500mg (ung liu duy nht) +Doxycyline 100mg ung 2 ln /ngy x 7 ngy.
+ Spectinomycine 2g (tim bp liu duy nht )+Doxycyline 100mg ung 2ln /ngy x 7ngy.
+ Ceftriaxon 250 mg (tim bp liu duy nht )+Doxycyline 100 mg ung 2ln/ngy x 7 ngy.
+ Ceftriaxone 250 mg tim bp liu duy nht+Benzathinepenicillin 2,4 G triu v, tim bp (liu
duy nht).
( Khng c xt nghim).
BNH NGOI DA
I. M u
Trong thi i ngy nay, cuc sng ca con ngi cng tr nn vn minh tin b hn, tuy nhin
chng ta li phi thng xuyn tip tc vi nhiu ha cht t trong cch n mc, v sinh c th
cho n ht th khng kh v chng ta cng phi vn ng no nhiu hn rt nhiu. Chnh cc
yu t lm cho cc bnh d ng da v cc ni khc c khuynh hng gia tng. Khi b
d ng th thng thng nhiu ngi phi s dng thuc chng d ng v vim da c s
dng rt ph bin trong thuc bi c cha cht corticoid c s dng v lm dng nhiu
nht.
triamcinolon, flucinlone ri tip theo nhiu nm sau vi chc loi thuc bi khc c tng hp
v bn ra th trng th gii. Vit Nam trc v sau gii phng thuc bi nh cortibion c
Synalar c sn xut v tiu th ti min Nam rt mnh, ngoi min Bc th ch yu l
bi ny rt l phong ph a dng t nhng loi sn xut trong nc cho n nhng loi nhp t
nhiu nc khc nhau. iu ny c th ni ln rng thuc bi c corticoid v ang c nhu
qu ngi ta c th phi thay thuc ang s dng bng thuc mnh hn hoc yu hn.
Gentrisone, Triderme
III. C ch tc ng
IV. Ch nh
Thuc bi c corticoid c ch nh iu tr:
1. Bnh da b vim: nh chm tip xc, chm th tng, chm khc.
2. Ri lon tng sinh da: vy nn.
3. Ri lon xm nhim da: sarcoidosis.
nguyn pht
- M ay - Pemphigus
- vy nn - Lichen phng
- Necrobiosis lipoidica
- Sarcoidosis
- Vim da tip xc d
ng
- Cn trng t
S hp thu ca corticoid ty theo v tr t trn xung di:
1. Nim mc
2. Bu di
3. M mt
4. Mt
5. Ngc v lng
6. Cnh tay v i trn
7. Cng tay v i di
8. Lng bn tay v bn chn
V. Chng ch nh
- D ng vi thnh phn ca thuc.
VI. Tc dng ph
- Ti ch:
Teo da
Rn da (Striae)
Gin mao mch, xut huyt di da, da.
Mt sc t
Lu lnh vt thng da
Lm tng bnh nhim trng, nhim nm, k sinh trng, virus.
Bi nhim nm Candida.
Ni ht k trng (miliaria).
Vim da quanh ming.
Pht ban dng trng c .
Pht ban dng mn trng c.
- H thng:
(pseudotumor cerebri).
H ni tit: c ch trc di i tuyn yn - thng thn (hypothalamic pituitary adrenal)
chng rm lng, ri lon kinh nguyt, mp vng thn mnh, mt trn nh trng.
H tiu ha: lot d dy, vim ty tng, i tho ng.
3. Theo di phn ng da ca tng ngi bnh thay i cch dng thch hp.
4. Khng th dng ng lot loi thuc bi mt cch cng nhc m cn ty thuc ngi bnh,
tng la tui, tng vng da.
9. Cn nn phi hp vi loi thuc ton thn khc, khng phi al2 corticoid v cn tm ra
HT