BOY TE CONG HOA XA HQI CHU NGHIA VIET NAM —— Dc lip - Ty do - Hanh phie $64416QD-BYT Ha Néi, ngdy O6thdng] 2ném 2023 QUYET DINH ban hanh tai ligu chuyén mon doan va diéu tri cae bénh Da ligu” BQ TRUONG BOQ Y TE Can cit Ludl Khém bénh, chita bénh nim 2009; Can cit Nghi dinh so 95/2022/ND-CP ngery 15 then 1 néim 2022 etta Chinh pli quy dinh chiee néing, nhiém vu, quyén han ve co cau t6 chiee cia BO Y té; Theo dé nghi cia Cue trwong Cuc Quin ly km, chiva bénh. QUYET BINH: Didu 1. Ban hanh kém theo Quyét dinh nay 1ai ligu chuyén mén “Huéng dan Chan dodn va dicu tri cde bénh Da Tiéu" Didu 2. Tai ligu chuyén mén “Hudng din chin dodn va diéu tri ede bénh Da ligu” duge dp dung tai cdc co sé khim bénh, chita bénh, Can ett vao tai ligu nay va diéu kign ou thé cia don vj, Giém dée co sé kham bénh, chita bénh say dung va ban hanh tai liu huréng dan chan dodn va didu tri cac bénh da liu phi hop dé thye hign tai don vi. Diéu 3. Quyét dinh nay o6 higu luc ké tir ngay ky, ban han, Diéu 4. Cac dng, ba: Chanh Van phong BO, Chanh thanh tra Bo, Cye truong va Vu trudng cae Cyc, Vy thude BO Y té, Gidm dée SY té cae Tinh, ‘Thanh phé trye thude Trung uong, Giam dée ede Bénh vign tue thude BO Y té, Thi tring ¥ 16 cde nganh chu rich ninigm thi anh Quyét dink nay Net nkiy KT. BQ TRUONG (le = Nhu Digu-4 at ong ES = BG trurong (dé ble); HU TRUONG ee Che Thit irae: \ J ~ Cong thong tin dign tir BO Y t&; Website Cue KCB, + Luu: VT, KCB,HUONG DAN CHAN DOAN VA DIEU TRI CAC BENH DA LIEU (Ban hémh kem theo Ouyét dinh s64416 ngdyOothdng12 nem 2023)3 MUC LUC ‘Chwong 1: BENH DA NHIEM KHUAN. BENH CHOC 9 NHOT, AP XE DA. 13 VIEM NANG LONG drshsshincoinia sitienrincin obs 17 HOI CHUNG BONG VAY Da DO TY CAU 21 BENH LAO DA 25 BENH PHONG 33 PHAN UNG PHONG 4 PHAN UNG PHONG LOAI I 45 PHAN UNG PHONG LOAI 2 : ENH DA DO NAM - KY SINH TRUNG. Chong BENH GHE. 66 VIEM DA DO DEMODEX 70 BENH LANG BEN B BENH DA DO NAM SOL 1 BENH DA VA NIEM MAC DO CANDIDA 4 81 VIEM AM HO - AM BAO DO NAM CANDIDA. oe 85 NAM DA DAU, NAM RAU, NAM TOC 88 NAM MONG oy ‘Chwong 3: BENH DA DO VIRUS. BENH ZONA 97 BENH DO HERPES SIMPLEX 2 — 104 BENH THUY BAU sts eri 108 BENH HAT COM. ul U MEM LAY 1s (Chuong 4: BENH DA TY MIEN. roms BENH LUPUS BAN BO HE THONG 1g VIEM DA CO 130 BENH XO CUNG Bi HE THONG és 139 HOI CHUNG TRUNG LAP... cs ri 148 BENH PEMPHIGUS a : — 157 PEMPHIGOID BONG NUGC 165 VIEM DA DANG HERPES........ 170 BENH IGA THANH DAI 1744 (Chong $: BENH DA D] UNG —MIEN DICH VA BENH DA VIEM. ‘VIEM DA TIEP XUC 172 VIEM DA CO DIA 185 VIEM DA TIEP XUC DO ANH SANG... 191 PHAN UNG THUOC CO TANG BACH CAU AITOAN VA TRIEU CHUNG TOAN THAN. 195 HONG BAN BA DANG. 200 HOI CHUNG STEVENS - JOHNSON VA HOAI TU THUONG Bi NHIEM DOC 204, SAN NGUA 209 BENH MAY DAY 212 HONG BAN NUT. 218 BENH AP TO. a 222 Chwong 6: BENH DO DA CO VAY visu VIEM DA DAU é 228 VAY PHAN HONG 233 VAY PHAN DO NANG LONG és 237 VAY NEN THE THONG THUONG .. 240 VAY NEN THE MU a 248 VAY PHAN DANG LICHEN 253 DO DA TOAN THAN i 258 BENH LICHEN PHANG 263 Chong 7: BENH LAY TRUYEN QUA DUONG TINH DUC. acon BOT BENH GIANG MAL 268 VIEM AM DAO DO TRUNG ROL . 283 BENH LAU. 285 NHIEM HERPES SIMPLEX SINH DUC 291 BENH DO CHLAMYDIA TRACHOMATIS 206 BENH SUI MAO GA, roti : i . 301 Chuong 8: UD: UNG THU BLEU MO TE BAO DAY......... iiss 310 UNG THU BIEU MO TE BAO VAY 313 UNG THU TE BAO HAC 10. 321 UNG THU BIEU MO TE BAO VAY DUONG VAT 326 BENH PAGET. 333 UONG TUYEN MO HOI 336 BOT HAC TO BAM SINH. acer " sie 339 BOT SUI THUONG Bi. 342ULYMPHO BO DA 344 ULYMPHOT ODA M7 UMACH MAU TRE EM 354 BOT RUQU VANG. : 361 UMACH SUNG HOA 363 BENH SARCOIDOSE. 366 ‘Chuong 9: CAC BENH DA DI TRUYEN.. DAY SUNG LONG BAN TAY, BAN CHAN DI TRUYEN 371 LY THUONG Bi BONG NUGC BAM SINH 375 BENH KHO DA SAC TO 379 UXO THAN KINH 383 DI SUNG DARIER, aeaeaaienes iat ciate 386 BENH VAY CA. i ; 388 ‘Churong 10: ROL LOAN SAC TO. BENH BACH BIEN us 391 TANG SAC TO SAU VIEM wee jet oer 404 RAMMA.... “. 410 ‘Chuong 11: BENH DA DO ROI LOAN CHUYEN HOA . UVANG 416 BENH GAI BEN. 420 VIEM DA BAU CHI RUQT.ncencsnmnene : lhe 423 BENHPELLAGRA. 426 BENH PORPHYRIN DA CHAM... 429 ‘Chwong 12: BENH LY PHAN PHY COA DA. BY TRUNG CA 433 KEN THUONG Bi 443 RUNG TOC MANG 446 RUNG TOC DO NOI TIET TO NAM i . 451SFU ACE AIDS AJC ALT ANA ASLO AST BCA BCC BCG BSA BSCC CEA cK cmv RP ct DFAs DLOI DNA DRESS ETA ETB EBV ELISA EMA ERKs FDA FTA abs. HCQ HE HY HIV HLA HPV HSV IFM IFN IL 6 D. MUC CHU VIET TAT 5 - Fluowacin Angiotensin Converting Enzyme Acquired Immunodeficiency Syndrome American Joint Committee On Cancer Alanine Transaminas Antinuclear Antibody Antistreptolysin O Aspartate Transaminase Bichloroacetic Basal Cell Carcinoma Bacillus Calmette - Guerin Body Surface Areas Basaloid Squamous Cell Carcinoma Carcinoma Embryonic Antigen Creatine Kinase Cytomegalo Virus C- Reactive Protein Computed Tomography Direct Immunofluorescence Assays Dermatology Life Quality Index Deoxyribonucleic Acid Drug Reaction with Eosinophilia and Systemic Symptoms Exfoliative Toxin A Exfoliative Toxin B Epstein-Barr Virus Enzyme Linked Immunosorbent Assay Epithelial Membrane Antigen Extracellular Signal-Regulated Kinases Food And Drug Administration Fluorescent Treponema Antibody Absortion’S ‘Test Hydroxychloroquine Hematoxylin ~Eosin Human Herpes Virus Human Immunodeficiency Virus, Human Leukocyte Antigen Human Papilloma Virus Herpes Simplex Virus Immunofluorescene Mapping Interferon InterleukinIPL MAP NAATs NB NST PASI PCR PDT PET PIH PR PRP PSCC PUVA RPR scc SJS TCA TNE TPHA TPPA uv UVA UVB VAS VZV VDRL WHO Intense Pulsed Light Mitogen-Activated Protein Molluscum Contagiosum Virus Multidrug Therapy Mycosis Fungoides Malignant Melanoma Magnetic Resonance Imaging Methotrexat Nucleic Acid Amplification Test Narrow Band Nhiém Sic Thé Psoriasis Area And Severity Index Polymerase Chain Reaction Photodynamic Theraphy Positron Emission Tomography Postinflammatory Hyperpigmentation Pityriasis Rosea Pityriasis Rubra Pilaris Penile Squamous Cell Carcinoma Psoralen + UVA Rapid Plasma Reagin Card Test Squamous Cell Carcinoma Stevens Johnson Trichloroacetic Tumor Necrosis Factor Treponema Pallidum Hemagglutionation’S Assay ‘Treponema Pallidum Particle Agglutination Assay Ultraviolet Ultraviolet A Ultraviolet B Visual Analogue Seale Varicella —zoster Virus Venereal Disease Research Laboratory World Health OrganizationChuong 1 BENH DA NHIEM KHUANo BENH CHOC (Impetigo) 1, DAL CUONG 1.1. Khai nigm Chéc Li bénh ly nhiém tring néng cap tinh trén da rat pho bién, dic trung boi t6n thuong co ban la cde bong nurée néng, rai ric, nhanh chong hoa mu, dap vo dong vay tiét. Bénh 06 thé gay cae bién chimg tai ché va toan than néu khdng duge phat hign va dieu trj kip thai. 1.2. Dich t& ~ Chée 1a bénh da nhiém khuan thudng gap o tré e1 ~ Yéu t6 thudn loi thirong gap 1a twdi nho, thii tiét néng dm, mia hé, didu kién ve sinh kém, bénh da phi hop nhu chay ran, ghé, cn tring can, viém da co dia... hoae suy giam mién dich hay dang sit dung cae thude tre ché mién dich. 1.3. Can nguyén/Co ché bénh sinh Do tu cau vang, lién cau hoae phi hop ca hai 2. CHAN DOAN 2.1. Trigu chitng lim sing ~ Chée duioe phan thanh 2: nhém chinh: Chée khéng ¢6 bong nude va chéc bong muse + Che khéng 06 bong nude: ton thuong ban dau la eae sin do, tién trién thanh mun nude nhé héa mi nhanh hode mun mit nhd, nhanh chéng dap v6 dong vay tiét mau vang mat ong, nén 6 uét. Ton thong thuong xuat hign quanh cde hdc tw nhién (mat, mili, miéng...) va cde chi, ¢6 xu huéng lan nén thuéng cé nhiéu t6n thuong, ¢6 thé lién két voi nhau thanh mang lén, + Che bong nuée: ton thing ban dau la bong nude néng, nhan nheo, chita dich vang trong. Khi dap vé dé lai vién vay xung quanh dat dé ust nhung khéng co vay tiét, sau d6 chuyén sang mau nau bong hose mau da. Ton thuong thudng xuat hién & mat, chi, thin minh, nach va.xung quanh ving hau mén ctia tré so sinh. = Chéc loét: ban dau li chéc théng thudng, néu khdng durge diéu tri bong nude lan rong, sau khi vo dé Iai vet loét su xuéng trung bi véi iéu “duc 15” ““punched- cout” trén phi vay tiét mau vang x4m ban, bé rin, g cao, mau tim, hay gap 6 chi dudi, Néu khong diéu tr, loét 06 thé rong trén 2-3em, tén throng lau lanh, dé Iai seo xéu, - Tén thong phéi hop khac nhu: viém bd mi, chéc mép hode viém cau thin nha 4 tré em nhung tién luong lank tinh,10 - Truong hop ming cé thé kém theo sét, ndi hach bach huyét ving, tiéu chy, mét moi, kém an - Tién trign: 4c bong nude anh sau 1-2 tudn, nhung bénh ¢é thé dai ding do tw lay truyén, vé sinh kém. Bénh c6 thé tién trién thanh viém mé bao, vigm bach mach, viém mi hach bach huyét, nhiém khudn huyét, viém phdi do ty cdu néu khéng duge digu tri gi. 2.2. Cn lim sing - Xét nghiém danh gid tinh trang viém: bach cdu, mau ling, CRP, procaleitonin c6 thé tang. - Xét nghiém té bio Tzanck: ¢6 thé cé té bao gai Iéch hinh, nhiéu bach cdu da nhan trung tinh, = Nhudm Gram dich hoa mii tgi tn thuong thay céu khuan gram duong xép thinh chudi hofe tiing dm, kém theo la bach cdu da nhan trung tinh, - Nudi cy dich hodc ma xac dinh ching gay bénh, lam khang sinh d6 gitp dieu tri nhiing trudng hop khé, 2.3. Chin doan xc djnh Chu yéu dya vio trigu chimg lam sang. 2.4. Chan doan phan - Nam da - Thuy dau ~ Herpes simplex ~ Hi ching bong vay da do tu cu ~Bénh zona ~ Pemphigus vulgaris ~ Pemphigoid 3. DIEU TRI 3.1. Nguyén tie - Két hop thude diéu tri tai ché va toan thin. - Chéng ngita: trinh tu lay truyén. - Digu tri bién chimg néu c6.1 3.2. Diéu tri cy thé 3.2.1, Didu tri tai chd - Ngam tim ngay mét lan bing nude thudc tim loang 1/10.000 hoe cae dung dich sat khuan khac. - Bong nude, bong mu: tam gac dip dung dich Jarish vao ton thuong ngay 2 lan sang tdi, mdi lin trong 30 phi. - Trung hop nhieu vay tiét: dip nude mudi sinh IY 9%, dung dich Jarish hode gac m@ vaselin ln tén throng, dp liga tue dén khi bong hét vay ~ Khang sinh tai chd: mupirocin, acid fusidic hoc retapamulin bai ngay 2 lin sang — 16i tai 16n thuong, thug ding trong 7 ngay. 3.2.2. Didu tr] toan than = Khang sinh: + Chi dinh khi tn thuong nhiéu, lan téa: Iya chon mot trong cae phac do sau: Khang sinh Liéu wong Ngudi lon ‘Tré em Cephalexin Ubng 250mg/lin x 4 lan/ ngay Ubng 25 mgikg/ngay chia 4 Tan Dicloxacillin Uéng 500mg/lan x 4 lan/ ngay Uéng 25-50 mg/kg/ngay chia 4 lan Cloxacillin 250-500mp/lan, 3-4 lan/ngay 50-100mg/kg/ngay, chia 3-4 lan Oxacillin Uéng 0.5-Igilan moi 4-6 gi | Udng 12.5 — 25mg/kg/ lan moi 6 gies ‘Amoxicillin’ | Udng 1-2 g chia 2—3 lin/ngay | 40-80 mg/ke/ngay , chia 2-3 ln clavulanic Cefazolin 250-500mg/lin, 3-4 lan/ngiy | 25-50mg/ky/ngay chia 3-4 lan Cefiriaxon 1-2g/ngay, ti da 4y/ngay./20-80mg/kg/ngay, tiém tinh truyén 1 Jan mach, ngay 1 lan Truong hop do tu cau ving khang methicilin Trimetroprim/ ] 160/800mg/lan x 2 Tan/ngay | 6-8mg _Trimetroprim/kgingay sulfamethaxol chia 2 in Vancomycin | 500mg/lan x 4 laningay 40mg/kgingay chia 4 Tan Hoae Ig/lan x 2 lan/ngay Linezolid ‘600mg/lin x 2 linngay TOmg/ke/lan x 3 Tan/ngiy + Trong trudng hop khong dap img v6i cae nhém khang sinh trén: c6 thé dimg nhom12 quinolon, macrolid hoae aminoglycosid + Néu chée khang thude hoae chéc loét phai diéu tri theo khéng sinh 46 ~ Didu tri bién chimg néu e6. 4, PHONG BENH ~ Chit ¥ phéng bénh cho tré nho, nhat 1a sau khi mac bénh do virus nhu sé. - Tam rita vé sinh ngoai da, cat toc, cat mong tay sach sé. ~ Tranh 6 lau nhiing noi am thdp, thiéu dnh sing. = Diéu tri sém va tich cue, tranh cha xat, gai nhiéu gay bién chimg. = Tran c6n triing dot13 NHOT, AP XE DA (Furuncle, Cutaneous abscess) 1, DAI CUONG 1.1. Khai nigm ~ Nhot la tinh trang viém cap tinh gay hoai tir nang lng va t6 chire xung quanh, - Ap xe da la mét 6 mu khu tra trong trung bi hode t6 chite dudi da, ¢6 thé gap & bat ki 6 vi tri ndo nhung hay gap hon & cae vj tri nép ké nhur nach, quanh sinh duc va hgu mon. 1.2. Dich té - Nhot thudng gap vé mia hé, nam nhiéu hon nif, Moi lira tudi déu co thé mic bénh, tuy nhién, bénh thudng gap hon 6 tré em. - Ap xe da cé thé gap ca 6 nhitng ngudi khoe manh, nhung hay gap hon ¢ cae doi tuong: béo phi, nghign thude la, tiéu duong, suy giam mién dich, tiém truyén thude. 1.3. Cin nguyén/ Co’ ché bénh sinh ~ Nhot: can nguyén gay bénh la tu cau vang (Staphylococcus aereus). Binh thong, vi khuan nay sdng ky sinh trén da, nhat la ca nang lng 6 cac nép gap (ranh mii ma, ranh lién méng....) hoe cae héc tye nhién (15 mai...). Khi nang léng bj t6n thong két hop véi nhing diéu kién thuan loi nhur tinh trang mién dich kém, suy dinh dung, méc bénh tigu dung, hit thude... vi khuan s@ phat trién va gay bénh. - Ap xe da: + Cha yéu do nhiém khuan, Vi khuan xam nhap qua da bj tin thurong, Cac can nguyén phé bin nat la: © Ty cau vang: c&n nguyén thong gap nat, tu cdu ving khang methicillin: gay ap xe da tai phat * Sireptococcus pyogenes » Vikhuan gram 4m, vi khudn ki khi + Cac can nguyén it gap hom: Mycobacterium tuberculosis va Mycohacteria khing dién hinh, nam + Ap xe v6 khuan * C6 thé do cae mé hoai tit, mé chét va cée té bio viém sau khi hét nhiém tring © Mot s6 bénh da viém gay pha ly m6 va hinh thinh ap xe ma khéng o6 mat vi Khuin gay bénh nhur viém tuyén mé hoi mu, trimg ca bye va trimg cA toi cap, benh Crohn da, viém m6 m6 durdi da. Apxe vo khuin ciing ¢6 thé xay ra sau tiém corticosteroid.14 2. CHAN DOAN 2.1. Trigu ching lam sang - Nhot: ton thuong ban diu ld sin nhé, mau do, sung né, chic, ty dé o nang léng, Sau d6, tén thuong lan réng héa mi tao thanh 6 ap xe, 6 giita hinh thanh ngdi mu. Thuong dau nhite, nhét la khi nhot khu tra 6 mii, vanh tai. Vi ti thudng gap Ia 6 dau, mat, c6, lung, méng va chan, tay. Sé luong tn thirong c6 thé mot hose nhigu, kem theo cde rigu chang todn than nhu s6t, mét mdi, hoi ching nhiém tring, - Nhot cum edn goi la nhot bay hay hau béi gdm mét s6 nhot xép thanh dam, Bénh thong gap @ nhiing ngudi suy dinh duéng, gidm mién dich ho&e mac cae bénh man tinh nhu tiéu dung, hen phé quan, lao phoi - Ap xe da thuong c6 biéu hign sung, néng, d6, dau. Kich thude thay d6i thuong tir 1-3em, doi khi co thé rit én, Ban dau phan img vim do cuong tu nén rat cimg, sau 46, cde 6 ma hinh thanh, lép da bén trén tro nén mong hon va si cdm giée mém hon, cé thé tur vo va chay mit. C6 thé c sung hach ving, sdt. 2.2. Cn lim sing - Mé bénh hoe: 6 ap xe & nang léng, cau trie nang léng bi pha va, gitta 1a 16 chite hoai tir, xung quanh tham nhap nhiéu céc té bao viém, chi yéu la bach cau da nhan trung tinh, - Siéu dm (Ap xe): démh gia kich thude va su khu tra ciia khéi dp xe. - Vi sinh: nhugm gram, nudi cay dinh danh vi khuan va lam khang sinh do - Xét nghiém danh gia tinh trang viém: bach cdu, mau ling, CRP, procalcitonin co thé tang 2.3. Chén dodn xe Chit yéu dya vio trigu chimg kim sing 2.4. Chan doan phan biét = Viém nang long - Herpes da lan toa = Tring ca + Viém tuyén mé héi ma + Kén thuong bi - Viéin can co hogi tir - Viém mé bao 3. DIEU TRI 3.1. Nguyén tie dieu tri - Vé sinh cd nhan. - Biéu tri chong nhiém khuan tai ché va toan than, - Nang cao thé trang. - Voi d ap xe: ean trich rach din Iuu va ding khang sinh toan thén.18 3.2. Diéu tri cu thé 3.2.1. Didu tri cho - Vé sinh ca nhan: rita tay thugng xuyén bang xa phong, tranh ty lay nhiém ra cic. ving da kha. = Didu tri tai chd: + Ogiai doan sém, chia ¢6 mi: khéng nan, kich thich vao t6n throng: béi dung dich sit khudn ngay 2~ -4 an. + Giai doan co mu: chich rach lam sach, din luu trong trudng hop 6 dp xe. + Sit dung dung dich sat khudn (povidon-iod 10%, hexamidin 0.1%, chlorhexidin 4%...) va thude Khing sinh tai chd (axit fusidic 2%, mupirocin 2%, neomycin, silver sulfadiazin 196), 3.2.2. Diéu tr] foan than ~_Khang sinh toan than: Iya chon mt trong eéc khang sinh sau: Ligu wong Khang sinh Tani Ta Cloxacilin Udng hoge tiém bap hoge tinh | Dudi 20 kg, uong hoe tiem mach (TM) cit 6 gid ding 250- | bap hoic TM cit 6 gic ding 500mg, 12,5 - 25 mg/kg Trén 20kg, liéu ding nhw ngudi lon Amoxicillin’ | Udng 875/125mg x2 Tin! ngiy | Udng 25 mylkg/ngay chia clavulanic hai lan Roxithromycin | Udng 1S0mg/lan x [an/ngay Uong 5 — 8mg/kg/ngay chia 21an ‘Azithromycin Ubng 500mg ngay dau, sau d6 250mg/ngay trong 4 ngay tiép Usng 0mg/kgingly x 3 ngay Clindamycin Tiém TM, 600mg x 3 ln’ ngdy ho’ udng 300 -450mg x 4 lan/ngay Uong hoae truyen TM, 10 20mg/kg/ngay chia ba lan ‘Trwdng hop do tu cau vang khéng methicilin ‘Vancomycin ‘Truyén TM cham 30 mg/ky/ngay, chia 4 lin (khéng ding qua 2pingiy), Tiém TM chim 40mg/ngay chia 4 lan (ctr 6 gid/lan) hoae sruyén TM 10mg/kg Trimethoprim] sulfamethoxazol (TMP/SMX) Uéng 160/800mg x 2 Hin/ngiy Uéng 8 (TMP)/40 (SMX) mg/kg chia 2 lan/ngay Linezolid Udng hose tru 600mg x 2 lin/ngay finh_mach Dudi 12 tuoi: dng hode truyén tinh mach 10mg/kg (t6i da 600mg) x 3 lan/ngay Trén 12 tudi: ding liéu nhu ngudi lin = Thdi gian digu tri khang sinh tir 7- 10 ngay. - Co thé sir dung cae thude chong viém giam dau NSAIDs hoje corticosteroid trong16 mét sé trudng hop. 4, PHONG BENT \Vé sinh 4 nhan sgch s&: cit méng tay, rita tay thudmg xuyén ‘Tranh str dung cac san pham gay kich tng da. Niing cao the trang.i? VIEM NANG LONG (Folliculitis) 1, DAL CUONG L.A, Khai nigm ‘Viém nang lng 1a tinh trang viém néng mot hoae nhigu nang long, 1.2. Dich té Bénh gap & bat ky ching t6c nao, ty 1é nam, ni twong duong. Bénh gap 6 bat ky lira tudi nao, nhat 1a thanh thiéu nign va ngudi tre. 1,3, Cin nguyén/ Co ehé bénh sinh ~ Nguyén nhan chit yéu la tu cdu vang (Staphylococcus aureus) va tree khudn mu xanh (Pseudomonas aeruginosa) = Cfo nguyén nhan kha + Nam: Trichophyton rubrum hoie Malassezia folliculitis (Pityrosporum folliculitis). + Herpes simplex virus thuéng gy viém nang léng ving quanh migng. + Viém nang léng khéng do nhiém khuan’ © Pseudo-folliculitis (gia viém nang Iéng) hay gap 6 vung cim do cao rau gay hién trong léng choc thit @ Viém nang long ting bach cau ai toan thudng gap 6 nhiing nguéi suy giam mién dich © Viém nang léng Decanvans hay gap ving da dau gay rung toc vinh vién. @ Viém nang léng 6 nhing ngudi céng nhan tiép xtc vi dau mé nhu tho loc dau, thy may. = Mét sé yéu t6 thuan loi + Tai chd: mac quin do qua chét, da aim ust, ting tiét md héi, gai, cao, cao ru, nhd Jong, céc thuée ho&e my pham gay kich img, ding thudc bdi corticosteroid lau ngay. + Toan than: béo phi, tiéu dudng, suy giam mién dich bam sinh hay mac phai, suy thin, chay than nhan tao, thiéu mau do thiéu sat d6i khi két hgp d6i voi nhing trudng hop vim nang f6ng man tinh18 2. CHAN DOAN 2.1. Trigu ching lim sing - Ton throng Ia nhiing san nho & nang léng, trén c6 vay tiét, khéng dau, sau vai ngay tién trin, tn throng 6 thé khoi khong dé lai seo. Vi tri & bat ky ving da nao cita co thé, trir 6 lng ban tay ban chan, thudng, gap nhat 1a & dau, mat, cd, lung, mat ngoai cdnh tay, dai, sinh duc, cdng tay va cing chan... + $6 Iugng tén thuong nhiéu hay it tiy theo timg trugng hgp. Hau hét cfc tragng hop chi cé mét vai ton throng don doc va dé dang bo qua. Mét s6 ngudi bénh cd nhidéu tén thuong, tai phat nhiéu Lin lam anh hurdng dén stre khée va chat luong cude Fe 2.2. Cin Lim sing Cf xét nghiém xac dinh nguyén nhan - Nudi y vi khuin Soi nim te tip Nuéi cay nam Sinh thiét trong mét s6 trvdng hop 2.3. Chéin dodn xde dinh Chu yéu dua vao lam sing 2.4, Chan don phan biét = Nhot - Sdn ngira + Trang ca 3, DIEU TRI 3.1. Nguyén tie diéu tri - Diéu tri theo cin nguyén (nhiém khuan, khéng nhiém khudn) = Loai bé cde yéu 16 thudn Igi - Vé sink ea nbn: rita tay thuéng xuyén bang xa phong sat khuan. .. - Trinh cao gai, kich thich ton thyong. ~ Tay timg bénh nhan cu thé ma chi can ding dung dich sit kiusin két hop voi khang sinh béi tai chd hod khang sinh toan than. 3.2. Didu tri cy thé19 3.2.1, Didu tr] tai ch - Dung dich sat khudn: sir dyng 2-4 lan/ngiy, c6 thé Iva chon mét trong cde dung dich sit khudn sau: povidon-iod 10%; hexamidin 0.1%; chlorhexidin 4%, Thuée khang sinh béi tai ché: ding mét trong cae thude sau: + Kem hode mo axit fusidic, bdi 1- 2 an/ngay + Mé mupirocin 2%, béi 3 Lan/ngay + Méneomyein, boi 2-3 Lin/ngay + Kem silver sulfadiazin 1%, béi 1-2 lan/ngay + Dung dich erythromycin, boi 1-2 lan/ngay + Dung dich clindamyein, béi 1-2 Lan/ngay BGi thude 1én t6n thuong sau khi sét khudn, thoi gian diéu tr tit 7-10 ngay. 3.2.2. Dieu trj toan than - Trig hop nang cn phéi hop dieu tri tai chd két hop véi toan than bing mét trong cae khang sinh sau: " Litu lwgng Knangiatalt Neudi lon Tréem Cloxacilin | Udng hoae tiém bap hoie tinh mach | Dudi 20 kg, uong hoa tiem (TM) ett 6 gids ding 250-300mg bap hode TM ctr 6 git’ ding 12,5 - 25 mgskg, Trén 20kg, ligu dimg nhw ngudi lon ‘Amoxicillin’ | Udng 875/125mg x 2 lin/ ngay Usng 25 mg/kgingay chia clavulanic hai Lin Clindamycin | Udng hoge truyén TM, 300-400mg x | Udng hoac truyéa TM, 10- 3 Kin’ ngay 20mg/kg/ngiy chia ba kin Trung hop do ty clu ving khang methicilin Vancomycin | Truyén TM cham 30 mg/kg/ngay, ]Tiém TM chim 40mg/ngay chia 4 lan (khong ding qua 2g/ngay) | chia 4 lan (oir 6 gig/lan) hoac truyén TM 10mg/ke ‘Thi gian diéu tri tir 7-10 ngay - Truong hop do nam hode nguyén nhan khéc can diéu tri theo nguyén nhan cu thé, + Do ném: ding eée thuée duimg toin than nhu fluconazol hode itraconazol két hgp véi cae loai diu g6i hoge tim chita selenium sulfide, ketoconazol hay ciclopirox.20 + Do virus Herpes simplex: uéng aciclovir lidu 200mg/lin x 5 lan/ngay hoac valaciclovir 500mg/lan x 3 lan ngay hoc famciclovir 500mg/lan x 3 lan/ngay trong, 5-10 ngay. + Do Demodex: ding permethrin 5% tai chd, udng ivermectin 200n¢/kg ligu duy nat, udng khi d6i hodc metronidazol uéng 500mg/ngay trong 15 ngay. 4, PHONG BENE V6 sinh cd nhain, + Trénh cac yéu té thuan loi nhu méi trudng néng am, cac hoa chat du mé. - Diéu tri sém khi cé tn thurong 6 da. ~ Tnréng hop tai phat cn luna y vé sinh t6t loai bé cdc 6 vi khudn trén da nhw ving, ma, ramh lién mang.2 HOI CHUNG BONG VAY DA DO TU CAU (Staphylococcal Scalded Skin Syndrome) 1,.DALCUONG 1.1. Khai nigm HGi chimg bong vay da do tu ciu (Staphylococcal Scalded Skin Syndrome - SSSS) la bénh nhiém tring da cép tinh do ngoai doc t6 cita tu ing theo during mau dén da gay nén, Bénh c6 tén goi khae 1a bénh Ritter, duge bac si ngudi Bite Gotftied Ritter von Rittershain mé ti lin dau vao nam 1878. 1.2. Dich té nm Bénh thudng gap 6 tré em dudi 5 tudi (hay gap nhat 1a 2-3 tudi), 6 cac nude dang phat trién, 06 thé thanh dich nhé tai nha tré hose phong nudi durdng tré so sinh. Bénh ciing cé thé xuat hién trén ngwoi lon, dac biét ngudi bi suy than hodc suy giam mién dich 1.3. Ciin nguyén/ ‘ché bénh sinh Tu cdu ving (Staphylococcus aureus) tiét ra ngoai doe t6 luu hanh trong mau ngudi bénh. Cé 2 loai déc t6 khdc nhau Ld exfoliative toxin A va B (ETA, ETB). Cac Gc t6 lam phan c&t desmoglein 1 (thudng nm ¢ lép hat cia thugng bi) gay ra cdc bong nude khu tra ndng, dé vo-va bong vay nhanh, 2. CHAN DOAN 2.1, Trigu ching lim sang C62 hinh thai 1am sang: the khu tri va thé lan toa ~ Thé khu tri + Khong ¢6 dau higu toan than, ving da xung quanh tn thuong binh thudng. + Ban do dang tinh hong nhiét, méin, tap trung chi yéu cae nép gdp (ving quanh rén hode ving ham ké, ving day chau, tang sinh mén 6 tré so sinh) nhung khéng tién trién thanh bong nude. ~ Thé lan toa + Thuong xay ra sau m6t nhiém tring o bat ki vi tri nao nhur viém mai hong, viém tai gitta, viém ket mac, viém rén, Mét s6 trrdng hyp hiém gap, xdy ra sau viém phdi do tu céu, viém mang trong tim, ap xe vi sau sinh, viém khép. + Toan than: tré mét moi, bit kém, kich thich, sét22 + Ban dé, min dang tinh héng nhiét lan toa 6 cac héc tu nhién hoac cae nép gap. Sau 24 - 48 gid’ hinh thanh cae bong nude, tao thinh cde nép nhan trén da lam da trong, thé san ya rap, sd nhu to giay nham. Sau d6 tién trién thanh bong nuéc mém, néng, nh@o, ranh gigi khdng 1% va lién két voi nhau thanh mang rng, dé vo khi va cham va thong v6 khuan (dau higu Nikolsky duong tinh), Cac bong nude sau khi trot de 16 t dau. nén da d6 am wét, vay bong ra méng, cudn lai nin giay cudn thuée la va +Tén thuong niém mae it gap, day 14 dae diém quan trong chan doan phan biét SSS véi di tmg thude thé nang. - Bénh thong dap img t8t v6i diéu tri va thuong khoi hoan toan sau 5-7 ngay ma khong dé lai seo. Truong hgp ning cé the gay ti vong, nhat la & tré suy dinh dudng, ngudi suy than hay suy giam mién dich do cac bién chimg nang nhw nhiém khuan huyét, viém phoi.. 2.2. Cn im sing - Cac xét nghiém danh gia tinh trang viém: bach cau, mau ling, CRP, procalcitonin co thé ting. - Nuéi cay tim vi khuan va lim khang sinh dé: vi tri ly bénh phim nudi cy, phan ap tim vi khudn: dich két mac, mi hong, phan, 6 md trén da. Khang sinh dd ¢6 ¥ nghia trong trudng hop vi khuan da khang khang sinh. - Cay mau: thudng am tinh 6 tré nh, c6 thé duong tinh & ngudsi lon. - M6 bénh hoe: o6 khe tach 6 throng bi phia dudi va trong lop hat. Cac Ihe tach 06 chita dich va 18 bao ly gai. Céc phan con Iai cla thugng bi khng thay thay doi dae higu va khéng thay xm nhiém té bao viém trong trung bi. Mé bénh hoc 6 ¥ nghia trong trong hop chan doan chua 16 rang. - Ki thudt phat hign gen ma héa ETA, ETB bing ky thudt lai DNA va PCR. 2,3. Chan dodin xc dinh Dya vio: - Lam sing - Cn lam sang 2.4. Chan dodn phan bigt - Hi chimg Lyell - Bong ning ~ Ban d6 do virus ~ Bénh Kawasaki = Ban do nhiém déec tré so sinh23 ~ Ly thugng bi bong mrée bam sinh ~ Pemphigus vay 1a 3. DIEU TRI 3.1. Nguyén tie didu tri ~ Danh gid toan trang bénh nhan, mie d6 ning cia bénh dé c6 huréng xit ly thich hgp. - Tré so sinh m&c SSSS can duge cach ly véi cae tré khae dé tranh lay nhiém chéo. ~ Diéu tri tai ché va toan than ~ Boi phy dinh dung, nude, dign giai. ~ Phat hign va dieu tri cdc 6 nhiém trimg khu tra dé ngan ngira vi khuan lan vao mau. 3.2. Didu tr cy thé 3.2.1. Didu tr] tai chd — Chim s6e tai chd: + Dung dich sit khuan: Tam rita hang ngay bing dung dich sit khudn (thude tim pha loding 1/10.000 hoc dau tam nhe nhang, tranh lam t6n thuong da thém, + Cham sc mat, migng khi cé ton thuong, ~ Khang sinh bai tai ché (acid fusidic, mupirocin....), béi 2 lan/ngay trong 7-10 ngay. 3.2.2, Diéu tri toan thin ~ Khang sinh toan than: Iya chon mét trong cac khang sinh sau: Khang sinh ju lugng Nguoi lén Tre em Cloxacillin 250-500mg/lin, 3-4 langay | 50-100mg/kg/ngay chia 3-4 lan Oxacillin 250-500 mg/lan mdi 4-6 git 12.5 — 25mg/kg/ lan mdi 6 gidr Cefazolin 250-500mg/lan, 3-4 lin/ngiy | 25-50mg/kg/ngay chia 3-4 lan Ceftriaxon 1-2g/ngiy, t6i da dy/ngay, | 20-80mg/ky/ngay, trayén 1 Tan truyén | lin ‘Truong hgp do ty cau ving khang methicilin Vancomycin | 500mgy/lan x 4 lan/ngay 40mg/kg/ngay chia 4 lan Hoac Ig/lan x 2 lan/ngay Linezolid 600mg/lin x 2 lan/ngay 10mg/ke/lan x 3 lan/ngay + Lya chon khac: khang sinh nhém quinolon, macrolid hofe aminoglycosid dya vio két qua khéng sinh 3, ~ Didu tr bién chimg néu 63.3. Didu tri hi try ~ Hasét ~ Bi dich, dign gidi: dinh gia mire d6 mat nude, dién giai do s6t va mat nude qua da, _ Dinh dung: ché d6 dinh duéng day dui dé tang cong cung cap nang Luong va protein cho vide linh vét throng. 4, PHONG BENE ~ Cich ly bénh nban cho dén khi khoi bénh. - Nang cao thé trang, Diéu tri som céc 6 nhiém khuan, Vé sinh ca nhiin,2k BENH LAO DA (Cutaneous tuberculosis) 1, DAL CUONG 1.1, Khai nigm ~ Lao da (Cutaneous tuberculosis - CTB) la bénh nhiém khudin da man tinh, do true khuan lao co tén khoa hgc la Mycobacterium tuberculosis gay nén. Bénh thuong gap 6 nhimg nue dang phat trién, di trong mac thudng la o nhing ngudi suy dinh dudng, suy giam mién dich. ~ Mét sé khai niém + Nhiém lao: 1a tinh trang ¢6 vi khudn lao trong co thé nhung khéng bi bénh. Vi hua ton tai trong co thé va ¢6 thé hogt dng khi sire dé khang cia co thé suy giam. Ngudi nhiém lao khéng c¢ biéu hign kim sing, co thé phat hign tinh trang nhiém lao thong qua ede xét nghiém mign dich hoc nhurphan img test da, hode xét nghiém IGRA (xét nghigm trén co so gidi phéng interferon gamma). + Bénh lao: Ngwdi bénh cé cdc biéu hign lam sang cua bénh lao, s6 hrong vi khudn Gngudi bénh lao nhiéu hon v6i 6 rong vi khuan 6 ngudi nhiém lao, + Neguy co chuyén tir nhiém lao sang bénh lao: khoang 10% nhiing ngwdi khoe manh bj nhiém lao tir Mic nho sé chuyén thanh bénh lao, Véi nhing ngwéi suy giam mién dich (nh mac HIV/AIDS...) thi nguy co chuyén tir nhiém lao sang bénh lao hoat dgng sé tang lén, 1.2. Dich t8 ‘Tirnam 2007, bénh lao li nguyén nhan gay tir vong do m6t tae nhan trayén nhiém nhat, vugt qua HIV. Theo bao cao cia TO chire Y té Thé gidi, nam 2020, téng sé ngudi bi bénh trén toan thé gidi 1a khoang 9,9 trigu, Viet Nam xép thir 10 trong 30 nude ¢6 génh nang bénh lao cao nhat va xép thir 11 trong s6 30 nude ¢6 ganh nang bénh lao da khang thude cao nhat. 1.3. Cin nguyén/Co ché bénh sinh ~ Lao da duge xép vao nhém bénh da hiém gap, do true khuan lao c6 tén khoa hoc la Mycobacterium tuberculosis giy nén. Lao da c6 thé kém theo lao 6 cae co quan khac nhur lao phdi, lao rugt. True khuan lao c6 thé truc tiép dén da tir co quan ndi tang hoic hiém hon 1a tir bén ngoai, = Cac yéu té lién quan dén bénh lao da: + Déc luc ca trye khudn, + $6 long true khuan,26 + Site 48 khang cita ngudi bénh: da s6 nhitng ngudi bi bénh lao da thé hién di img véi tuberculin hoae BCG. Trong lao nang thi phan img nay am tinh +Nghién rugu, dinh dudng kém, mie cae bénh man tinh hoge gidm mién dich lim cho bénh tram trong hon 2. CHAN DOAN 2.1. Trigu ching lim sing Bénh lao da duge chia thanh hai nhom chinh: lao da thye su va ban lao. ~ Lao da thie sy (True cutaneous tuberculosis): ton thuong da la biéu hign truc tiép cita nhiém tring tai vi tri ton thuong da. Cé thé xae dinh vi khuan Myeobacteria bang cae xét nghiém nhu nhudm soi, nudi cdy. Vige phat hign vi khudn cé thé khé khan hon cae bénh c6 ton thong it vi khudn. ~ Cie ban lao (Tuberculid) la két qua ctia cae phan (mg mign dich qua duémg mau véi cée thinh phan khang nguyén eiia M.ubereulosiy, Phan ing throng xiy ra 6 nhimg ngudi cé mién dich tat. 2.1.1. Lao da thye sy (True cutaneous tuberculosis) - Sing lao (Tuberculous chanere): cén due goi la lao so nhiém, diy 1a mét tin thong hiém gap, xay ra sau khi Mycobacteria xm nhép tryc tiép qua mét vét throng nhiig bénh nhan chwa c6 dap img min dich. Sau khi nhiém 2 — 4 tuan, tai vj tri xam nhap xuat hién san mau dé nau, c6 thé hinh thanh yét logt khéng dau, bo nham nho. C6 thé xudt hién hach ving hoc khong. Néu khong duge diéu tri, bénh c6 thé tién trién thanh lao tang, lupus lao, lao lan toa, hode ty khoi dé lai seo. - Lao siti (Tuberculosis verrucosa cutis): cée t6n thuong xuat hién nhing ving bi An throng va cde ving tip xtc v6i vi khudn, Vi tri thudng gap nhat 6 tay, dau g6i, mat ca chén va méng. Tén thuong ban dau la sin mau dé nhgt, cimg, an kinh khong, xep, cdc sn lon dan, gidta tin thuong day simg, sau dé sui 1én nit né, cd thé co mu, xung quanh ¢6 ving thim nhiém mau tim tham, trén c6 vay da lan vay tiét, ngoai cing c6 mét ving xung huyét mau dé. Tién trién lau nam, tén thong lan ra xung quanh va dé Iai seo. - Lupus lao (Lupus vulgaris): 1a mt trong nhiing loai CTB phé bién nhat, hay gap 6 vung dau, cd, chi duéi. Tén thuong 1 cdc mang tham nhiém mau nau dé, bé mat cd vay, tién trién cham, linh giita dé lai seo co kéo. Théng thurimg chi c6 1 tin thong duy nhat, 46i khi lim sang gidng dang nam sporotrichosis nén dé bi chan doan nham. - Lao ké (Acute miliary cutaneous tuberculosis): Bénh thuong xay ra 6 nhimg bénh nhan suy giam mién dich (nhu déng nhiém HIV) va cé lao lan ta. Vi tri thudng gap 6 tay chan, than minh, Tén throng 1a cae san, mun mi, xuat hnyét, c6 thé c6 hode khong 6 trung tam hoai tir hose 16m gitta,27 ~ Gém lao (Metastatic tuberculous abscess): Hay con goi la ap xe lao. Bénh la két qua ciia su lan truyén true khuén theo durong mau tir 6 bénh tién phat trong truong hop mign dich kém, T6n thuong la cée cue, lite déu mho, chic dudi da, sau d6 tr nén mém, ap xe héa, Da phia trén cé thé v6 tao thanh vét loét khong déu. Tién lwong xau. ~ Loét lao & 16 tw nhién (Orificial tuberculosis): bgnh thudng gap 6 ngwdi trong thinh suy giam mién dich, mac bénh lao ndi tang dang tién trién. Vi tri hay gap & migng (khéu cai cimg, ludi, mdi), ngoai ra c6 thé gap & hau mon, sinh duc. thutong ban dau 1 cae cuc nho mau dé phit né, nhanh chong vo dé lai cdc vét loét, dau, thudng khéng lanh tw nhién, Thuong thay cac 6 lao khac trong co thé (nhu lao phéi). ~ Lao tang (Scrofuloderma): vi tri hay gp 6 cé, ngoai ra c6 thé gap 6 ben, than minh, ham dui, nich, tay. Tén throng 1a cdc unhé mau dé dui da, khong dau, sau 46 vo hinh thanh cc vét loét gidi han khong 16 rang véi mé hat 6 day, Nhiéu 16 1 c6 thé Tién két véi nhau tao thanh céc duéng ham dudi da. Tén thong o6 thé tién trién anh, seo co kéo tao nén khoi dinh khong déu, xo cig manh. 2.1.2, Ban lao (Tuberculids) = Mét s6 dic diém hé trp chan doan bao gdm: tién str truée dy hod hién tai co mac Jao, test tuberculin duong tinh, dap img hoan toan véi dieu tri lao. M6t s6 bénh da iu duge cho la ¢6 ign quan dén true khuin lao va duge dua vio nhom ban lao, tuy nhign chi m6t s6 duge coi 1a ban lao da thre su. - Ban lao thue sy + Lao dang lichen (Lichen scrofulosorum): Tén thuong 1a cac san lichen tap trung thanh dim, c6 vay dinh, khong cé trigu chimg co nang. Vi tri thuéng quanh nang lng, sip xép theo cae nhom hode hinh vong hoje thanh céc mang, chi yéu 6 ngue, bung, hmg va gée chi, Hau hét cae trong hp 06 6 lao toan than tiém an + Ban lao san hoai tir (Papulonecrotic tuberculid): Tén thuong dang sin, myn mit va nét, mau ndu d, cig, déi ximg, ten c6 vay hod vet loét, khi anh dé lai nhing vét seo lim. + Hong ban rin Bazin (Erythema induratum of Bazin): Tén thyong la cae cue nho, khdng dau, mém, thurong xuat hién & e&ng chan hai bén. Cée cuc 06 thé loét néng, bar rich, t6n tai lau, hdi phuc cham, Tén thuong thutmg xuat hign & nit gidi. ~ Tén thuong dang ban lao: Mét sé tinh trang u hat man tinh 6 mat nhu Lupus lao lan toa 6: mat (Lupus miliaris disseminatus faciei) va ban lao dang trimg ca do (rosaceiform tuberculid) 06 biéu hign la cae san d6 thim nhiém don hinh 6 m@t. Trude 46 cde tinh tang nay duge xép loai lao da, tuy nhién cdc bang chimg con han ché 2.2. Can Him sing ~ Nudi cdy vi Khun: La tiéu chun ving dé chin doan bgnh lao, déng thiri xae dinh tinh khang thude. Bénh pham lay tirmé sinh thiét, dich tiét tin thuong. ~ Xétnghiém AFB nhudm soi true tiét: Kha nang chin dodn cao nhéit vai bénh phim28 tir céc ton thuong wot hodc dich tiét c6 sé hsong vi khudn cao nhw lao tién phat, lao ting, loét lao tai hée tw nhién, gom lao, Bénh pham lay tir mé sinh thiét 6 ria tn thuong, dich tiét ton thuong, = M6 bénh hoe + Tiéu bin nhugm HE: M6 bénh hoe dae trung trong lao da la u hat lao, vi tri 6 16p ha bi. Tén thirong u hat dién hinh bao gm cac té bao biéu m6 va cac té bao khdng 16 da nhan rai rc, kém theo su tham nhiém cae té bao don nhén. Trung tim ciia u lao hoai tir va d6i khi voi hoa, Hinh thai u hat lao thay d6i theo cae thé CTB. Thé béi Sng lao ‘Tham nhiém bach cau trung tinh day d&c, ap xe hoa va hoai tur 6 lép trung bi sau va ha bi, Khdng c6 u hat Die diém m6 bénh hoe Lao st Dic trung la ting simmg, tng sinh cac té bao dang biéu mé, hinh thank cac ap xe & trung bi néng. Co su xuat hién cua té bio khong 1d va hoai tur hu tri Lupus lao. Dic diém mé bénh hoe da dang, vi tri nang lao thuong & trung bi néng. Khong ro hodc khéng ¢6 t6 chute hoai tir 6 gia nang lao. Bao quanh t6 chite hoai tir 1a ede té bao biéu mé, cde té bao khéng 16 da nhan, ngoai cing la céc lympho bao, Thugng bi co thé loét véi syr xm nhap ca 18 bao viém hén hop. Trong trudng hop tién trién lau ngay, lép gai c6 thé day 1én véi sy ting sinh gia ung thu biéu md, Lao ké Thuong bi ing simg hoa, tang sinh lép gai hoe u nh, Thudng c6 tham nhiém day dic bach cau trung tinh va dp xe 6 Idp trung bi, cé thé xuat hign lympho bao, tuong bao, Ludn xuat hién hoai tir khu tra, Gém lao Nang lao dién hinh Lan t Loét lao tai | Thuong bi: e6 thé cd loét, U hat ludn xuat hign o tung bi cic 18 ty nhign vi tri 6 lop trung bi sau va ha bi Lao ting ‘Tat ca cdc tring hop déu c6 u hat lao, chil yéu & ha bi, thudmg c6 hoai ti. 1/3 céc trudng hop co té bao khéng 16. Phan [én cdc truong hop cling, xuat hign ap xe ting bach céu trung tinh Lao dang Cac nang lao Khu tri 6 bé mat da bao quan céc nang léng va éng tuyén lichen mé hdi, bao gém cic té bao biéu mé, bach cdu lympho va cac té bio khéng 16, 06 thé khong thay 16 chire hoai tit Ban lao sin —_| Dc diém phé bién 1a viém mach ting bach cau va the mach, c6 thé xuat hoai tir hign hoai tr fibrin. Dac tring 1 hoai ti hinh ném 6 trung bi néng. ‘Thuong khdng cé u hat lao Hong ban ran | Dac diem tuong tw viém mé mé dudi da, cac nang lao khu trit hodc lan Bazin t6a véi su thm nhiém nhiéu bach cdu da nhan trung tinh & cae mach mau lon hoe nhé. + Tigu ban nhugm Ziehl — Neelsen: Nhugm Zichl — Neelsen dé phat hign29 Mycobacteria khang acid la mét phuong phdp nhanh chong va tiét kiém chi phi, Tuy. nhién khéng dic higu véi true khuain lao va c6 46 nhay thap. - Test tuberculin (TST): Dya trén phan img qué man chém lign quan dén té bio lympho T. - PCR lao: Phat hién DNA cia M.tuberculosis trong cée mau bénh pham dong thdi xe dinh dét bién gen lién quan dén khang thudc. ~ Xétnghiém gidi phéng interferon — gamma (Interferon-Gamma Release Assays — IGRA): Hai loai IGRA duoc FDA céng nhan: QuantiFERON — TB In - Tube (QFT) va T-SPOT.TB, Két qua xét nghiém khéng bi anh hudng bdi tiém phong lao, tuy nhién khéng phan bigt duge gitta lao dang hoat dng, lao tiém an hoge da nhigm lao trude dé, xét nghiém khéc + Xét nghiém tam soat HIV: khuyén céo tam sodt nhiém HIV 6 tat ca cde bénh nhan nhiém true khuan lao do nhiing ngudi nhiém HIV co nguy co mac lao cao gap 30 Ian so vi nhiing ngudi HIV am tinh + Tam soat cée 6 lao ngoai da: ¢ Lao phdi: Soi AFB dim 6 tit ed cde bénh nhan ¢6 trigu chimg lao phdi, chup X- quang neve, chyp cat 16p vi tinh, nudi cdy vi khuan. * Lao hach bach huyét: siéu am, chyp cat lop vi tinh. « Lao mang bung: chup edt Iép vi tinh, + Lao néi so, lao xuong: chyp cong hudng tir. 2.3, Chan doan xac dinh ~ Tiéu chuan vang li cdc phuong phap phat hién Mycobacterium, bao gom nudi cay vi khuan va xée dinh DNA M.tubereulosis bing PCR. - Cie yé t6 gidp goi ¥ chan doan: Biéu hign lam sing va tién sir mac Lao. AFB nhudm soi trye tiép Test tuberculin Xét nghiém gidi phéng interferon — gamma, M6 bénh hoc. 2.4, Chan dodn phan bigt tt ok ~ Viém da ma hoai ther ~ Nhiém nam Blastomycosis. = Nhiém ndm Chromoblastomycosis ~ Dj tg thude.- Uhat Wegener, - Trig c4 d6 sin ma. - Gom giang mai - Lichen spinulosus. ~ Cham - Coecidioidomycasis - Viém ludi, = Nhiém Mycobacterium khong dién hinh: ~ Bénhu hat man tinh, - Bénh Weber — Christian. - Nodular pernio. 3. DIEU TRI 3.1. Nguyén tie diéu tri - Nang cao thé trang = Cham soc tai chd. - Khang sinh diéu tri lao. 3.2. Didu tri cy thé 3.2.1. Diéu tr] tai chd - Diéu tri ban lao: Diéu tri trong ty nhur véi lao da thy sy. - Déi v6i mrdng hop lupus lao ho’c lao sii, c6 thé 4p dung cac bign php khée nhau dé logi bo tn thong nhu dot dign, laser CO2, hose Ap nite long. + Déi véi cae trudng hop loét hoai tir thi lam sach ton thuong déng vai tro quan trong, Kim yét thong nhanh lanh. 3.2.2. Dieu tr] toan than - Khang sinh diéu tri: cing nhu diéu tri lao phéi va lao cde co quan khac, viée diéu tri lao da can phdi hop nhiéu logi thude khée nhau (da héa tri ligu). Tuy theo ting trudng hgp cu thé dé chi dinh cae pha dé, - Diéu tri bao gém 2 giai doan: + Giai doan tin céng kéo dai 2 thang, gdm 4 loai thude: rifampicin, isoniazid, ethambutol va pyrazinamid ding hang n; + Giai doan duy tri kéo dai 4 thang, gom 3 loai thude: rifampicin, isoniazid va ethambutol ding hang nga = Phée 46 nay phit hop véi lao phdi va hiu hét lao ngoai phi, Néu c6 lao lign quan31 dén viém mang nao, xuong, khép hode cét séng thi théi gian diéu tri lau hon, tir 9 dén 12 thang. ~ Tén thuong da cai thign tir 4 — 6 tudin, khoi hoan toan sau 1 — 5 thang. Néu tén thuong tiép tuc tién trién ho&e khéng cai thign di tuan tha didu tri, can xem xét lai chan doan hoje nghi ngé vi khudn khang thude chéng lao hang 1. trj lao khang thude ~ Vi khudn lao khang ca rifampicin va isoniazid duge goi li lao da khang thude (MDR ~ TB). Lao siéu khang thude (XDR-TB) khi MDR ~ TB o6 thém khang thude voi bat ki fluoroquinolon va it nhat mét thudc tiém dong thir hai. ~ Diéu tri MDR— TB bao gém thdi gian diéu tri tan céng 6 — 12 thang va diéu tri duy tri 18 thang, ~ Thude bac hai (huréng dan diéu tri lao duge wu tién 1a bedaquiline, fluoroquinolon (levofloxacin ho%c moxifloxacin), ethionamid, ethambutol va _pyrazinamid Linezolid, amikacin, cycloserin, pretomanid, delamanid, va clofazimin ki mét s6 loai thude khac dang duge sir dung 3.2.4. Mét s6 loai thude chéng lao méi ~ Bedaquiline: duge FDA chap thudn yao nam 2012 dé str dung trong diéu tri lao phdi Khang thude, Bedaquiline 1a m6t diarylquinoline hoat dong theo mét oo ché méi va do dé c6 hiéu qua 6 ca lao nhay cam véi thuéc va MDR-TB. Bedaquiline chi khuyén co cho lao phdi khang thude do ty Ié tir vong duoc quan st thy cao hon khi sir dung ~ Pretomanid va delamanid 1a nitroimidazole hoat dng chéng lai MDR-TB vi XDR- ‘TB. Pretomanid duge chap thuan béi FDA vao nam 2019 dé str dung két hop voi bedaquiline va linezolid cho XDR-TB va MDR-TB khéng dip tng. Delamanid da duge phé duyét dé sir dung 6 Chiu Au cho ngudi lon va tré em trén 3 tdi mac lao phoi MDR32 Bang 1: Lieu lugng cic thudc chéng lao theo cfin ning Thude Liéu Lua chon thit | Isoniazid ‘Ngudi lén: 5 mg/kg (thurmg 300mg) hat Tré em: 1omg/kg Rifampin Neudi én: 1Omg/kg ‘Tre em: 10 — 20 mg/kg Ethambutol 19 — 25mg/ke. Pytazinamid [30-40 mg/kg Lya chon tr | Bedaquiline 400mg hang ngay trong 2 tuan, sau dé 200mg hai 3 lan/tuan trong 22 tan Linezolid 10 ~ 12 mg/kg (can nang > 15kg) Levofloxacin | Ngudi kin: 500 ~ 1000mg ‘Tré em: 15 — 20mg/ke Moxifloxacin | Newdi lin: 400mg Tré em: 10~ 1Smelkg Clofazamine _| 2 ~ Smg/kg Ethionamid 15 ~ 20mg/kg (ngudsi lon va tré em) Pretomanid 200mg x | lan/ngay trong 26 tun Delamanid 100mg x 2 lan/ngay (cin nang > 34kg) Trong qué trinh digu trj can theo doi chire nfing gan, thén, cng thire mau va soi day mat. 3.2.4, Didu trj khde - Ché dé an uéng, dinh duéng t6t - Ning cao thé trang. 4. PHONG BENH Phong bénh lao la Ap dung cac bién phap nhim gidm nguy co nhiém tye khudin lao va nguy eo chuyén tir nhiém tao sang bénh lao, - Kiém soat vé sinh moi trudng. - Sir dung phuong tign phng hé ca nhan cho nhan vién y té - Gia tiép xiie nguén lay. - Tiém vacein BCG (Baeille Calmette-Guérin) - Diéu tri lao tiém an33 BENH PHON' (Leprosy) 1. DALCUONG LL. Khai nigm Bénh phong (Leprosy) la mét bénh nhiém tring kinh dién do trye khuan Mycobacterium leprae (M.leprae) gay ra. Tre khuan phong cé ai tinh véi da va than Kinh ngoai bién nén cdc ton thuong cita bénh chit yéu biéu hign 6 hai co quan nay. Bénh phong khéng gay tir vong, tuy nhién néu khOng duge phat hién va diéu ti sém, ca ton thuong than kinh cé thé gay hau qua tram trong nhu dj hinh, tan tt lim cho ngudi bénh bj ky thi, xa Janh. 1.2. Dich té ‘Theo bao cao ciia T6 chite Y té Thé gidi (WHO), nim 2021, trén pham vi toan cau c6 hon 133.000 trudng hop mac bénh phong mdi, Tai Viet Nam, hién nay theo s6 ligu cia Bénh vign Da liu Trung wong, c6 hon 10.000 trung hop dang duge quan ly. Voi vide ap dung da hod trj ligu (MDT) tir nm 1980, s6 Iuong bénh nhin phong trén toan thé gidi da giam mot cach dang ké, Hau hét cde nude trong ede chau luc da hoan thinh chi tiéu loai trir bénh phong véi ty 1é nu hanh duéi 1/10.000 dan so, Tuy nhién s6 bénh nhan phong méi hang nim vin xuat hign rai ric 6 mGt s6 nude tai chdu A, chau Phi va Nam My. Tir nim 2017 dén nim 2022 c6 trén 400 bénh nhan méi duge phat hign, trong 46 c6 nhiéu trudng hop khng dién hinh duge chén dodn s6m, diéu ti kip thoi nén ty 1g tan tat giam mot cach dang ké. 1.3. Cain nguyén/ Co ché bgnh sinh = Can nguyén gay bénh phong la tre khudn phong c6 tén khoa hoo la Mycobacterium leprae (M. leprae) gay ra. - Tryc khudn phong cé cae dic diém nhu sau: + La tre khuan khang cn khang toan + Chua nudi cay durge trén méi trong nhan tao + Chu ky sinh san tit 12 - 13 ngay rian s6ng 6 méi trudng 1-2 ngay + Nhigt do thudin loi: 30-32 46 C .N DOAN 2.1, Trigu chiing kim sing 2.1.1. Tén thurong da ‘Tén thuong da trong bénh phong rit da dang, phong phi tuy theo thé bénh.4 Cac tin throng sau day thuong hay gap nhit: + Dit (Macule): gap trong phong thé bat dinh ([: Indeterminate). Dat ¢6 thé ¢6 miu tring, tham hode héng, sé rong it, kich thuée khoding 2 dén 3 cm duong kinh, dic biét ¢6 réi loan cém gide nhe tai ton thuong. - Mang tham nhigm (Infiltration plaque): hay gap trong phong thé tung gian, ¢6 the khu trit hay lan ta, ranh gidi khéng 18 rang véi da lan. - Ci (Tuberculoid): gap tong phong thé ci (T: Tuberculoid). Tén thuong chic, noi cao hon mat da, ¢6 mau hong hay dé tham, kich thude tir mét dén vai milimet. Cae ci:tép trung thanh mang goi la mang ci, Mang cti gisi han 13 vi vimg da lanh, trung tm 1m hode lén seo. Bé mat thudng khé rap, 6 thé c6 vay da, long rung, ri loan cam gide rat r6 tai ton thuong. - Uphong, nét, cue (Leproma, nodule, papule): gp trong phong thé u (L: Leproma), s6 lugng ton thuong nhiéu, lan toa, di xing, ranh gidi khong 10 véi da lanh, tham nhiém sau, bé mat thudng bong, mau hong, mat cam gide. 2.1.2. Ton thuong thin kinh ngoai bién - Viém day than kinh ngoai bién: 14 biéu hién rat thudng gap trong bénh phong. Tuy timg thé ma viém than kinh ngoai bién c6 biéu hién khac nhau, Cac day than kinh viém to va dau va dé lai hau qua tram trong néu khong duge xit ly kip thoi. Trong phong thé cd, day than kinh bi viém to, chit va khong déu, Neuge lai, trong phong thé u, nhiéu day than kinh bi viém to déu va mém. Cae day than kinh hay bj viém li: day than kinh 6 néng, day than kinh try, day thin kinh hong khoco ngoai, day than kinh giita... Viém day than kinh c6 thé don déc hoae nhieu day than kinh tn thuong cing mét lie, dae biét la trong con phan ting. ~ Réi loan cam gie: gidm ho%e mat cim giée néng bao gdm cém gide dau, néng lanh va xile gic. Nhiing vi tri thurong gp: ving da co t6n thuong, giae mac, long ban tay, Jong ban chan. Mét s6 trudng hop r6i loan cam gide c6 thé gap o ving da Linh. ~ Réi loan van déng: yéu, ligt va teo cdc co khi c6 ton thurong cée day than kinh, Tuy timg day than kinh bj ton thong ma cé biéu hién cc hinh thai tan tat khac nhau. O mat, tn thong nhanh chi phi cho co vong mi cia day than kink s6 VIL gay ra hign tuong “mat thé”. G chi tén ton thuong day than kinh tru gay ra ban tay “vudt tru”, tn thuong day than kinh gitta gay ra “ban tay khi”, 6 chi dusi, tn thong day than kinh héng khoeo ngoai gay ra hign tugng “chan cat can”, 2.1.3. RGi loan bai tiét - Gidm hode mat kha ning bai tiét m6 hoi lam cho da kh6, nirt né. ~ Tang tiét chit ba im cho da béng. 2.1.4. Réi loan dinh dwéng35 ~ Loet 6 ga ~ Rung long may thong 6 1/3 ngoai. ~ Day simg 6 long ban tay ban chan, teo da. ~ Xép xuomg va tiéu xrong, 2.15. Cac ton thuong khite ~ Viém mii, viém hong, viém thanh quan, ~ Vigm két mac, gide mac, mong mat wv. ~ Vidm xuong va tiéu xong ~ Vig tinh hoan, ~ Ching vii to 6 nam giéi ~ Mét sé cac co quan nhu gan, lich, hach c6 thé tim thay trye khuan phong nhung Khong ¢6 ton thuong. 2.1.6. Tan tt do bénh phong ‘Tan tat trong bénh phong co thé xuat hién truée, trong hoc sau diéu tri. a, Tan tt tién phat Tan tat tién phat (primary deformity) la nhimg tin tat truc tiép do truc khuan phong gay nén tir hau qua ctia viém dy than kinh ngoai bién. Cé ba loai tan tat tién phat hay gp nhat gom: giam/mat tiét mé héi, mat cam gide da va teo/liét co. Ngoai ra, cée tOn thyong than kinh cé thé anh hung t6i dinh dudng, phan phdi mach mau cho cée du xurong nhé, gay ra tinh trang tiéu xwong,“rut cde ngén”. Tan tat tién phat bao gom: - Mat cam gidc da, mat cam gide gid mac = Ligtco, teo co - Mat nhiim khéng kin, - Cd ede ngén tay, chain = Rut cde ngén Chan “eat edn” b. Tan tat thir phat Loai hinh tan tat nay thudmg xuat hign trén cae bénh nhan da c6 tan tat tién phat, nhung do khéng biét céch cham sée, diéu tri nén bi chan thuong, nhiém tring, bong... gy hau qua rat tram trong. Cac tan tat thir phat hay gap bao gdm: ~ Loét, seo xdu ~ Béng/thuong tich = Cut ngén/ban tay, ban chan~ Giam thi lve, mi 2.2. Cn lim sing 2. Xét nghigm rgch da - Chi dinh: + Dé chan doan thé bénh, nhém bénh (PB/MB) + Theo doi diéu tr). + Nghi ngé tai phat sau khi hoan thanh MDT. Mé bénh hoe = Thé 1: Hinh anh ciia viém da kh6ng dac higu voi su xdm nhap quanh céc huyét quan va than kinh ciia ce lympho bao va té chite bao. = Thé TT: Xam nhp viém thanh nang dién hinh (khéng ¢6 chat hoai tir ba dau) véi cie dae diém: + Xam nhp viém sat vao thuong bi, khéng c6 khodng sing Grenz + Nang gdm c6; trung tam 1a té bio khéng 16, thir tw ngoai la té bao ban lién, lympho bao, té bao xo 6 ngoai cing + Nang throng cé hinh dai xap xép doc theo céc thanh phan phy cia da, sqi thin kinh, + Soi than kinh cé thé bi pha huy mét phan hoc hoan toan. + BH 4m tinh hose duong tinh trong mot sé it tudng hop. - Thé B: C6 khoang sang Grenz, dudi khoang sing 1a se xm nhgp viém Tan toa clia t6 chite bao, t6 chire bao sang (hay t6 chire bio o6 héc sang), té bao Vichow, it lympho bao. Cac soi than kinh khéng bi cdc té bao viém pha hiy. BH durong tinh manh (++) ~ Thé LL: Thugng bi teo, dui thgng bi 06 khoang sing Grenz, duréi khoang sing Grenz la su xm nhap vim diy dic, lan toa cia 16 chite bio ¢6 hoe sing lén, té bio Vichow, Co it ho&e khéng cé lympho bao. Soi than kinh khéng bj pha hity hoan toan béi cae té bao viém. BH duong tinh rit manh (++4+) tép tung thinh dam hoae bd. 2.2.3, Xét nghigm PCR (Polymerase Chain Reaction) Xétnghigm PCR c6 d9 nhay va a9 dac higu cao, Tuy nhién xét nghigm doi hoi trang thiét bj, chuyén mén va ky thugt chuyén sau. Xét nghiém nay thye hién khi edn xac dinh truc khuan khang thudc hay tai phat. 2.3. Chan doan xac djnh Mét ngudi durge chén doan 14 mic bénh phong khi it nhét ¢6 1 trong 3 déu higu duréi day - Tén thuong da bi mat hay gidm cdm gide.37 - Day thin kinh ngoai vi day hoac to kém theo mat cam gide vi/hoae yéu cde co duge chi phéi boi day than kinh do. Can loai trir cae nguyén nhan khac gay viém hoje t6n thong day thin kinh ngoai bién, ~ Phat hign true khuan khang con khang toan trén xét nghiém rach da/day than kinh ngoai bids in, i nhimng trrdmg hop khi tham khém lém sang va xét nghiém rach da con nghi ngd thi c - T6 chize héi chan tai dia phuong véi su tham du cita cae can bé chuyén khoa ¢6 trinh 46 thude tuyén trén (huyén, tinh hoge/va trung wong) va can bé chnyén khoa khic néu can, ~ Lay bénh pham chuyén vé trung tam dé lam b6 sung cdc xét nghiém vi khuan, chan doan mé bénh hoe, PCR dé c6 thém eo s6 chan doin bénh va hoi chan Iai. dinh ky kham va lim lai cdc xét lan, Phai ghi chép chi tiét két qua mdi lan kham va lim xét nghiém yao nghigm nbil hd so bénh dn, 2.4, Chain doin thé 2.4.1. Phéin logi bénh phong theo nhém bénh cia Té chiée y té thé gidi (WHO) ‘Dé tign Igi cho vige diéu tri va theo déi bénh phong 6 thye dia, WHO phan Jogi cde bénh nhan theo nhém nh sau: ~ Nhém it vi khuan (PB - Paucibacillary): la nhimg bénh nhan cé tir 1 dén 5 tén thuong da va khéng tim thay truc khuan phong tai ton thuong (BI =0) + Nhém nhiéu vi khuan (MB - Multibacillary): Bao gdm cae bénh nhan 6 it nhat 1 trong 3 bigu hign dui day. + Co tir 6 ton thuong da tr6 Ién, hose: + C6 tén throng than kinh (viém day than kinh don thuan, hoic phdi hop voi tin thuong da khéng tinh sé lugng), hode + Tim thy truc khudn trén xét nghiém rach da/day than kinh, 2.4.2. Phan logi theo Ridley - Jopling Dya trén dap img mién dich qua trung gian té bao (CMD). Ridley va Jopling 4a phan logi bénh phong theo cdc thé sau da ~ The I: Day la the bat dinh, CMI cé the thay d6i. Tén thurong da la dat thay di mau sic, cam gide it thay di. ~ Thé TT: thé cit cuc 1a thé dn dinh c6 dap img mign dich qua trung gian té bao tot nén tén thuong it, khu tri, bénh khoi nhanh hoa c6 thé tw khoi. Ton throng 1a cée cii to, nhé, mang cil, viém day thin kinh ngoai bién + Thé LL: thé u eye la thé nang nhat (trude day cin goi la the CMI rit tinh”), vi dap dng yéu nén tn thuong lan toa, thim nhiém su, bénh phai diéu tri lau. Tén38 thuong 1a cac u phong, nét, cue, méng tham nhiém, lan tba, doi >ting, viém day than kinh ngoai bién - Thé BT, BB, BL la céc thé trung gian od dap img CMI khéng 6n dinh nén ¢6 thé i thé bénh. Ton thuong la cac mang thdm nhiém nhe, c6 thé khu tra hode lan toa. Viém day than kinh nhiéu, dae bigt trong phan img phong. — TT —> Khéibénh Nhiém M.Jeprae mién dich trung gian t@ (CMD So dd 1. Cic thé phong theo phan lo: 2.5. Chin doan phn bigt Ridley ya Jobling Can phan bigt cée thé bénh khac nhau vei mgt sé bénh da sau day: ~ Phong thé I: Phan biét véi: lang ben, bach bién, vay phan tring, bét sic 16, loan sie 66 khi ~ Phong thé T (BT, TT): Phan biét véi: ndm da, sarcoidosis, giang mai Ll, Lupus ban 46, Lao da, U hat hinh nhdn, Lupus lao... - Phong thé B, L (BB, BL, LL): Phan biét voi Sarcoidosis, Mycosis Fungoides, Sarcoma Kaposi, ung thu da ~ Cae tén throng than kinh khéc: + Viém ré than kinh. + Cae tn thuong thin kinh sau chan thuong. 3. DIEU TRI 3.1, Nguyén tie diéu tri - Ap dung phéc 46 da hod tri ligu eda WHO cho bénh nhan phong. - Dieu tri bién ching ciia bénh phong, phong ngira tin tat do phong, = Didu tri, chm séc va quan ly thing xuyén cho bénh nhan phong tai dia phuong. 3.1. Didu tri cy thé39 3.1.1, Theo nhém bénh Theo khuyén edo ciia Té chite y té thé gidi ndm 2018, didu tri bénh phong da duge thay ddi, Su thay déi nay dya trén cae khéo sat, nghién ctru cita cde chuyén gia toan edu, Dac biét, diéu tri theo phic 46 of, bénh nhan khang thude va tai phat van xuat hién & mOt s6 nude. Dé giam thiéu ti da nhuge diem nay, WHO da khuyén cio thay d6i phéc dé diéu tri nhu sau: Ca hai nhom PB va MB diéu tr bang 3 loai thudc 1a: Rifampicin, Dapson va Clofazimin v6i liéu Luong, cdch uéng giéng nhau. (Trude day uhom bénh nhan PB chi diéu tri 2 thudc la Rifampicin va Dapson) ‘Thoi gian diéu tri cu thé: 6 thang déi véi nhém PB va 12 thang d6i véi bénh nhan thuée nhém MB. Bang 1, Cac phac dé didu trj cia WHO (2018) aa rua ir ‘Thdi gian 6m tudi oe ieu MB PB Rifampicin | 600 mg/lan/thang 300 mg/lan/thang va Nguoi lin Clofazimin 12 thang | 6 thing 50. mg/ngiy Dapson 100 mg/ngay Rifampicin | 450 mg/lan/thang post Clofa 150 mg/lan/thang va (Ok gah) SPB = a se ve! | 12thang | 6 thang vi>-40ka mg cach ngay Dapson 50 my/ngay Rifampicin | 10 mg/kg/lin/thang Clofazimin | 100 mg/lin/thang, 50 mg 2 lan/tuan Dapson 2 mg/kg/ngay __ Lien Fz x6 em Guge dinh nghia la dudi 15 tubi tai thdi diém duoc chin dodn. ‘Dbi voi tré c6 trong Luong co thé dui 40kg c6 thé tham khdo cach tinh ligu sau: Tré em < 10 tudi Hoge <40 kg 12thing | 6 thing - Tré ¢6 trong lugng tir 20 - 40 kg: + Rifampin: 300 mg/thang, + Clofazimin: 100 mg/lan/thang, 50 mg 2 lan/tuan (vao cae ngay ¢6 dinh trong tuan, gidta cac lan udng cach nhau tir 3 - 4 ngay) + Dapson: 25 mg/ngay (1/2 vién 50 mg) Tré 06 trong lugng dudi 20 kg: Rifampicin: 10 mg/kg/thang Clofazimin: 6 mg/kg/thang, | mg/kg/ngay Dapson: 2 mg/kg/ngay te40 3.1.2, Diéu tr] phong khang thude Chan doan phong khang thuée dia trén két qua xét nghiém PCR phat hign ving gen khang Dapson hoae Rifampicin cia vi khudin, Nguyén tic digu tri ~ Khang rifampicin: Clofazimin két hgp it nhat hai loai thuée: clarithromycin’ minocyclin va quinolon trong 6 thang, sau dé Clofazimin két hop v6i mét trong cdc thude trén trong 18 thang tiép theo. ~ Khang dong thi rifampicin va ofloxacin: Phoi hop clarithromycin, minoeyelin va clofazimin trong 6 thang, sau dé clarithromycin hoe minocyclin két hop clofazimin trong 18 thang tiép theo. ~ Phae dé diéu tri cu thé Bang 2. Phic dd khuyén céo cho bénh phong khang thudc Diéu trj Logi thudc bj khang 18 thing tig ant ig tiép theo 6 thang dau (hing ngay) (hlisg ney) Ofloxacin 400 mg* + ‘Ofloxacin 400 mg* minoeyelin 100mg + hode minocyelin 100mg + Clofazimin 50 mg Clofazimin 50 mg Kbing Rifampleln. | rinacinatio mg™ + clarithromycin 500 mg, + Clofazimin 50 mg Ofloxacin 400 mg* + Clofazimin 50 mg Clarithromycin 500 mg + | Clarithromycin 500 mg minoeyclin 100 mg + hod minocyclin 100 mg + Clofazimin 50 mg Clofazimin 50 mg. Khiing Rifamy va ofloxacin * Ofloxacin 400 mg c6 thé thay thé bang levofloxacin 300 mg hoge moxifloxacin 400 mg = Sang lg¢ lao trén nhimg bénh nhan phong bat dau diéu tri bang phic dé c6 cae thude trén (do fluoroquinolon c6 higu qua chéng Iai vi khuan lao). Khi dng mic lao cin diéu tri theo phao dd higu qua voi oa hai bénh dé dé phng bénh lao khang thudc. - Theo déi dign tam do, do nguy co kéo dai khoang QT ya r6i loan nhip tim khi sit dung clarithromycin, minocyclin va quinolon ~ Theo di chat ché va bao cdo ca bénh phong khang thude véi chinh quyén dia phuong, BO Y té va WHO. 3.2. Bidu trj dy phong41 ~ Sit dung rifampicin ligu duy nhat (Single-dose rifampicin - SDR) diéu tii dv phong cho ngudi lon va tré em tir 2 tudi tr6 len da hoge dang siép xtie* Voi ngudi mac bénh phong, sau khi sang lo¢ bénh phong, lao va khéng c6 cdc chéng chi dinh ‘Tiép xitc: mt ngudi 6 gan bénh nhan phong trong mot hd? gian dai duge coi 1a “tiép xac” véi bénh phong, ¢é thé di nhiém hodc chua nhiém bénh. “7hot gian dai” duc dinh nghia 14 tép xtc v6i bénh nhan phong chia diéu tri trong 20 gidy mdi tudin trong it nhat ba thang trong mot nam. Bang 3, Liéu duy nhAt rifampicin (SDR) Tudi/eén nang Rifampicin lieu duy nhat 2 15 tudi 600 mg 10-14 tudi 450mg ‘Tré em 6-9 tudi (>20kg) 300 mg Tre em <20kg (= 2 tudi) 10-15 mgykg, 4. DU' PHONG Phong ngira bénh phong thong qua dr phdng mién dich (vie-xin): - BCG khi dén 80% - Tiém lai BCG (ligu BCG thir hai sau ligu khi sinh) higu qua khéng r9 rang. h Lim tang tée dung bao vé cia SDR é nhiing ngudi tiép xii tir 57%42 Phy lye 1: Quy trinh rach da 1, Chuan bi: Trang thiét bi: ‘Tian toan sinh hoc cap 2 (néu co) Kinh hién vi quang hoc Dung cy say lam (néu c6) Cin dao phau thudt (Inox) Dung cu, héa chat va vat tu tigu hao Ludi dao phau thuét (thing ding hrdi dao s6 15) Lam kinh Dau soi kin Dung dich fuchsin 1%, Dung dich cén tay HCI 1%, Dung dich xanh methylen 0,2% Bong Cin 70 46 Dén cn Bat lita Panh Khay dung bénh phim Bat chi viét kinh Giang tay, mi, khau trang 2. Vj tri lam rach da: rach da it nhat 3 vi tri, trong dé rach ra tai dai tai va tn thong da la yéu cau bit bude. Cac vi tri rach da bao gom: + 4 Hai dai tai Tén thurong da: rach tai ria ton thong néu tén thong ranh gidi 13; rach tai trung tam ton throng néu ton thuong ranh gidi khong 16, Viing da tran day 6 trén cung léng may, Dau géi hode khuyu tay Mat mu ngon tay Vi tri da phat hién duong tinh trude dé: dé theo doi va phat hién tai phat bénh 3. Ki thudt: - BOi té tai vi tri chi dinh (néu bénh nhan van cn cam gidc). ~ Sat khudn vj tri rach da bang con va dé kho = Ding ng6n tr va ngén cai nding viing da dinh lay bénh pham va kep chat lai de lam ngimg hoae gidm chay mau dén mite t6i thiéu, Phai duy tri ap re sao cho phan da bi kep trang ra sau it gidy. ~ Tay cén lai dimg dao phau thuat rach mt dudng dai Smm, sau 3mm43 ~ Giit nguyén 4p lye bang céc ngén tay, xoay ludi dao theo mét géc vudng véi vet rach va lay dich mé bang canh sc cua loi dao nhiéu lan theo mot hung. - Phét dich mé Ién lam kinh theo hinh tron dudng kinh khodng 8-10mm, Mau bénh pham khdng duoc cé mau. ~ Mau cd chira mau déu khong dat tiéu chun, c6 thé lay tip Lin thir hai sau khi Jau vét rach bang béng gon trong khi van duy tri ap le cla ngén tay. - Cé dinh bénh pham bang céch ho mat duéi lam trén ngon lira trong 2 gidy - Nhudmm Ziehil — Nelsen, doc va nhan dinh két qua. 4. Nhén dinh két qua: + Chi sé vi khuan (Bacteriological Index - BI): nim trong khoang 1+ dén 6+, tiy thude vao sé long true khudn quan sat durge trong vi truéng, Bénh nhin phong thé u khong durge digu tri thrdng ¢6 BI 5+ aén 6+, san didu tr] chi sd giam tir 0,75 dén 1+ mdi nim, Chis6 vi khuan M6 ta ics 1 10 vi khudn trong 100 vi trrng a 1-10 vi khuain trong 10 vi rutng 3+ 1-10 vi khuan tong 1 vi trudng a 10- 100 vi Khuan trong 1 vi trong 3 100 - 1000 vi khuan trong 1 vi trrdng 6 Trén 1000 vi khuan trong 1 vi trudng, + Chi sé hinh thai hoc (Morphological index - Ml): ty 1é phan tram vi khudn thé chic (hinh dang va kich thude vi khudn binh thudng, goi ¥ vi khuan séng) trén tong 6 vi Khuan riéng ré dém duge. Chi s6 MI sé giam xuéng 0% sau 4 - 6 thang khi didu tr ding va du theo phac 43 Bénh phong 6 giai doan sém va cae thé bénh phong nhe hon (thé it vi tring, PB) rat khé phat hign true khuan khi xét nghiém.44 PHAN UNG PHONG (Leprosy reactions) Phan img phong (Lepra Reaction) la cdc dot viém cap tinh do dap tng mién dich cia co thé déi véi khang nguyén M. Lepra. Cac con phan ing nay cé thé xuat hign trade, trong hoae sau diéu tri. Day 14 mot trong nhang bién chimg thudng gap, gay tin thong day than kinh va dé lai nhieu di chimg tram trong néu khong dirge phat hign va xir ly kip thoi, Chinh vi vay nhan biét som cae trigu chimg 4é dieu tri ding dan cdc phan img phong 1a v6 cing quan trong, gidp gidm bét nguy co tan tat cho ngudi bénh, C6 hai loai phan ing phong: ~ Phan img bgnh phong logi 1 hay cén goi la phan img dao nguge (RR: Reversal Reaction), hoac phan img lén cap (Up-grading Reaction). - Phan ing loai 2 hay cdn goi la héng ban nat ban nat do phong (ENL: Erythema Nodosum Leprosum)45 PHAN UNG PHONG LOAI1 (Type I leprosy reaction) CUONG LA. Khai nigm Phan img phong loai 1 con goi la phan tng lén cap hay phan tmg dao ngwac. Day 1a phan img vim do dap ing mién dich qua trang gian té bao (CMI) vi khang nguyén ciia.M. leprae. Biéu hin dic trung cita loai phan img nay 1a cde ton thong da bang chéc tro nén tay do, phi né va c6 thé loét. Mot 86 trong hop nghiém trong 6 thé kém theo sét cao, pha bin tay va ban chan, viém day than kinh cap tinh... Phin img phong loai 1 14 nguyén nhan chinh din t6i tin tt trong bénh phong, Viém day than kinh ngoai bién do phan img phong loai 1 xay ra rat nhanh, tham chi chi trong mot dém cde ngén tay da ¢6 thé bi “cd” hay chan da bi “edt can” 1.2. Cin nguyén/ Co ché bénh sinh Phan ting phong loai 1 duge coi 1a mot dap (mg t6t cua CMI di véi ce khang nguyén ctia true khuan phong. Chih vi vay, phan itng nay chi xay ra 6 cae thé phong trung gian nhu BT, BB va BL. Day la céc the phong cn ¢6 sire dé khéing va thay doi tuy theo tinh trang mién dich cing nhu dap (rng diéu tr} ‘Théi gian xudt hign con phan img thudng la khi dip img CMI tang cao va c6 mit cia khang nguyén true khudn phong tai t6 chire da, than kinh. Phan img phong Jogi 1 thung xay ra tir 6 -12 thang sau khi bat diu MDT, nhung e6 thé xay ra sau khi hoan thanh MDT, ngay ca sau khi bénh nhan hoan thanh phae dd diéu tri 3 - 5 nam. Phan img cding c6 thé gap 6 bénh nhan chua dirge diéu tri va la li do dau tién khién bénh nhan dén co sé-y t8. 2. CHAN DOAN 2.1, Trigu ching Lim sing 2.1.1. Phong thé trung gian cil (BT - borderline tuberculoid ) ‘Trong thé trung gian ct, su chénh Iéch gitta CMI va M. leprae it nén ty 16 xuat hign phan img RR thap va mise d6 phan img nhe, héu qua it tram trong hon, - Tén thuong da: + Thuong xay ra 6 bé tn thuong voi cae trigu ching do, sung né, thm nhiém. Cé thé gap toan bé ton thurong phi né, sung lén nhanh chong. + MOt vai ton thuong v6 va loét trong nhiing trudng hgp phan img ning + Khéng phai tat ca cae tén throng da ci déu c6 biéu hign phan tg dao nguoe va thurong khong xudt hign tén thuong mdi. Khi lui bénb, t6n thuong xep xudng va bong vay. = Ton thuong than kinh: 1. D446 + Cae day than kinh thuémg bj anh huong 1a day than kin try, thin kinh gitta, than kinh quay, than kinh mae chung, than kinh chay sau va than kinh mat, + Méthode nhiéu day than kinh ngoai bién bi tén thuong c6 biéu hién: sung to, nhay cam, dau, mat chire nang van déng hoac cam gidc. * Tén thuong than kinh nhe: bénh nhin chi thay dam ditt va rit bong 6 ving da do day than kinh d6 chi phdi. So nan 6 cam gic dau nhe, nhay cam. * Ton thuong than kinh nang: bénh nhan thay dau nhise nhiéu & cdc ving da do cae day than kinh bj viém dé chi phdi. Cac day than kinh nay ting nhay cdm nhidu khi cham vo hoac s@ niin, ~ Toan trang: bénh nhan mét moi, khé chju kém theo sét. 2.1.2. Phong thé trung gian (BB - borderline borderline) Thé nay c6 su can bang gitta CMI va M. Leprae, phan img co thé xay ra rit manh néu ¢6 su thay d6i cia mot trong hai yéu t6 nay. = Tén thuong da: tén thuong da dét ngét tay d6, sung né, trung tim lm. Truéng hop ning ¢6 thé loét, phi mat, ban tay, ban chan, ¢6 thé xuit hign ton thong méi thuong than kinh: nhiéu day than kinh tn thuong sung to, nhay cam, dau nite, c6 thé gay ligt nhanh va mat chite nang van dng, cém gidc, dau ~ Toan trang: st cao, mét moi, khé chiu, chan an. 2.1.3. Phong thé trung gian u (BL - borderline lepromatous) Su chénh Iéch gitta CMI va. M. leprae it. Vi vay, ty 1€ xuat hién con phan ting trong phong thé trung gian u khéng cao va mite dé thuong nhe. - Tén thong da: ton thong lan rng nhanh véi dae diém: dé, bong, cing mong, ranh gidi khong rd voi da lanh, dé bj loét. C6 thé xuat hién nhiéu ton throng mdi. ~ Tén throng than kinh: hau hét cdc day than kinh ngoai bién bj anh huéng & mite a9 nhe. M@t sé trudmg hgp day than kinh ngoai bién sumg to, mém, dau, ~ Toan tang: bénh nhan mét moi, s6t cao lién tue 39 - 40°C. Mot s6 bénh nhan 6 kém theo tén thuong cia héng ban mit hode ¢6 thém ede biéu hién cua cae co quan khée nhur viém mong mat, viém tinh hoan, viém ngén tay, ngén chan, chay mau cam, pha thanh quan. 2,2. Cn Mim sing a: Xét nghigm rgch da Thue hign khi chan doan nghi ngé véi bénh tai phat. Trong trrng hop phan img phong, cdc chi s6 truc khuan phong (BI, MI) khéng tang Ién so voi xét nghiém in gn nt 2.2.2. M6 bénh hge Hinh anh mé bénh hoe ton thurong da thudng gap nhat trong phan img phong loai 1 la: xm nh§p lympho bao dang u hat, phi né nha trung bi, két dae nhan (pyknosis) cla té bao lympho, phi: né trong u hat; xdm nhap lympho tai mé md, quanh nang long,47 2.2.3. Siéu dim than kinh ~ Sigu am day thin kinh trong mt s6 trudmg hop dé xéc dinh mite 46 va vi tri t6n thuong cia day thin kinh. ~ Tén thuong than kinh co thé danh gid qua hinh anh day lén ca day than kinh, cae t6n thuong giém am va tin higu tang sinh mach trén siéu am doppler - Tuy nhién, xét nghiém nay phin 1én mang tinh chi quan va dO chinh xé¢ han ché, phy thude nhiéu vao kinh nghiém ctia cae bac si chan doan hinh anh. Hon nia, 6 rat it bang chimg cho thay c6 méi quan hé gitta hinh thai trén siéu am va biéu hin t6n thurong than kinh, Chit §: trong qud trinh diéu tri, cén lam mt sb xét nghiém khde nue: - Cée xét nghiém co ban céng thite méu, sinh hoa (chite nang gan, thén, dudng mau, dign giai do), HIV, nude tieu. ~ Xét nghiém loai trir lao (xét nghigm dom, X-quang ngue...). - Kham phan: xét nghiém phan nhim phat hién nhiém ky sinh trig durong rudt (néu co sé c6 thé thye hién dugc), ~ Kiém tra bat ky 6 nhiém tring néu nghi ngo. 2.3. Chan dodn xiie dinh + Chan doan xée dinh chit yéu diya vao lam sang: + Bénh nhan duge chan doan phong cae thé trung gian BB, BT, BL cé thé trong giai doan dang, da hode chia MDT. + Dién bién 1am sang cap ti + Tén throng da cii tay 46, 06 thé xuat hign thém cae ton thong méi + Viémn day than kinh ngoai bién: sung, dau, ting nhay cam kém theo ton thong chire nang than kinh (van dong, cam gidc). - Can im sing: + Siéu fim: diy than kinh diy, khéng déu, ting kich thude, ting sinh mach. + Xétnghiém rach da: Bl, MI khéng ting. - Xét nghiém mé bénh hoe: ¢6 hinh anh de trung cia phan ing phong loai 1 2.4, Chan doan mire d@ con phan tng - Phan ting nhe: + Phiind, ban dé chi cde tén thuong da hién c6. + Khong c6 biéu hign ton thuong than kinh (sung to, dau, ting nhay cam, r6i loan/mit chire nang). + Toin trang: thudng khong nh huéng, d6i khi bénh nan c6 thé s6t nhe.48 ~ Phan ting nang: khi xuat hign m6t trong cae dau higu dudi day: + Dau, suy gidm chite nang than kinh (cam gide, van déng), + Phi bin tay, ban chan + Sétkém cae trigu chimg toan than nhu khé chiu, mét moi. + Dau khép + Tén thong da sung dau, ting nhay cam + Lot ving da tén thuong. 2.5. Chiin doan phiin bigt - Phan itng phong loai 2 - Bénh ly tén thuong day than kinh do nguyén nhan khée: dai thio dudng, HIV/AIDS, thiéu vitamin B12, chén ép than kinh, bénh ly rong tuy. - Phong tai phat 3. DIEU TRI 3.1. Nguyén tie didu t Tiép tue phac 46 diéu tri da hoa (MDT) néu chua hoan thanh iéu tri ndi tra tai co soy té trong trudng hyp phan img nang. - did i ngay khi phat hign c6 phan img - Tang etrong ché 46 An udng, dinh diréng, nang cao thé trang ~ Nghi ngoi, bat dong cde chi 06 viém day thin kinh - Vat ly ti éu sau khi tinh trang viém diy than kinh da cai thién, 3.2. Didu tri cy thd 3.2.1, Mite d@ nhe - Lyra chon mt trong sé thude giém dau, chéng viém khéng corticosteroid (NSAIDs): + Aspirin: 325 - 650mg/lan cach nhau 4 - 6 gid. Tdi da 4g/ngay. + Indomethacin: Khoi dau liéu 25 mg x 2 - 3 lin/ngay, ting thém tir 25 dén 50 mg mdi tuan. Téi da 200mg/ngay. + Ibuprofen 200 - 400 mg mdi 4 gid. Tdi da 2400mg/ngay. + Paracetamol: 500mg/lan céch nhau it nhat 4h. Téi da 4e/ngay. + Tramadol; 50 - 100mg/lan, Téi da 400mg/ngay. = Cén danh gid nguy co tim mach, hé hap, xuéit huyét tiéu hoa, réi loan déng mau.49 - Danh gia ton thuong sau méi 2 tuan, néu khong kiém soat digo xét ting liéu thude diéu tri. Truong hop van khong kiém soat duge phan img hoge mire 6 chuyén ning can chuyén phdc do diéu tri theo hudng dan diéu tri phan img nang (can hoi chan chuyén gia). 3.2.2. Mite d6 ning a. Lua chon s6 1: Corticosteroid = Chi dinh: + Phan img loai 1 khong kiém soat duge bing paracetamol ho& NSAID; + Viém diy than kinh: tn thuong chire nang thin kinh méi xuét hign Dau 6 mét hode nhiéu day than kinh ¢ Bénh nhan phan nan vé suy gidm chit nang than kinh (mat cam gic hoac yéu co...) © R6i loan van d6ng, cam gidc khi thim kham « Viém day than kinh am tham, 46i khi khong c6 trigu chimg 16 ring. Can theo ddi va dan gid chire nang thin kink dé phat hign sém cdc dau higu t6n thuong (Tham Khao phu luc). Prednisolon la loai corticosteroid thuring duge sir dung. Litu khoi dau tir 0,5- 1,0 mg/kg/ngay. Trong hau het cic uudng hop ap dung lieu khoi dau khodng 0,Smg/kg can nang sau dé gidm liéu cham, ligu trinh kéo dai 20 tuan cho thay két qua 161 nhat. Bang 1: Phic dé diéu tri phan tag phong logi 1 vdi prednisolon theo khuyén cdo WHO 2020 Ligu Tuan Wong | 1-2 34 5-8 9-12 13-16 17-20 méi ngay 40mg |x 30mg __|x x 25 mg x 20 mg x x 10 mg x Smg x50 - Phac dé giam liéu predaisolon (Bang 1): + Liéu khoi dau 4p dung 30mg hogc 40mg/ngay trong 2 tuan dau, sau do giam xudng 25mg (trong hop liéu khoi dav 1a 30mg) hoac 30mg (trudng hop liéu khéi dau la 40mg) trong 2 tuan tiép. + Tir tuan thir S - 12: ding liéu 20mg + Tuan 13 - 16: 10mg + Tuan 17 - 20: Smg - Trong mét sé tring hop phan img nang hod dai ding, ligu khdi déu cao hon va thoi gian diéu tri lau hon, Mot sé bénh nhan mie cde bénh kém theo (bénh dai thio dudng) 06 thé sit dung liéu thip hon hoae két hop véi thude Khao, liéu long dirge diéu chinh theo dap img lam sang. Nhitng trrong hgp nay can hoi chan thém § kién tir chuyén gia, - Obatky liéu diéu tri nao, néu cde du higu lam sing cia phan img ting lén hose khéng thuyén giam thi ting liu lén 30 me/ngay, sau dé giam dan liéu trong khoang thoi gian 20 tuan nia theo phac 6 tiéu chun, Néu bénh nhan 4a hoan thanh mét ligu trinh corticosteroid nhung lai xwit hign phan ang mOt Kin nifa, 06 thé bat dau lai ligu trinh tong ty. ~ Chite nang than kinh cai thign nhanh trong cdc trrdng hop ton thuong than kinh méi (dudi 6 thing). Tuy nhién qua trinh phuc hoi chire nang than kinh ca cée ton thuong nang sé mat nhiéu thang hoae ¢6 thé khong hdi phuc. Do dé, vige tang ligu prednisolon hoc kéo dai théi gian diéu tri corticosteroid cin duge xem xét va hi chan. - Tae dung phu ctia corticosteroid + Suy giam mién dich: * Mac lao, nhiém tring huyeét, viém tay xuong. © Cac bénh nhiém khuan va nhiém ky sinh trong dudng rudt. Can diéu tri tinh trang nhiém trang theo phic 46 inh duge can nguyén cu thé. Trong trudng hop khéng lam duge xét nghiém, khuyén cdo cdc trrng hop bénh nhan tude khi diéu tri phdc a6 corticosteroid sit dung albendazol (liéu danh cho nguéi lon 400mg, 2 lan/ngay trong 3 ngay). + Dai thio dudng: Néu bénh nhan 6 tién sir dai théo dudmg hoae tinh trang ting dung huyét méi phat hign, can duoc hoi chan chuyén khoa néi tiét dé phdi hop didu tr. Tinh trang ting dung huyét cé thé ty hét khi ngimg sir dung corticosteroid. + Loang xuong, hoai tit v6 mach chom xuong dili: can chi y dae biét & cac bénh nhan Ién tudi, it van dong, + Réi loan tam than: pho bién 1a hung cam. + Roi loan tiéu h6a, loét dung tiéu héa.31 + Hoi chimg Cushing: mat tron nhur mat trang, mun trimg ed, ram Tong va tang, cn, béo trung tém, Tinh trang nay sé cai thign khi dimg corticosteroid, + Ube ché ting truéng 6 tré em: do tre ché vo thugng than va truc tuy + Teo tuyén thugng than (bénh Addison). + Tang hnyét ap, ting nhan ap, duc thay tinh thé. b. Thuéc wa chon thir hai: Cyclosporin ~ Cyclosporin 14 mét lyra chon thay thé an toan cho nhiing bénh nhan bi viém day than kinh khéng cai thign véi prednisolon hode xuat hign nhiéu téc dung phy lién quan dén prednisolon, Trude khi Iya chon cyclosporin digu tri, cd thiét phai hoi chan chnyén gia. ~ Chéng chi dinh: suy than, suy gan; ting huyét 4p khéng kiém sot duge; bénh nhan suy giam mién dich, bénh nhan mac HIV; c6 bénh ac tinh (u lympho T @ da, melanoma...); nghién rugu. reatinin mau mdi 2 tuan cia bénh nhan. Dimg, - Theo dai: theo doi thuéng xuyén huyét ap, theo dai trong 3 thang, sau d6 theo ddi hang thang, dyra vao creatinin dicu tri khi creatinin tang trén 30% so vGi creatinin nén. 3.3. Didu trj khde ~ Cac thude giém tac dung phy cita NSAIDs, corticosteroid én dudng tiéu héa nhur ire ché bom proton, gastropulgit, bé sung canxi + vitamin D cho cae bénh nhén digu tri corticosteroid kéo dai, cé nguy co loang xuong (bénh nhan Ién tudi, man kinh). ~ Nghi ngoi va han ché van déng trong giai doan cap tinh cia dot phan img, sir dung nep hoae bé bot hd tr cho cae chic tén thuong than kinh, dic bigt vio budi 416i ~ Khi trigu chimg dau cia giai doan cap tinh giam, tap kéo gian thy dong cac co bj anh hudng dé duy tri kha ning van dong cua khop ~ BOi dugg am cho da kho. 3.4, Theo doi 3.4.1. Trong qua trinb digu tri - Trong giai doan cap: danh gia chire nang van déng va.cam gide cla than kinh hang ngay (xem phy luc), - Theo dai todn trang, tién trién ca t6n thuong da, khép, than kinh. - Trong giai doan phan img én dinh, cdc con dau gidm, khi bénh nhan duge diéu tri ngoai tra, tai kham mdi 2 tuan hode khi c6 cae dau higu bat thurong, ~ Theo dai tac dung phu cita thude.52 3.4.2. Sau didu t ~ Két thie phae dé diéu wi phan img, kham dinh ky theo huéng dan cua nhan vién ye. - Tai kham ngay néu xudt hign bat ki cae cic dau higu bat thudng: ban dé tai cac ton thuong da, yéu moi co, mat cam gide, sét, 4, PHONG BENH ~ Theo di, thiim kham dinh ky bénh nhén phong dang diéu tri da hod tri ligu hoe da két thie da hoa tj ligu. - Tai khdm ngay néu xudt hign bat ki cae cae dau higu bat thuong: ban do tai cae ton throng da, yéu moi co, mat cam gide, sot. Biéu dé 1: Chén dodn Ioai phan tmg phong (WHO 2020)53 Biéu dé 2. Diéu tri phan ing phong loai | va viém day than kink (WHO 2020)54 Biéu do 3: Theo déi bénh nhan phan ing phong loai 1 va viém day than kinh (WHO 2020) Phan ting phong loai 1 diéu tri bang corticosteroid ‘Kham moi 2 tuén: Khong d6 dau hoa tin throng than kinh them Khéng Tigp tue phae d6 chudin Xéttangiidu corticosteroid, giam liéu ‘ ae corticosteroid Piéu tri khdc: G giai doan cép, bat déng chi tin thuong dé giam — dau va tranh ton thuong than kinh them, Khi than kin hoi phue, tap vat ly tri ligu. |35 PHAN UNG PHONG LOAI2 (Type 2 leprosy reaction) 1. DAL CUONG 1. Khai nigm — Phan tg phong logi 2 hay con goi li hong ban nit do phong (ENL: Erythema Nodosum Leprosum) la m6t phan img viém hé thong, dién bién timg dot, hay tai phat, thudng xuat hién 6 nhing bénh nhan phong thé u (LL, BL) va hiém khi gap 6 bénh nhan thé BB — ENL xay ra khoang 1.2% cac trrdng hop bénh phong va 15.4% trong sé cac trudng hop phong thé u (Lepromatous leprosy - LL), ty 1é nay thue té con duge bao cdo la cao hon trong mét s6 nghién ciru. ENL efing 6 thé xay ra nhieu dot trén cing ‘bénh nhan — ENL cé lién quan dén dip img mién dich, anh hung lan toa khap eo thé, khdng chi tn thuong 6 da — ENL eé thé xuat hign cp tinh, trong trutmg hop phan img nang néu khong duge phat hign va xtr ly kip thai cé thé gay nén nhiing hau qué nghiém trong. 1.2. Cin nguyén/ co ché bénh sinh — ENL la mot bién chimg do dap img mién dich xay ra pho bién nhat 6 nhimg bénh nhan dang MDT nhung cing 6 thé xiy ra truée hoge sau khi két thie dieu tr. — Vai trd cia cae cytokin duge giai phéng tir té bao lympho T, dai thyre bao va phite hop mign dich déng vai t chinh trong co ché bénh sinh ctia ENL. bao lympho 'T sau khi durge kich hoat sé hoat hoa cae dai thyre bao chira truce khuan Mleprae, dai thye bao sau dé sé gidi phong ra céc khang nguyén M leprae, cdc cytokin (TNF-a, IFN-y) va trinh dign khang nguyén t6i té bao 'Th1. Cae cytokin duge gidi phéng kich hoat bach cau da nhan trung tinh, cae t€ bao mién dich khae. ‘Tir d6 mot loat ede cytokin, cdc té bao mién dich durge kich thich tham gia vao phan img gy ra céc ton thuong cde mé ee quan. — Qua trinh tao phire hgp mign dich khang nguyén ~ khang thé ciing dong gop vao co ché hénh sinh cua benh. Cac phire hop mién dich thug duge hinh than ngoai mach mau 6 nhing noi M. Leprae hign dign voi ndng 46 cao (da, day than kinh, hach bach huyét va tinh hoan), Nhimg phite hop nay két hop véi bé thé (complement) g”ly ra phan ting viém, dn den cfc biéu hign trén lm sing. Phte hop mign dich, bo the King dong tai tit 16 chite, da, day than kinh... gay hién tugng vier, phir ng, stmg va co thé tao thanh cae 6 ap xe. — Qué trinh viém day than kinh trong ENL xay ra tir nr, khée v6i qua trinh viém trong phan img loai 1. Vi vay, tan tat do viém day than kinh trong ENL eding xay ra tir ti va ty Ié thap hon. Tuy nhién, ENL cfing cé thé gay ra phan img viém 6 nhiéu co quan khac: khép, hach, tinh hoan, mat.