BNH HC DA LIU

TI LIU SU TM TNG HP DCH

Gii thiu Information Mc lc


Bin son ebook : L nh Sng
I HC Y KHOA H NI
Trang web : www.ykhoaviet.tk
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in thoi : 0973.910.357

THNG TIN

V VIC XUT BN BCH KHOA Y HC 2010 :
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cnh vic cp nht cc bi vit mi v cc chuyn khoa mi,cng nh thay i cch thc trnh by, Bch
Khoa Y Hc 2010 c chia ra lm nhiu cun nh ( Tng dung lng ca tt c cc cun khong 20.000
trang), mi cun bao gm mt ch ca Y Hc, nh th s gip bn c tit kim c thi gian tra
cu thng tin khi cn. Tc gi xin chn thnh cm n tt c nhng kin ng gp ph bnh ca qu{ c
gi trong thi gian qua. Tt c cc cun sch ca b sch Bch Khoa Y Hc 2010 bn c c th tm thy
v ti v t trang web www.ykhoaviet.tk c L nh Sng xy dng v pht trin.
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 :
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Tn ti khon ngn hng : L nh Sng
S ti khon : 5111-00000-84877

CNH BO :
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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
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GII THIU

B sch ny c L Sng su tm , bin dch v tng hp vi mc ch cung cp mt ngun ti liu
tham kho hu ch cho cc bn sinh vin y khoa, v tt c nhng ai c nhu cu tm hiu, nghin cu, tra
cu , tham kho thng tin y hc.
Vi tiu ch l b sch m , c xy dng da trn ngun ti liu ca cng ng , khng mang mc
ch v li, khng gn vi mc ch thng mi ha di bt kz hnh thc no , nn trc khi s dng
b sch ny bn phi ng vi nhng iu kin sau . Nu khng ng , bn khng nn tip tc s
dng sch :
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 php 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.
V l b sch cng ng, to ra v mc ch cng ng, do cng ng , b sch ny c pht trin c
hay khng mt phn rt ln, khng ch da vo sc lc, s kin tr ca ngi to ra b sch ny , th
nhng ng gp, xy dng, gp , b sung, hiu chnh ca ngi c chnh l ng lc to ln b sch
ny c pht trin. V mt mc tiu tr thnh mt b sch tham kho y khoa tng hp ph hp vi
nhu cu v tnh hnh thc tin trong lnh vc y t ni ring v trong cuc sng ni chung . Tc gi b sch
mong mi bn c nhng li ng gp chn thnh mang tnh xy dng, nhng ti liu qu m bn
mun san s cho cng ng , v mt tng lai tt p hn. l tt c nim mong mi m khi bt u
xy dng b sch ny , ti vn kin tr theo ui .
Ni dung b sch ny, c th ch ng trong mt thi im nht nh trong qu kh v hin ti hoc
trong tng lai gn. Trong thi i cch mng khoa hc cng ngh tin nhanh nh v bo nh hin nay,
khng ai bit trc c liu nhng kin thc m bn c c c th p dng vo tng lai hay khng .
tr li cu hi ny, ch c chnh bn thn bn , phi lun lun khng ngng-T MNH-cp nht thng
tin mi nht trong mi lnh vc ca i sng, trong c lnh vc y khoa. Khng ai c th, tt nhin b
sch ny khng th, lm iu thay bn.
Nghim cm s dng b sch ny di bt kz mc ch xu no, khng c php thng mi ha sn
phm ny di bt c danh ngha no. Tc gi b sch ny khng phi l tc gi bi vit ca b sch ,
nhng mt rt nhiu cng sc, thi gian, v tin bc to ra n, v li ch chung ca cng ng. Bn
phi chu hon ton trch nhim vi bt kz vic s dng sai mc ch v khng tun th ni dung b
sch ny nu 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.
Lng, Ngh An. Thng 8/2010



ABOUT

ebook editor: Le Dinh Sang
Hanoi Medical University
Website: www.ykhoaviet.tk
Email: Lesangmd@gmail.com, bachkhoayhoc@gmail.com
Tel: 0973.910.357
NOTICE OF MEDICAL ENCYCLOPEDIA PUBLICATION 2010:
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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

Da gm 3 lp: thng b, trung b, h b v cc phn ph ca da.
1. Thng b.(cn gi l biu b .epidermis)
Trn cc lt ct m hc ca da bnh thng, ranh gii gia thng b v trung b khng bng
phng m li lm do c nhiu nh ca thng b nh nhng ngn tay n su vo trung b.
Nhng ch li ln ca trung b gia cc nh thng b gi l nh trung b.
Thng b chia ra thnh nm lp: lp y, lp gai, lp ht, lp sng v lp sng.
1.1. Lp y.(basal stratum)
lp y c hai loi t bo cng nm trn mng y l t bo y (t bo sinh sn) v t bo
sc t.
T bo y c hnh tr, nm vung gc vi ng phn cch gia thng b v chn b (mng
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.
T bo hc sc t (cc t bo sng hay cc t bo ui gai), c ngun gc thn kinh, chng c
kh nng tng hp sc t melanin. Khi nhum mui bc thy t bo c nhiu nhnh bo tng
di, trong bo tng c nhng ht sc t en. Khi nhum hematoxylin- eosin chng l nhng t
bo sng, nhn bt mu sm, bo tng bt mu kim nh.
Mng y khng bt mu thuc nhum thng thng. Khi s dng thuc nhum acid schiff,
mng y bt mu -( l mt vch mng, m c, thun nht, v n cha mt lng kh ln
polysaccarid). N l mt hng ro khuych tn cc ht nh nh thuc nhum... lan vo chn
b.
1.2. Lp gai(Stratum spinosum)
Cc t bo lp gai c hnh a din, nm trn lp y, c t 5-10 hng t bo. Cc t bo nm
st nhau, ni vi nhau bng cc cu ni bo tng, r rt hn lp y. Di knh hin vi in
t cc t bo ny khng ni hn vi nhau m ch tip xc bng cc th n (desmosome) cha
nhng ht m c m bn cht l phospholipid. Khi tch cc t bo gai ri nhau ra th thy
trn b mt c nhng nh bo tng ging nh nhng ci gai. Trong bo tng c nhiu t
trng lc qui t vo cc cu ni. Chng c th hp li thnh b. Cc t bo gai cng c kh
nng sinh sn bng gin phn. Hot ng gin phn ca lp y v lp gai u mnh m v
lin tc. Khong t 19-20 ngy thng b ca ngi li c i mi mt ln.
1.3. Lp ht:(Stratum glanulosum)
Cc t bo ca lp ht gm t 3- 4 hng, chng c hnh dt, nm trn lp gai. Trong bo tng
cha cc ht sng keratohyalin. Nhng ht ny xut hin chng t qu trnh sng ho bt u.
Keratin thuc nhm protein si c cha nhiu gc aminoacid, arginin, lysin, cystidin... chng
kh bn vng vi nhng tc nhn ho hc nh acid hoc base. B dy ca lp ht dao ng
ph thuc vo mc sng ho. Lp ht dy nhng ni c lp sng dy. nhng ni c
sng th thng khng c lp ht.
1.4. Lp sng(stratum lucidum): Lp ny ch c lng bn tay, bn chn, n nm trn lp ht
v gm nhng t bo trong, thun nht, khng c nhn, dt, chng sp xp thnh 2 hoc 3
hng. Cc t bo ny cha cht eleidin, hnh thnh do ho lng cc ht sng trong cha nhiu
nhm disulfit.
1.5. Lp sngeStratum corneum)
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.
Sc t (melanin) da do t bo sc t (melanocyte) tng hp. C khong 10- 15 t bo y li
c mt t bo sc t. Bnh thng cc t bo sc t nm xen ln vi cc t bo y, khi sc
t cn nhiu th t bo sc t (melanocyte) c c trong lp gai (vng da b rm nng) v
trong cc i thc bo chn b.
1.7. T bo Langerhans : l mt loi t bo ring bit, nm lp gai. Cho ti nay phn ln cc
tc gi cho rng t bo ny l tin n ca h thng min dch t bo ca c th.
2.Trung b (cn gi l chn b.Dermis)
V cu trc trung b gm 3 thnh phn :
+ Nhng si chng , si to keo l nhng si thng khng phn nhnh cu to bi nhng
chui polypeptit ( khong 20 loi axit amin). Si to keo c th b ph hu bi men colagenaza
do vi khun tit ra. Si chun l nhng si ln hn c phn nhnh, n bt ngun t si to keo.
Si li to thnh mng li mng bao bc quanh mch mu, tuyn m hi. Cu trc ca n
ging ht si to keo.
+ Cht c bn l mt mng nhy gm trytophan, tyrosin,...N b ph hu bi tryosin.
+ T bo gm t bo x hnh thoi hoc hnh amp, c tc dng lm da ln so. T chc bo
hnh thoi hoc hnh sao, n c th bin thnh i thc bo ng vai tr quan trng trong vic
bo v c th. Tng bo tham gia qu trnh chuyn ho heparin, histamin.
+ Ngoi cc thnh phn trn trung b cn c nhng ng mch, tnh mch, bch mch ( h
thng ny c bt ngun t cc m ri su )v h thng thn kinh ca da.
3. H b .(cn gi l m di da.Subcutaneous)
Nm gia trung b v cn hoc mng xng, h b l t chc m bit ho thnh t chc m,
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.
Gm c thn kinh, tuyn m hi, tuyn b , nang lng v mng
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.
- Tiu th Golgi- Mazzoni ging loi trn nhng nh hn.
- Tiu th Ruffini cho bit cm gic nng.
- a Meckel- Ranvier v tiu th Meisser cho cm gic tip xc.
- Tiu th Krause cho cm gic lnh.
4.2. Tuyn m hi gm c 3 phn :
- Cu bi tit hnh trn khu tr trung b su hoc h b, c 2 lp t bo gia l nhng t bo
bi tit, chung quanh c lp t bo dt bao bc.
- ng dn on qua trung b c cu trc nh phn cu nhng t bi tit.
- ng dn on qua thng b c on xon c, cng ra ngoi cng xon nhiu , gm mt lp
t bo c nhim ht sng.
4.3. Tuyn b : nm cnh bao lng v thng vi nang lng bng ng tit. Mi tuyn b c nhiu
thu, mi thu gm nhiu lp t bo: ngoi cng l nhng t bo tr ging t bo lp c bn, ri
n lp t bo to cha nhng ht m, trong cng c nhng lp t bo cha y m lm cng
v t bo, ri chy ra ngoi thnh cht b(sebum). ng tit c cu to bi t bo sng.
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:
Mng l mt tm sng mng nm gn trong mt rnh mt lng ca u ngn. Mng c mt
b t do, ba b cn li c cc np da ph ln gi l b sau v hai b bn. Phn mng b
sau c hnh vt gi l r mng. Phn cn li dy u, hnh khum gi l thn mng. Thng b
di mng tip vi thng b da np gp sau v cc np gp bn. Thng b di r mng
gi l mm mng gm lp sinh sn v lp gai. Cc t bo gai tin dn ln v dt dn li thnh
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
chc chn v c nh.


2. I CNG BNH DA V HOA LIU

Ts Nguyn Khc Vin
i tng ca mn hc bnh da l nghin cu tnh trng da, nim mc, cc phn ph ca da
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).
Bnh da liu c ni nc ta t lu. Nhn dn cng c nhng bi thuc iu tr bnh
da liu. Trong cc ti liu ca Hi Thng Ln ng, Tu Tnh c ni n mt s bnh da
liu. Di thi Php thuc c chuyn ngnh da liu nhng mi ch tp trung mt s
t thnh ph ln.
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 . .
1. Tnh hnh bnh da liu trong nhn dn v qun i.
+ Trong nhn dn.
- 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.
- Bnh phong vn l mt bnh cn phi quan tm nhiu( mc d sau 20 nm tch cc thc
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
phn bit i x vi ngi nhim HIV/AIDS c nu ln ( c th gii cng nh trong nc) v
k th, phn bit i x l khng ng vi nhn quyn, gy nn nhiu tc hi lm cho ngi
bnh sng khng cn ngha, lm ngun ly lan mnh hn trong x hi... lm cho vic phng
chng cn bnh ny cng kh khn hn.
Nhm bnh da ngh nghip cng cn c lu : v t nc ta trn con ng cng nghip
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.
Qun i l mt b phn dn s c tnh c th ring, khi tuyn qun la chn c cc
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
103 c nm ch c < 10 bnh nhn mc bnh lu hoc giang mai vo iu tr, vi nm mi c
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 .
- Khuyt tt ca da v nim mc.
- Bnh to keo
- Bnh do ri lon chuyn ho.
- Nhng bt thng v sinh l da, sinh ho da, pH da, lipit da, kh nng khng kim khng
toan, trung ho kim, trung ho toan cng c mt nh hng nht nh n s pht sinh pht
trin cu bnh da.
+ 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
nhn gy bnh, do thuc iu tr khng hp l ca bnh nhn v thy thuc.
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 ...
+ Tc hi v kinh t x hi: v l mt bnh ph bin v mt nhiu thi gian khm bnh, iu
tr . Cc thuc da liu k c thuc bi nhiu khi rt t, nht l i vi cc trng hp bnh nhn
nng.


3. KHM BNH DA LIU

1. Nguyn tc khm bnh da liu.
Khm bnh da liu cn tun th mt s nguyn tc sau:
1.1. t bnh nhn trong iu kin thun li quan st.
+ nh sng t nhin y quan st, nhn nh chnh xc tn thng v mu sc, hnh
dng...
+ Thun li v tm l: bnh nhn tin tng, hp tc thun li cho vic
khm bnh.
+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).
+ Trang thit b ph hp, v sinh sch s to n tng tin tng.
+ C th c mt bc cao khong 30 cm cho bnh nhn khi cn ng ln cho d quan st
khi khm bnh.
1.2. Theo mt trnh t nht nh:
Khm t ngn chi n gc chi, t vng h n vng kn hoc khm ln lt t u n chn
trnh b st thng tn, sau khm k cc vng tn thng chnh, nhn nh tn thng
s ng, tnh cht...
1.3. T m, thn trng:
Cn khm k, t m, quan st k mu sc,hnh th, tn thng c bn, cch sp xp, phn b
ca tn thng, nu cn phi s nn, nh gi mt , khm c lng, tc, mng, nim mc,
trnh khm qua loa, s si dn n nhn nh sai tn thng, chn on sai.
1.4. Ton din:
nh gi ton b da c thv c lng tc mng, nh gi s b hot ng chc nng ca ton
b c th, ca cc c quan ni tng nh tim mch, tiu ho, gan, thn, ni tit c nh hng
n qu trnh bnh l da.
2. Cc bc tin hnh.
2.1. Quan st v tr:
+ 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,
vy nn thng xut hin vng da u, 2ci tay, da vng xng cng...
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).
Sau khi quan st v v tr nn rt ra mt nhn xt, t kt hp vi nhn nh v tn thng c
bn v cc yu t khc gip cho chn on.
2.2. Phn tch tn thng c 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...
+ Mu sc: hng, , sm, tm...
+ Mt : s nn bit mt mm, cng, cng, chc.
+ 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.
+ Tn thng s ng l loi g: sn, c, cc, mn nc, bng nc... y l im rt quan
trng, nhn nh chnh xc tn thng s ng gip ch nhiu cho chn on.
+ 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,
ban sn m ay, ban . Cn phn bit tn thng s ng nguyn pht v th pht, v d:
trong bnh gh, tn thng nguyn pht l mn nc v ng hang, tn thng th pht l
vt trt, vt xc gi, vy tit, so thm mu, bc mu.
+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:
+ Ni tn thng t ngy, thng, nm no? Lc bnh nhn ang lm g, u.
+ 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.
+ x tr g, kt qu ra sao (thuc g tt, thuc g khng tt...). Cc yu t lm tng gim bnh
nh thi tit, n ung, thuc men.
+ Gia nh, tp th c ai b bnh ny khng?
+ Trong tin s bn thn c bnh g lin quan khng? B bnh ln u hay ti pht nhiu ln.
+ Hin nay cm gic ti ch, tnh trng ton thn ra sao.
+ Nu l bnh ly truyn qua ng tnh dc th cn hi k: giao hp vi ai, tn thng ni bao
nhiu ngy sau giao hp. Tn thng bt u nh th no, din bin ra sao. Sau c giao
hp vi v (chng) khng, iu tr g cha...
2.4. Chn on v chn on phn bit.
+ Cn c vo c im v v tr v cc tnh cht ca tn thng s ng, kt hp vi bnh s,
tin s ra chn on ph hp.
+ Chn on quyt nh khi c xt nghim vi khun hc, min dch hc, m bnh hc da.
Da vo v tr, tn thng s ng v cc yu t khc cn bin lun chn on mt cch r
rng, c lp lun vng chc,logic.
Chn on phn bit vi cc bnh c v tr hay tn thng s ng v cc tnh cht, din bin
gn ging vi bnh c chn on.
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
chn on v chn on quyt nh.
3. Mt s xt nghim ,khm nghim c bit gip cho chn on.
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.
+ Xit ln da bng u t bt ch tm chng da v ni (dermographism)
+ 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, ..).
+ Th ng Tzanck (cn gi l chn on t bo hc ca Tzanck): chn mt bng nc mi,
dch cn trong, dng dao v trng chc cho v ra ht dch, no nh nn tn thng, pht cht
no ln lam knh, c nh bng cn v nhum giemsa. Trong bnh pemphigut s thy cc t
bo gai chng to t cc cu ni lin gai. Trong bnh vi rut s thy cc th bao hm v t
bo khng l.
+ Lm sinh thit da (biopsie):
Ct to, su, c vng lnh v tn thng so snh.
Ch m bo thm m da (thng l hnh bu dc nu cn khu 1, 2 mi).
Khng lm dp nt bnh phm, ct gn.
Cho ngay vo dung dch bo qun (bouin), khng kh.
C giy t, nhn ngoi l, c tn r rng trnh nhm ln.
a cng sm cng tt n khoa bnh l gii phu.
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.
3.3. Gy bnh thc nghim trn sc vt.
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...).
3.6 Th ng i vi cm ng tia ngoi t (liu sinh vt - biodose)..
3.7. Cc xt nghim huyt thanh chn on giang mai:nh BW, VDRL, TPI, FTA.,TPHA.... RPR
card test ,ly mu hoc dch tu sng.

4. BNH DA NGH NGHIP
(Occupational diseases)
Bnh da ngh nghip (B D N N ): Do cc yu t vt l ( nh sng, phng x, bc x ...) ho hc
(ho cht...) vi sinh vt hoc cn trng ( rui vng) cc yu t mi trng sn xut tc
ng trc tip ln da hoc trn c th ngi lao ng sau mt thi gian xut hin thng tn
bnh l trn da.
Bnh da ngh nghip chim khong 50% bnh da d ng ,trong s 90% l do ho
cht.
I- Nguyn tc chn on bnh da ngh nghip.
1- Cn c vo hnh nh lm sng: Phi loi dn cc bnh khng do ngh nghip.
2- V tr thng tn : Khu tr ch yu vng h, gii hn r rt ch vng tip xc khng
c vng da khc.C khi in r hnh nh ca vt tip xc .V d : quai dp cao xu, ng nghe in
thoi.
a s phn h nhng cng c trng hp phn kn nh th hi,bi gy kch thch,
gy d ng qua ng h hp sau mi pht ra tn thng da.
3 - Thi gian xut hin v tin trin ca bnh.
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.
Hi k v tin s bnh da c t trc.
4 - Phi iu tra tn c s sn xut xem iu kin lm vic c tip xc vi cht gy bnh
khng ? xem xt qui trnh sn xut, mc tip xc, mi trng lao ng.
Cng nhn c nc tm ra sau lao ng khng. Trong lm vic c mc qun o
bo h lao ng khng. Trong c s sn xut c thuc bo v da khng?
5 - Ly mu cc cht kch thch tip xc phn tch lm th nghim da hoc lm
thc nghim trn ng vt, sc vt.
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.
+ Dng nh sng Wood soi trn da : nu c ng cc cht goudron, than th cc
cht hunh quang ln.
+ Lm phn ng kt hp b th huyt thanh bnh nhn + cht nghi gy bnh v d sun
ft kn.
+ Sn sinh s lng bch cu i kim trong bng nc, cht gy d ng bch cu i
kim tng cao hn do cht kch thch.
+ Test p da, (patch- Test).
Nghi ng cht gy bnh ly cht pha vi dung mi (du,nc ct, aceton,lanolin,
vaselin ,nc mui sinh l ) nng tu theo cht .
Nu d nguyn dng rn c tn nh ging nh bt mn ri cho p ln da ,dng 1
ming gc 1 cm2 t cht ln gc p ln vng da khng c thng tn.
+ 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
ming nylon to hn ming gc ph ln ri bng dnh c nh .
+ c kt qu sau 24 gi c trng hp phn ng mun 48 h,72h sau.
c kt qu : * n thun ( )
* v ph ti ch (+)
* + sn ph (++)
* + sn ph + mn nc (+++)
Ch :Trnh nhm vi d ng do bng dnh c nh cc mu gc tm ha cht th test
p da.
Khi lm phn ng vi nhiu cht trn da c th da s phn ng qu mnh.
+ Phng php nh git c dng rng ri khi cht tip xc l nhng ho cht.
Tin li hn l d s dng v gn ph hp vi iu kin tip xc sn xut .
+ V tr : Vng bng trn rn n h sn phi ta khoanh vng trn O ng knh 2,5 - 3
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.
+ nh gi kt qu ging nh phng php trn.
Ch : Khng c tm ra lau chi trn vng da lm th nghim trc khi c kt qu.
Khi nghi ng phi kim tra bng test p da vi cht .
C 2 phng php trn khi c kt qu kt lun phi thn trng v mn cm cho
.Khi m tnh cng khng loi tr c (do nng KN khng thch hp khng gy phn
ng).
+ o pH da : Tnh cht ca ho cht tip xc l kim hay toan pH da ph thuc vo ion
H + v OHqpH da ngi ln 4,9 - 5,9 bnh thng.
Nghin cu pH da l nghin cu kh nng trung ho ca thng b i vi axit v
kim.Tm hiu pH da gip cho chn on sm v ra nhng bin php phng bnh i vi
cc bnh da ngh nghip.
+ Xc nh cc kh nng m ca da nh kh nng khng kim khng toan, trung ho,
kim toan.
II- Cc biu hin lm sng theo ngnh ngh.
1- Bnh da ngh nghip trong ngnh ho cht.
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.
V d: Tip xc vi du thng chm
Acid Nitric rng lng ,tc i mu.
Clo Trng c.
H 2SO4 lot da
Phot pho hoi t 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.
chn on dng phng php test p da.
2 - Bnh da ngh nghip trong nng nghip.
2.1. Vim da m : ( Pyodermite )
Hay xy ra ma cy cy, gt hi do tp khun.
Lm sng: Nhng mn m, mn nht ( nang lng ) do t cu hoc lin cu, c trng
hp thnh vt lot chn do ngm xung bn t , thng l vi khun ym kh.
iu kin thun li : Lao ng mi trng nhiu bi ra m hi nhiu lm gim sc
chng ca da, ca ng l nhng vt xy xc da, a cn trong qu trnh lao ng.
2.2. Bnh da do ho cht s dng trong nng nghip: Phn ho hc,thuc tr su c th
xut hin cc bnh vim da, nhim c d ng, da ton thn trong phn ho hc (Super pht
pht) hi phn sng ln mt lm vim b mi, vim kt mc biu hin l da mt , trn nn da
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.
Khi ngng tip xc phn ln vi ngy bnh gim v khi hn..
-Vi Nitrat bn rung khi tip xc xut hin cc sn mu vng da cam quanh cc nang lng v
cc sn tn ti rt lu k c sau khi ngng tip xc vi vi.
- Cc loi thuc tr su cng c th hay gy tai bin da ngoi cc biu hin lm sng
nh vim da ,cn c th gy nhim c d ng, da ton thn.
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
thi bnh tin trin nng dn v c th gy t vong.
2.3. Vim da do u trng sn vt: thng xy ra cho nhng nng dn lm rung nc c th
vt.
Bnh thng pht trin vo ma cy hoc ma gt hi.
-Nguyn nhn gy bnh l do 1 loi u trng sn vt hnh thoi c ui n, ui kp pha
sau, loi u trng ny sng c th c. Khi vt m c n . u trngc 1 thi gian k sinh
trong rut vt ri theo phn vt ra rung bm vo da ngi gy bnh.
- Lm sng : Trn da vng ngm nc (li) l nhng sn mu ring r bng u inh ghim
ging mui t n ngy th 2, th 3, xm v tr cc b phn ngm di nc.
Triu chng c nng sm nht l nga vi gi,na ngy, nga c th ko di c m gy mt
ng.
Gi nhiu trn da xut hin vt xc v mn m do bi nhim.
3- Bnh da ngh nghip trong ngnh xy dng.
- L bnh vim da do xi mng (crm, coban ) ngoi ra cn cht do lm tng chng mn ca xi
mng.Cc cht tc ng ln da ca ngi cng nhn theo c ch d ng.
- 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
v bong vy c trng hp thng tn u tin l nhng vt trt hoc dy da km theo triu
chng c nng nga v ban m ging nh bnh gh. Khi bnh tin trin lu di biu hin lm
sng ging chm mn da dy thm nhim , v tr thng tn vng da h c bit ra cc ngn
tay c nhng mn nc lin kt thnh tng m xen k m dy da ging t a (dysidrose).
4 - Bnh da ngh nghip trong ngnh du m, than.
Gm cc cht Hydrocacbua, cc cht hu c v cc cht th kh oxygen , sulfua, Nit. Sau khi
chng ct du m th c :xng, du ho,du nhn, nha du ho ( hc n ).Hc n sau khi
t nhit > 340 , cht cn li l nha than trn vi than bt ng thnh bnh than chy
tu ho.
Khi tip xc vi cc cht du v dn xut ca du cng nhn c th b nhng bnh da c nhng
triu chng khc nhau : Vim da, xm da nhim c, vim nang lng, qu sng.
III - Nguyn tc d phng v iu tr bnh da ngh nghip.
iu tr bnh da ngh nghip ging nh iu tr cc bnh da khc, thuc bi tu theo giai on
tin trin ca bnh .
Cp tnh chy nc dng dung dch mt da,gim vim
Bn cp ,ht chy nc : thuc h
Mn tnh,kh : Dng thuc kem, m corticoid.

Mt s nguyn tc cn ch :
- Tn thng da do cht kim :Khng nn p dung dch nc v nc lm tng tc dng ca
cht kim tt nht p bng dung dch du.
- 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 .
Nguyn tc chung phng chng
-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 .
- Cn o pH da , xc nh cc kh nng m cho ngi d tuyn cng nhn.
- Tng cng bin php v sinh lao ng: qun o lao ng, phi c ring ,phi c nc
tm ra sau lao ng cn c x phng hoc thuc bo v da trong qu trnh lao ng, bi
trc khi lao ng.
Thuc bo v da:
- Loi a nc : Pommade pte hydrophile bo v i vi cc cht du m , sn phm ca du
ho, dung mi cc cht sn nha, Hydrocarbua.
Thnh phn cc cht d ngm nc v d tan trong nc.
V d : Kaolin 20g
Lanoline 20 g
X phng 72% 20g
Nc 40 ml
Hoc :
Casein 19 g 7
Ru ethylic 58, 7 Gng tay bng thuc
Glycerine 19,7
Amoniac 1,9
Sau khi dng ra bng nc nng ,nc lnh, x phng.
- Loi k nc (Pommade Hydrophobe)
Gm nhng cht khng ngm nc v khng ho tan trong nc dng bo v da.
V d :
Acide boric 5g
Oxyt km 5g
Bt Talc 15g
Du thc vt 75g
Sau khi lm vic ra sch bng x phng v sn sc da nu da kh bi lp mng
h Brocq lm mm da .
H Brocq gm : Oxyt km 30 g
Lanoline 30 g
Vaseline 40 g
T l : 3 : 3 : 4 .
Thuc chng nng : Spectraban cream.


5. VIM DA C
( Dermatomyosite)
i cng :
- L bnh c thng tn ch yu da v c.
- C 2 gii u b nh nhau.
- Bnh pht ra tui trung nin.
- Cn nguyn cha r.
- Xp vo nhm bnh t chc to keo ( collagnoses ).
Thng pht ra sau 1 bnh nhim khun ton thn hoc khu tr nh vng hm mt.
Mt s tc gi cho l do thiu sinh t.
iu kin thun li do tc ng ca nng gn y xp vo nhm bnh t d ng.
Thng tn da bt u bng ban cp v ph thng tn c l do qu trnh ri
lon chc nng ca cc cht v d : Na
+
v Clqthm vo t chc cn Ca
+ +
v pht pho t
t chc thm vo trong mu, Albumim / mu h.
1- Triu chng lm sng :
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
trong vng vi thng.
Cc thng tn khi pht khu tr mt thng ph mi mt di hoc da u, gy,
mt bn c , mu bn tay , u gi, thn mnh v cc phn khc ca cc chi. Cc vng thng
tn da v c c th khng n khp vi nhau. Cc dt mu tm i xng c th xut hin
trn nn da bnh thng hay da ph c khi km theo nga v bong vy mng nh. Trn nn da
cn thy cc chm xut huyt sau thnh thm da, dn mch , da di b teo, dy sng.
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 .
Trong cc t vng bnh xut hin ph cng khu tr hoc lan to lm hn ch c ng
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
mi v dn dn c khuynh hng co cng c i li kh khn bc tng bc nh, cc phn x
c v gn thng b gim v c khi mt hn , kch thch in c thng gim.in c thy r
in th nhiu pha, cc sng thp, ng biu din rung c nhanh, nu qu trnh bnh l lan
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.
- Cc xng di c hin tng tiu xng , cc ngn tay t di, tm ti.
- 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.
- tr em bt u cc chi di , cc c thanh qun thng b thng tn v c trng
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.
- Khi pht : triu chng kn o bt u di dng au mi cc c : nhm thng b : c b vai
, c cc chi c 2 bn c tnh cht i xng.
- au c cng au thay i c th b lc u sau mt i, bnh nhn au khi i li , khi bp
vo c km theo mi c gy kh khn khi c ng i li.
- 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
nh ni cao trn mt da.
Chn on da vo t chc hc , in c.
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.
- h b: thm nhim gm t bo lm ba v t bo n nhn ln , trong trng hp bnh kinh
din c hin tng teo, x ho, vim cc mao mch v c cc hc t lp nh.
- Cn cc t chc c : C hin tng thoi ho m, ph cc khe t bo,cc nhn t bo b
phn ra nhiu nhn v 1 s b teo.
5 - iu tr
- Bin php : c bn l corticoide, l v kh chnh, cn cc phng php khc coi nh h tr.
Liu tn cng 1- 2 mg/ kg / ngy ( Prednisolon 5 mg ) dng c th 2 ngy ln hoc 1 ln / 1
ngy .Tc dng ging nhau m li t tc dng ph hn
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.
- Thuc khng st rt : chloroquin , Nivaquin c kt qu tt i vi triu chng ca da cn i
vi c khng c kt qu.
- Nu c nhim khun km theo : phi dng khng sinh chng cc nhim khun , thng
dng nhm Cycline , Macrolite.
Rovamycine 3 tr / ngy x 10 - 15 ngy.
- Sinh t cc loi.
Sinh t E c tc dng quan trng nu dng vi liu y c th c tc dng tt.Dng ko di
vi liu 400 mg / ngy trong 1- 2 thng.
Ch n hng ngy cn s dng du thc vt.
- 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.
Ngy u 3 vin chia 3 ln , ngy th 2 : 2 vin / 2 ln. Ngy th 3 tr i 1 v / ln . iu tr
n khi ht au khp xng.

6. VIM DA M
( Pyodermites )
I - i cng
Bnh thng trn da c nhiu tp khun, phn ln l t cu v lin cu, nhiu nht l nhng
vng lm lng v lm m hi, cc np k, l chn lng. Ni tp trung m hi, cht b nhn, bi
bn cng l ca ng vi khun xm nhp vo da.
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.
iu tr vim b m khng nhng ch iu tr chng nhim khun ti ch ngoi da, m cn phi
ch nng cao sc khng, thay i phn ngca c th, nht l i vi vim b m mn
tnh, ti pht dai dng.
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
chn lng, ri rc hoc thnh cm bt c vng da no tr lng bn tay, bn chn.
C nhng th bnh chnh sau:
1/ Vim nang lng nng(superficial folliculitis):( cn gi l chc Bockhart)
- L tnh trng vim nng u l chn lng. Ban u l chn lng hi sng , au, sau thnh
mn m nh, quanh chn lng c qung vim. Vi ngy sau mn m kh, li mt vy tit
nu xm trn. Sau cng vy bong khng li so.
- V tr thng gp u, trn, gy, cm, lng. mi mt gi l chp. da u tr em thng
li so nh, tri tc lm tm.
- 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
2/ Vim nang lng su :(Deep folliculitis)
- 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.
- Nu nng cho ung tng t khng sinh chung.
Kt hp cho thuc gii cm, an thn, nu cn c th cho tim vacxin t cu .
Trnh tr st mnh lm v m, lan m ra vng da ln cn.
3/ inh nht : ( furoncle)
- Cng l trng thi vim nang lng. V c t cu khun cao nn vim ton b nang lng, lan ra
c t chc xung quanh, lm hoi t c mt vng biu hin thnh "ngi" gm t bo, xc bch
cu.
- V tr hay gp gy, lng, mng, cc chi.
- 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).
Nu inh nht to c th km theo st, ni hch au vng tng xng
inh nht l tai gia rt au, nhn dn gi l "ng ng".
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
v d gy nhim khun lan rng.
i vi nht by : Ch ci thin iu kin sinh hot , lm vic iu ho, trnh ru , c ph
thuc l, n t ng. dng tng t thuc khng sinh, an thn, gii cm. Ch chng to bn ,
iu ho chc phn gan , iu tr i ng nu c.
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.
- Ni thnh cc, ban u cng sau mm dn , v m , ri rc hoc thnh cm
- Tin trin dai dng , hay ti pht nht l v ma h.
- 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.
III- Vim b m do lin cu
1/ Chc ly ( Phng da impetigo contagiosa)
Trn thc t trong bnh chc , t cu v lin cu thng phi hp vi nhau. Tr em hay b hn
ngi ln.
- Thng bt u u, c, mt , cc chi, t lan ra cc ch khc . Rt d ly nn cn gi l
chc ly.
- 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.
tr em chc u thnh tng m vy vng xm, dnh bt tc, di lp vy da cht , rm
nc. Gh, v Eczema tr em d km theo chc u.
Chc ri rc ton thn, c th km theo st bin chng vim cu thn cp, n cng chn, mi
mt do vim cu thn. Chc thng gy hch vng tng ng.
- iu tr:
Chc c nhiu vy : p gc chm ra cc dung dch st khun sau bi thuc mu.
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
silver,m bactroban.Nu c st , ni hch nhiu : cho thm khng sinh ung .
Khi tm gi, trnh k c mnh ln tn thng.
- Phng bnh : nh tr cn phng trnh ly lan khng dng chung chn khn mt vi ngi c
bnh.
2/ Chc lot ( ecthyma) :
L mt th chc, nhng tn thng lan su n trung b.
- Thng gp chc lot bnh nhn thiu dinh dng thiu v sinh c th yu km ,c bnh
i ng hoc nghin ru.
- V tr thng chi di, nht l chi c gin tnh mch.
- Bnh bt u nh chc, bng mt phng nc hoc mt phng m . Sau khi phng m v,
ng vy dy mu vng xm hoc nu en , c vy thnh nhiu lp n cao ln gi l
vy c(rupia). Bc vy li mt vt lot ng thnh, nn ti, rm m, t n tht . Da xung
quanh vt lot ti tm, tin trin dai dng , lu lnh .
Chc lot nng , tin trin lu ngy c th thnh lot su qung. Vt lot c ranh gii r, thng
l hnh bu dc , c khi c g, lot rng v su nn bn , t chc da xung quanh x cng , mu
ti tm, tin trin rt dai dng.
- 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.
Chiu tia cc tm ti ch kch thch ln da non.
Nng cao th a bng dinh dng, sinh t A, B1, C.

3/ Hm k ( intertrigo)
C tc gi gi lvim b thng b vi khun ( dermoepidermite microbienne).
Thng gp tr em, nht l tr em mp mp, hoc ngi ln bo mp, ra m hi nhiu.
V tr : cc np c, k bn, k mng, k sau tai, c khi rn,cc ngn da ( i vi tr em thng
gi l hm).
Cc np k trn thnh m , trt, rm dch, pha ngoi thng c vin rc da mng. Do c
st, bn thu m trt lot chy nc, chy m, rt au st.
- Nguyn nhn: ngoi lin cu, cn ch n vai tr ca nm candida albicans (trn nn
trt, c mng trng nh sa, c vin rc da vn vo ngoi vi).
- iu tr :
Ra bng nc thuc tm 1/4000, chm dung dch yarish , nitrat bc 0,25%. Bi thuc mu, h
nc, khng nn bi thuc m lp nhp. Rc bt talc boric 3% c tc dng tt.
ng y: chm nc l thm lm( ui tm).
- Phng bnh : ma h i vi tr em cn nng tm ra, thay t lt, rc bt talc, phn rm vo
cc np k.
4- Chc mp(perlech):
Thng gp tr em, n c hoc km theo cc tn thng khc do lin cu:
- Hai k mp b nt trt, rm dch, ng vy vng d chy mu, au rt, lm tr kh b.
- Thng km theo hch au di hm.
- 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 .





5.Vim qung (erysipelas)
-.Cn nguyn Bnh sinh :
L mt bnh nhim khun da v di da vi chng Streptococcus. pyogenes tng c t.
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
bm sinh. Cc tn thng ti ch c xu hng ph, vim ng bch mch. Gn y ngi ta
ngh nhiu n cc khuyt tt ca h thng lymph c th dn n hay mc bnh Erysipelas.
S khu tr gn , khng ri rc c th lm ta phn bit c gia Erysipelas v vim m t
bodo lin cu trng.
. Lm sng .
Thi gian bnh 2- 5 ngy , sau st cao t ngt, mt i khi co git tr em km vi au
u, st rt v nn ma . Da vng sp tn thng cm thy cng v ngy th 2 thy , ph,
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
thy mn nc ria hoc c khi l m ph n ,sng nng au gii hn r, gia m tn
thng l phng nc thm ch lot hoi t.
Khng iu tr g bnh ko di t 1- 3 tun ri khi dn, m da gim dn, b mt c th
xut hin rc vy da nht l cc vng c mn nc hay phng nc trc y.
V tr thng thng ca tn thng l bng- tr s sinh. Mt , da u, tai, tr ln hn. ngi
ln gp chn 50 % trng hp, 35 % mt, 3 % tai, cn c th thy xt hin tn thng
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,
bch cu tng cao cng thc chuyn tri, albumin niu.
Cn iu tr phi hp vi cc bin chng km theo nh vim cu thn, p xe di da, nhim
trng huyt. Nu c bin chng nh vy th t l t vong 50 % tr em.
Bnh c th ti pht khi c s gim min dch hoc s ko di ca cc yu t gy bnh. H
lymph b ph n, c th mt mi l du hiu bo trc cho t cp hay cc t ti pht xut
hin li trn cc v tr c ca bnh.
Cn chn on phn bit vi vim t chc lin kt do lin cu khun trn c s ton trng suy
yu hay c mt yu t ti ch thun li no . Tn thng l cc m a cung , ph, sng
mu m khng c cc triu chng ton thn khc. Vim t chc lin kt tr em gy au n,
tn thng cng , ri dn dn dn n to m, v m thnh l d.


-. iu tr .
Cn phi iu tr khng sinh mnh ngay t u thng dngtim 1 t Lincomycin, Gentamycin
, thm ch dng Rocephin. Cc trng hp ti pht , ph h thng lymph mn phi dng liu
nh Penicyllin ko di hng thng thm ch hng nm hoc lu hn na. Trong iu tr lu
nn phi hp vi iu tr triu chng gim au , an thn, sinh t cc loi

7. VIM DA PHNG DO KIN KHOANG
( Paedrus)
1. i c ng :
- Paedrus l mt cn trng thuc h Staphylinidae. Loi th ng gp l P.literalis,
P.fuscipes... Paedrus thot nhn nh con kin mnh di thanh 7- 10 mm. Nhn dn th ng
gi cn trng ny bng nhiu tn kin khoang, kin kim, kin lc, kin go, cm cp,
kin nht, kin cong t... u nh c ru nhn hoc hnh bu dc cong v pha trc .
Mnh mang 3 i chn. Bng c 8 t do, mt s t c mu hung, mt s t c mu
en. Trn mnh c cnh rt ngn ch che c 3-5 t bng, hai cnh cng trn, hai cnh la
d i. Paedrus chy v bay rt nhanh, khi chy cong t ln nh t b cp. Cn trng sng bng
cht hu bin ca thc vt , ng vt, hoc n cc cn trng nh , cc xc cht sc vt, phn.
Chng sng ch c phn rc , c mc, ra m ly, di ng gch, trong v cy nt n, i
khi trong c t chim, t mi.
- 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.
Theo mt s tc gi dn sng vng chu th sng Vnga th ng b vim da do Paedrus.
Mt bo co khc thng bo c mt v dch vim da phng n c do paedrus xy ra vo ma
h nm 1958- 1959 Achentina (A. Conders).
Thng 5 - 1960 Nguyn S Quc v cng s bo co c mt v dch vim da phng n c gm
31 bnh nhn c lm sng t ng t nh vim da phng n c do paedrus . Chng ti cho
rng cng c th l mt v dch do paedrus.
2. Hnh nh lm sng :
Bnh th ng xy ra vo ma h, v m a lm ngp rung cc cn trng bay theo nh n vo
cc nh bn cnh ng rung. i a s cc bnh nhn( 78,14 %) l nhng ng i lm vic
d i nh n, v phn ln trong s h u pht hin triu chng lm sng u tin vo bui
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.
Tn th ng c bn 100 % c biu hin bng cc m , nn hi cm, c cc mn n c v
phng n c, gia c mt vng hi lm thm ch hoi t ko di thnh vt di 3- 10 cm gi
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.
Tn th ng nh vy tin trin t 3-7 ngy th ng vy tit kh v rng dn li m da sm
mu, ton b t tin trin ko di 5- 20 ngy.
C mt s t bnh nhn ch ni mt m da lm tm mn n c hi nga , tn th ng mt i
sau 3-5 ngy, khng thnh phng n c phng m.
Trong mt ma ma bnh nhn b i b li 3-4 ln .
Cn lm sng khng c bin i g c bit tr khi c nhim khun. M bnh hc ch l mt
vim da khng c hiu.
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 lm vic d i nh n ch trnh phn x p mit khi c cm gic cn trng ri vo c
vo mt. hoc dng cc li mt nh che ca s trnh cn trng bay vo nh.
- 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.
- Khi bt u thy rt vng da no c th chm dung dch n c mui , n c vi ngn
khng ni thnh phng nc phng m .

8. SI MO G

TS Nguyn Khc Vin
1. i cng :
1.1. Mm bnh.
Tc nhn gy bnh l HPV, thuc loi papova virus c DNA. Th ng l cc tp 6 v tp
11. i khi c th gp tp 16, 18, 31 v 33. Ng i ta tm thy HPV trong cc nhn ca
cc t bo biu m b nhim v cho rng tp 16, 18, 31 v 33 c lin quan ti lon sn v
ung th sinh dc.
1.2. Ngun bnh :
Ngun bnh l nhng ng i nhim HPV, c nam ln n, nht l gi mi dm.
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,
thn d ng vt v da bu. n b th ng mi ln, mi b, m vt, vng quanh niu
o, y chu, m o v c t cung. C hai gii cn c th b y chu, hu mn,
ng hu mn, trc trng, niu o, bng quang v hu hng.
+ Tn th ng c bn: ban u l cc sn nh mu hng hoc mu trng hng. Sn tin
trin to dn, si ln to thnh cc khi ging hoa sp l hoc dng qu du, lc u
cc sn ch nh bng u inh ghim, v sau c th to bng qu to, mt mm, b
mt g gh. Sn c th kh hoc trt, tit dch mi hi thi do c st v bi nhim. S l
ng cc sn c khi ch c mt vi tn th ng ring r, nh ng th ng tp trung thnh
cc m.
+ Triu chng chc nng: th ng khng c triu chng g tr khi khi xi lm bnh
nhn c cm gic v ng vu kh chu hoc khi b bi nhim gy au nh.
3. Chn on.
+ Chn on bnh ch yu da vo biu hin lm sng ca bnh. Mt s t tr ng hp
xc nh chn on bng m bnh hc.
+ Chn on phn bit:
- Giang mai giai on II c sn si (condylomata ata) sinh dc, hu mn v np k.
Cc sn ny th ng c chn rng, b mt t g gh v thng b m t, c th km
theo cc tn th ng ca bnh giang mai cc v tr khc v xt nghim huyt thanh
giang mai d ng tnh.
- Ung th t bo gai
- 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%..
5. Tin lng v bin chng.
- Bnh d ti pht.
- ph n xi mo g m o, c t cung nu khng c iu tr kp thi d h bin
thnh ung th c t cung.
6. Phng bnh.
+ Dng bao cao su (condoms) trong quan h tnh dc c th gim s ly truyn ca
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.
+ Tt c cc bnh nhn xi mo g cn c lm huyt thanh chn on giang mai v
xt nghim pht hin nhim HIV.

9. XM DA
( MLANODERMIES).

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".
Phn ng Dopa c tin hnh nh sau: phin da c ct bng ng lnh tip sc vi
dung dch Dopa 1-2% trong 24 gi nhit phng. Nu sau soi knh hin vi thy t
bo bt mu nu xm, l phn ng Dopa dng tnh.
Nhng t bo Dopa (+) c kh nng to sc t c l di nh hng mt oxydaza trong t bo
l nhng nguyn bo melanin: c mt lp y thng b v c lng cn gi l cc " t bo
tua". C nhng t bo khc, mc d nhim sc nhng khng to sc t m nhn sc t t
nguyn bo melanin, l cc t bo mang melanin c th gp trong trung b. Trong trung b
su cn c th c cc nguyn bo melanin nhu m. L nhng t bo ln hnh thoi " Dopa+"
( trong cc bt xanh, bt sc t...).
V sau cc thc nghim ca mt s tc gi ( Lignac 1922) cho thy cc mnh da un si 10
pht hu sc t vn c th nhim sc di nh hng ca tia cc tm trong mi trng c
oxy, nhng chm v nht hn l trc khi un si. Ko di bc x tia cc tm da li bc mu do
qu oxy ho.
Nhng cng trnh gn y ca cc tc gi M cho bit trong giai on u Tyrosin chuyn
thnh Dopa, di nh hng ca mt tyrosinaza vi s c mt ca oxy v n giai on 2 qua
mt s cht trung gian chuyn thnh melanin giai oan ny cng vn c vai tr ca Tyrosinaza
ch khng phi Dopa-oxy-daza. Cc tc gi M nhn mnh : vai tr ca ng (Cu).
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
hunh ( soufre) l c ch i vi to melanin.


Tyrosin
Di nh hng ca Tyrosinaza.
C mt xy.
Dopa
Di nh hng ca Tyrosinaza ( hoc Dopa-oxydaza).
C mt xy.
Melanin:
2. Nhim sc ton thn.
Xm da lan to ton thn thng l hu qu ca mt s bnh nhim khun, ri lon chuyn ho
thuc phm vi bnh hc chung.
- Xm da Addison: xm da v nim mc. Xm da bt u t nhng vng da vn xm mu (
u v, nch, np da, c quan sinh dc), trn cc phn da h ( mt, bn tay) trn cc vng da
b kch thch lu ngy, trn cc so, ch gic, ch dn cao c th lm ni mt m xm da tim
tng.
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.
Cc mng cng c th b xm mu, nim mc thng c nhng vt mu nu xm ( pha trong
m, vm khu ci, mi, li, li, nim mc sinh dc).
Xm da ch l mt trong nhiu triu chng ca bnh Addison. Ngoi ra cn mt mi, r ri cc
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...
C trng hp ch c xm da n thun ( th n nhim sc n thun ngi lao, thnh tng
vt xm da lan to, khu tr mt s vng ( c, ngc, bng, c quan sinh dc).
- Xm da ni tit khng do thng thn:
Trong bnh Basedow, u tuyn yn... c th gp xm da ton thn.
Mt s bnh nhim khun mn tnh, st rt, l amp, mt s bnh mu ko di ( thiu mu,
bch cu a sinh), km theo hoc khng cc tn thng ni tit, c th c xm da ton thn.
- Xm da ngi lang thang : ngi ngho, i, suy kit, c bnh chy, rn dai dng,,, c th
c xm da kt hp, vt gi xc, vim b m, nht l vng gy tai, lng, tht lng, i.
- Xm da do bnh sc t mu ( Hmochromatose) xm da l mt trong nhng triu chng chnh
ca bnh x gan nhim sc, cn gi l " i ng ng en" ( Diabt bronz) nim mc
thng khng c hoc rt t khi b xm .
- Xm da nhim c.
X gan, thiu nng gan mn... c xu hng km theo xm da.
Mt s cht ho hc hp thu vo c th c th gy xm da.
Cht Asen ( nht l Asen khong vt): trong iu tr, n ung, ngh nghip do nhim c... ko
di c th gy xm da lan to, xm hoc nu nht, nht l phn h, km theo vt xm m
mu hn, do da c mu xm loang l, thnh chm. Tay chn c th c dy sng, si, c th
tm thy asen trong nc tiu, tc, da.
Quinin, atbrin, nivaquin... c th gy xm da lan to hoc khu tr.
- 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.
Liken phng gy xm da hnh chm, hnh li ria cc m xm mu cn xc nh chn on
bng sinh thit.
3. Nhim sc tng vng .
Nhng yu ngoi gii, vt l, c hc, ho hc c th gy xm da lan to, nhng thng gp
nht l xm da khu tr. Trc c ban r. Rm nng l mt xm da khu tr in hnh
phn h. Xm da do bc x U.V cng l vo loi . Xm da do nng, do tip xc lu ngy vi
mt to nhit thng l mt xm da khu tr lan to hoc hnh li.
3.1. Xm da do lng p ( l si) l th ph bin v d nhn nht trong s xm da do nng.
Thng gp mt trong cng chn, i, hoc bng thnh mt xm da hnh li, , xm da,
tn thng khu tr mng li mch mu di da.
Sau mt thi gian chy tia X, da cng thng b xm , nu xm.
Trong xm da do cm ng nh nng, tn thng thng km teo da, nhng c th c vai tr
ca yu t khc ( ni tit, thiu vitamin) in hnh l ban dng Pellagre v bnh Pellagre.
T p, gi lu ngy cng c th xm da.
3.2. Xm da do Hydrocacbua v hc n... i khi gp cng nhn tip xc du m, xm da lan
to cng tay, c, mt, km theo rc da v qu sng nang lng " n du" " xm da nhim c
Habermann- Hoffmann" xm da km dy sng nang lng do du m chi tc... cng c xp
vo loi ny.
Rm da ( Chloasma) nm m gm nhng vt xm mu vin nham nh, khng u nhng rt
r, hu ht l i xng mt. Cc m xm da ni trn, vng di hc mt, thi dng, g
m gia hai lng my, phn trn sng mi, cch xa ra tc, v pha trn 2 lng my,
thnh ng vng cung. Mi mt v cm thng khng b. Gia cc m xm da thng c cc
vt da lnh xen k. Mu i t vng n nu xm, khng c ban rc da cng nh khng c
teo da, khng nga.
3.3.Nm m thng xut hin trong lc c mang ( mt n ngi c mang) sau khi , c kinh
li, c th mt nhng cng c khi ko di nhiu nm, n qu thi k mn kinh thng km
theo xm mu ng trng gia bng, v, m h.
Nhng cng c th gp ngi khng c mang, thm ch c n ng, gp ph n c vim
t cung, vim ng dn trng, ri lon bung trng, c lin quan r ti chc phn tuyn ni tit (
bung trng, tuyn yn).
iu tr thng t kt qu. iu tr ging nh mt xm da Riehl. C th bi th cc thuc , rc da
ty mu. Khng nn p tuyt CO2, c th lm tng bnh.
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.
Bnh ny do Andersen, Haxthausen ( 1930 - 1933) nghin cu.
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.
Bnh hu nh ch gp ph n 30- 50 tui.
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
hp vai tr ca nh sng r rt, bnh tng vo ma h.
Ban u ch l nhng vt, nhng im xm da rt nh, nhng sau lan rng nhanh, lm cho
ton da mt b xm. R nht l thi dng, trn, g m, c. trn xm da thng cch
ng ria tc khong 1 cm, mi, quanh ming thng t b hn, 2 bn c, gc c v phn h
ngc thng b, gi ln yu t cm ng nh nng. Cc vng khc him b hn.
im ni bt ca xm da Riehl l hnh mng li, cc l chn lng khng b thnh vt lm tm
nh, san st.Nhng cng c khi thnh m xm da lan to, ng u.
Mu t vng t m n nu xm, i khi ng mu tm hoa c.
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
bnh rt phc tp: c vai tr ca nhiu yu t.
Vai tr ca nh sng. Do tc dng trc tip hoc do cm ng nhng porphyrin rt t khi cao.
Cht im trang c th gy cm ng.
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...
Vai tr ca ng (Cu), m t l thng cao trong mu bnh nhn.
Mt s cht c th gy xm da: hc n du m, than , cht nhum tc, cht im trang.
Ri lon ni tit: thng thn , gip trng, tuyn yn.
Vai tr ca giao cm: xc cm hoc lo lng, lm ni bnh hoc tng bnh.
Lin quan gia xm da Riehl v liken phng, c trng hp ly ken phng tin trin di dng
mt xm da Riehl.
Do Guogerot. Degos... coi xm da Riehl ch l mt hi chng nm trong khun kh cc bnh
xm da.Theo Degos th 2 yu t ch yu gy bnh l : vai tr ca cc cht gy xm da v vai
tr ca giao cm.
iu tr.Theo cc yu t nguyn sinh bnh trn.
- i vi nh nng: c th bi kem bo v, hn ch cc cht im trang.
- 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.
Vim da xm da nhim c dng liken v phng nc do Hofmann, Habermann.
Hebermann t t 1918 khc vi xm da Riehl ch: gp ch yu nam gii c tin s tip xc
hc n du m trong ngh nghip (cng nhn qun gii, li xe. Cng nhn gii nha ng,
cng nhn c kh, th in kim kh).
Xm da thng bt u phn h, lng bn tay, mt ngoi cng tay, sau mi lan n mt (
trn thi dng) xm da thng kt hp vi dy sng l nang lng v vim nang lng (n du).
Trn lng bn tay c th c cc phng thanh dch v phng mu, ngng tip xc vi cc cht
ni trn, bnh thng gim hoc khi .
C 2 c ch sinh bnh: do kch thch ngoi gii v do cm ng nh nng ( bi mt cht dn
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,
diamin) c th gy bnh ny.
- Bnh da nhim sc quanh ming ca Brocq: sng nhim sc quanh ming. Do Brocq t t
1923. Hu nh ch gp ph n, khu tr i xng qunh ming, cm, rnh mi, m. Cc vt
mu nu, vng nht, ranh gii khng r, m xm da bin i hng ngy. n knh th nht
bt v c kt hp ban v xm da khng c rc da. Bnh tin trin tng t, ko di, bnh c
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.
Theo Degos bnh ny c 2 c ch: yu t ti ch, kt hp da du v nhim khun nh trong
ban eczema v yu t ri lon ni tit ( bung trng) do c th coi nh mt dng ca chng
rm da hoc xm da Riehl.
iu tr :thuc sc dim sinh 4% sng, dung dch cn iod ti kt hp testosteron 10 mg mi tun
3 ng, tim bp tnh t ngy th 13 ca thi k kinh.
4. Xm da khu tr.
- Tn nhang ( Ephlides) nhiu tc gi xp vo nhm cc bt nhim sc ( Naevi pigmentaires)
Jansson ( 1950) cho l cng tnh cht vi nt rui ( Lentigines) c tnh cch gia nh.
Xut hin vo tui thiu nhi, tng vo tui 18-20 sau nht dn, sau cng c th mt hn
thng di truyn theo tnh tri, tin trin theo mu: tng vo ma h, ma ng c th ln hn.
nh hng ca nh sng i vi nt rui km hn. Do tn nhang, thng ni nhiu vng
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
h bin , ch nh hng thm m.


10. X CNG B ( SCLRODERMIE )
I- i c ng :
- L bnh thuc bnh cht to keo (collagne).
- Collagene l mt Protin si khng ho tan, l mt thnh phn ca x ng, sn, rng,
gn, thnh mch mu, da chim 35 %.
C 4 tp : Tp 1 : xng , da, rng.
Tp 2 : sn
Tp 3 : ng mch ch .
Tp 4 : mng c bn .
Bn tp khc nhau thnh phn axt.amin ca n. 1/3 protein ca c th ng i l c
collagene , x ng v da cha nhiu collagene nht . Nu c ri lon t l collagene cc tp th
s sinh ra bnh ca t chc lin kt. Trong tng hp collagene phi c t l nht nh tc l c
s cn i . Khi c ri lon t l tng hp dn n bnh ca cht to keo, so li, so ph i
v gy tng mng hot dch trong vim khp dng thp.
Cc Collagene c tng hp bi nguyn bo si (Fibroblaste) hoc tnh cht t ng
ng din ra theo 2 th . Mt th ni bo , mt th ngoi bo. ni bo cho ra tin
collagene, ngoi bo l collagene sinh tng hp collagene c iu ho bi nhiu yu t:
Hoc mn : somatrope, mt s cc yu t khc ( thyrocalcitonine).
Hoc mn c ch nh th ng thn ( cortison). Thymus.
II- X cng b :
1753, tc gi Carlo Carzio nh ngha x cng b l mt nhim cm tin trin ca da
tng ng qu sn cc si to keo ca trung b. Hin tng c gi l Carlo Carzio..
Bnh ny th nng gi x cng b h thng khi cc tng ca cc c quan u b nht
l h thng tiu ho, khp, phi, thn v tim. Cc th nh hn ch tn th ng cn, c, x ng
ngay d i vng da b tn th ng ch nh h ng chc phn v thm m , c 2 th u c
bt th ng ca nguyn bo si. Ng i ta khi qut li c 2 tp x cng b. Tp h thng gm
c x cng vin on lan to(Acrosclrose diffuse) hay cn gi CRST (Calcinosis - Raynaud's
Phenomenon- Sclero dactyly - Telangiectasie).
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.
Tp khu tr : th mng , th di ( vt dao chm trn ) th git, th vnh .
III- Cn sinh bnh hc :
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 :
- Bnh l cc mch mu nh: Cn c vo cc nhn xt v siu cu trc v min dch
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.
Cc tiu cu vi cc trung gian ho hc v yu t tng tr ng ca chng c l tiu
cu c vai tr ct yu trong s to thnh x ho.
Nhn xt : ng ch l tin thn ca collagene tng ln ch yu xung quanh mao
mch.
- Ri lon v min dch : Cc ri lon min dch pht hin trong x cng b h thng ch a
r tnh cht bnh sinh v d : s tng bt th ng chc phn ca LT gip dn n s tng
qu mc lympho kin hot ng i vi tng hp collagne ca cc nguyn bo si.
Interleukin I do bch cu n nhn ( Monocyte ) th kch thch sn sinh collagne v s
sn sinh ny b M Interfro c ch.
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.
S tng hp v s ho ging collagne : l h qu 2 yu t nu trn c vai tr trong s
tch t cc tiu qun th nguyn bo si, c s tng hp collagen mnh. S tng tr ng
ARN thng tin trong tng hp collagen b c 1 trong mi tr ng nui cy nguyn bo si x
cng b.
Trong cc k gian bo cc cn ca Aminotit tt tn cng ca cc tin collagne c
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 :
- C th c ri lon thn kinh chc phn ngoi vi .
- Mt s x cng b mng c th do hu qu ca nhim bnh Lyme sau khi b ve t, do
b nhim xon khun nn trong iu tr ng i ta dng penicilline.
IV- X cng b h thng.
1- Dch t : Gp n / nam = 3/1 , tui bt u 20 - 50 tui.
Gp nhiu quc gia v cc chng tc.
Bnh bao gm cc tn th ng da gip cho vic chn on v tn th ng da cng
gy ra tn ph chc nng nng . Cn tn thng ni tng dn n gy nguy him tnh mng.
2- Tin l ng : Dai dng lm cho bnh nhn tn ph .
3- Lm sng :
- Tn th ng da :
+ Hi chng Raynaud' ( phn bit bnh Raynaud' )
95% c hi chng Raynaud'.
Th ng l du hiu u tin i tr c cc du hiu khc t vi tun n vi nm.
L mt tin l ng xu nn khong cch gia hi chng Raynaud' v s xut hin x
cng khu vc ngn : v d bn tay 2 bn , i khi 2 bn chn.
Hi chng ny chn on d trn lm sng .
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
ca mu bn tay sau vi pht cc ngn tay tr nn tm ti v au nhc thi gian ca cc cn
thay i tu theo tng tr ng hp.Pha " ngt " ny rt cn cho vic chn on v phn bit vi
tm ti thng th ng .
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 .
+ X cng da : Bt u mp ngn tay lan rng theo cc kiu khc nhau v c gi tr
tin l ng nht nh. Theo tc gi Barnett ( 1988) phn loi sau 1 nm bt u :
Tp 1 ( chng cng ngn )
V tr x cng ----- Thi gian sng st
Ngn tay,ngn chn, x cng khng lan n 10 nm
qu t x ng bn tay, ngn tay. 71 %
Tp 2 ( x vin on )
V t qua khp bn tay, ngn tay v tn ----- n 10 nm
th ng mt,thn mnh ch a b . 58 %
Tp 3 ( x lan to )
C tn th ng thn mnh lan to ----- n 10 nm
21 %
Hu qu :
Tp 1: - Tn ph
- Ngn tay thon li khng gp c
- Mp ngn tay da mng nh dnh vo x ng.
- Lot au xut hin mu.
- Mng tay lon d ng thay i mu sc.
- Chc phn tay b mt.
- Chn cng xy ra t ng t .
Tp 2, 3:
- Lan ra mt cc chi v thn.
- Trong cc th tin trin chm x cng ngn tay, chn rt pht trin. Khi s x
cng bt u nng mt, thn, cc bp chn.
- 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 ).
- Gin mao mch ln tn, c tt c cc th x cng b lan to hay c mt v
cc vin on.
- Lng ng canxi trung b gp trong tt c cc x cng b ngay c trong cc
th khu tr, gp nhiu ngn tay v chn.
Hi chng Thibierge v Weissenbach ( CRST ).
Biu hin cc nt, m trng thy c s nn c y l hu qu ca thiu mu ti
ch. Cc lng ng ny l nguyn nhn ca lot au dai dng, lot chy ra mt cht lng dng
phn vit.
- Tn th ng cc c quan khc :
+ Tn th ng thn : L nguyn nhn gy ra t vong trn 1/2 s bnh nhn x cng b b
cht.
Th cp gy cao huyt p c tnh 2/3 bnh nhn c tn th ng thn th ng gp tn
th ng thn cp ca x cng b c tn th ng da nhanh nhay sau hi chng Raynaud'.
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 :
Tn th ng c tim sm thm lng th pht sau bt th ng ca vi tun hon c tim.
Vim mng ngoi tim th ng va phi t khi hn mn tnh nu c dn n mn tnh
th ng tin l ng xu.
Suy tim th ng th pht ca tn th ng thn, cao huyt p, t khi l do x phi.
i khi suy tim l do x c tim ( him ).
Trn nguyn tc x cng b khng gy tn th ng ni tm mc.
+ Tiu ho :
Thc qun : 75 % cc ca th ng tim tng 1/3 tr ng hp th ng xut hin sm v
l 1 yu t quan trng chn on .
Rut non hay b hn d dy v t trng gy hi chng khng tiu nng.
Hi chng gi tc ca x cng b iu tr ni khoa c th khi c.
+ Tn th ng khc :
* au khp i theo cc du hiu u tin ca x cng b gp 50 % tr ng hp nh ng
au khp ny khng li di chng.
* Tiu x ng i khi kt hp vi x x ng th ng xut hin t th 3 cc ngn tay .
* Tiu x ng quanh rng 30 % cc ca.
* Tn th ng c v lm sng ging vim da c .
* Tn th ng gan : gp 50 % tr ng hp x gan mt nguyn pht.
* Tn th ng thn kinh ngoi vi him gp .
4- Tin l ng v tin trin :
Tin l ng nng ln ph thuc vo tp theo bng phn loi ca Barnett nh ng thng th
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.
5- Cc th lm sng v hi chng bin gii :
- X cng b h thng tr em him tn th ng da hn ng i ln, nh ng hi chng
Raynaud th ng khng c. Cc nhim khun xen k lm cc triu chng nng ln.
- Trong cc tin trin gy t vong, tn th ng tim gy t vong 1/2.
- Tn th ng thn tr em t hn ng i ln.
- Tr em chm ln chm ln cn.
- X cng b h thng v thai nghn : C v khng nh h ng n sinh sn nh ng hin
t ng xy thai t pht, cht non, cht l u c t l cao khong 1/3 cc ca cng b, c th do
nhim c thai v non trong x cng b h thng . 2/3 cc ca ch a thy nh h ng n tin
trin ca sinh sn. Bnh nng khi c cha , c tc gi li cho rng bnh ng k khi c
cha , nu tn th ng nhiu tng nh hng xu n thai.
6- Chn on : Theo tiu chun ca ARA.( Hi thp khp M )
Tiu chun chnh : Thm nhim da vin on.
Tiu chun ph : - X cng ngn thay chn hoc lot hoc so mp ngn tay chn.
- X phi 2 nn .
Chn on quyt nh : Ch cn 1 tiu chun chnh .
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' .
- Nu hi chng ny c 2 bn bn tay v bn chn rt kh chn on cn tm k :
gin mao mch ln tn, x cng da kn o vng u v b vai.
- Nu hi chng Raynaud' c c 2 bn th nhiu kh nng x cng b.
2- Acrosclrose ( x vin on ).
Bm sinh, do chuyn ho b ri lon , do c , do t min, vim da loang l bm sinh.
Bnh Porphyrie, Mucinose, nhim c Blomycine, D.Penicilline, x ph tp Buschke, x
ph tr s sinh.
7- iu tr :
- Kt qu iu tr rt d dt.
- iu tr th :
+ Dng cc thuc vn mch chng hi chng Raynaud's v x cng vin on.
Nifdipine ( Adalate) 20 mg / ln x 4 ln / ngy ( khng dng cho ng i c thai ).
+ Dng cc thuc chng vim : Prednisolon liu 1 mg/ kg / ngy v gim liu khi c tin
b lm sng khong 2 thng.
+ Nu dng c Cyclosporin A cng tt .
+ C th dng M Interferol.
+ Dng D. Pnicillamine ( Trolovol ) liu tng dn bt u 50 mg ln 100 mg ln n 300
mg / ngy trong thng 1 cho ln n 600 mg/ ngy trong thng th 2.
( Ch khng qu 900 mg / ngy ).
+ Yu t 13 ca s ng mu : ( Fibrogammine) nh git tnh mch chm 2 l / ngy
trong vng 21 ngy . Sau tng t 10 ngy / ln x 1 l.
+ Vit D 3 liu tng dn.
+ Vt l tr liu : tm ngm n c m .
IV- X cng b khu tr :
1- Th : X cng b mng : c 1 mng hoc nhiu mng xut hin bt k trn da , u
tin vt hng sau hi tm, nhit ti bnh thng, vt to dn v c mu trng x c ng
nh, thm nhim . Hnh bu dc, kch th c tu tng trng hp m to nh khc nhau.
Da vng tn th ng khng bp vo c, khng nhn nheo.
Tn th ng c 1 vin ( bng ) mu hng xn bao xung quanh tn th ng rng 2-6 mm
, mu vng bin mt khi tn th ng n nh hoc ang thoi trin.
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
di dai dng, c hin t ng teo da.
Ch tn th ng da u ch tn th ng dn n rng tc ( so khng c tc ).
2- Th x cng b gii:
Th ng gp cc chi . mt, thn mnh rt him
- 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 .
Bt u t ngt t ng nh do 1 sang chn gy nn , c th c mt hoc nhiu chi
b cng mt lc v ci tr c ci sau khng th gii quyt c, bnh gy ra x teo chi.
- 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.
Cng c khi bt u thi d ng i xung pha tr c tai lm tn th ng hm d i
hoc bt u cm.
Cn phn bit x cng b da mt vi bn teo mt ( Romberg).
Ngoi ra cn gp x cng b git trn hi lm nh c mng ph ln trn .Biu hin
nhng vt trng nh x c. C khi nhim sc ngay t u.
- X cng b hnh nhn : bao qui u, ngn tay, ngn chn.
3- Mt s th khc :
- m mt sc t kiu bch bin: lng tc bc i , cn theo di c th l mt x cng
b khim sc.
- Mt m da no , mt thi gian di , bong vy sau mi hnh thnh x cng b.
- X cng b tr c c tn th ng bng n c hoc bng n c ln mu.
- X cng b c tng can xi trung b dn n tn th ng lot.
- X cng b rng lan ton thn khng c hi chng Raynaud'.
- X cng b khng r nguyn nhn ca Pasini v Pierini c im x teo da gp trung
nin v thanh nin tr, v tr hay gp thn mnh. Tn thng gm 10- 12 tn th ng . Kch th
c mi tn th ng vi cm ng knh. Khng nhim cm cng da m teo da ngay ng thi
c nhim sc da. Bnh n nh trong vi thng,tin l ng tt.
- Vim bao c c bch cu EO ( Shulman) xem nh mt th x cng b khu tr .Bnh
bt u c tnh kch pht. Khng c hi chng Raynaud', th ng xut hin sau mt gng sc.
X cng ch yu h b v bao c. Khng c tn th ng ni tng .
4- iu tr :
- Dimethylsulfoxyde (DMSO) dung dch 50- 90 % bi ti ch 1 ln/ ngy, bi ng vo
ch tn th ng. Nu bnh nhn c tn th ng rng th chia ra bi mi ngy mt m.
- Corticoide ton thn liu 0,5 mg / kg / ngy ( Prednisolon ) dng ko di trong 3 thng
nn dng sm .
Trong 20 ngy u tin nn kt hp tim Penicillin 1 triu / ngy .


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
b gim st, hoc xy ra t nhin nh mt h qu ca tui tc, hot ng do cc bnh c ch
min dch hoc do thuc iu tr bnh ni khoa, lm tng nguy c b zona.
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
khe mnh b zona, l khng hp l lm (Ragozzino MW, et al. 1982).
Nhng ngi HIV (+) c tn s mc bnh cao hn nhng ngi c huyt thanh (-). Mt nghin
cu di hn cho thy nhng ngi HIV (+) c t l mc zona mi l 29,4/1000 ngi nm. So
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
hp nhng BN khng c nguy c r rng no mc zona (v d nhng ngi c v khe mnh
di 50 tui).
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
cm mn nc trong 3 5 ngy sau v din tin qua cc giai on ha m, lot v ng vy.
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
v c thi gian tr li kt qu xt nghim nhanh hn (Dahl H, et al. 1997). Ging nh nui cy
virt, nh lng min dch hunh quang trc tip c th phn bit gia nhim virt Herpes
Simplex v nhim virt Varicella Zoster. K thut phn ng khuych i chui gien bng enzym
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 v cc bin chng khc
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
hnh cao gp 15 v 25 ln, theo th t cc thi im 30 v 60 ngy. Mi mc tng mt nam
tui i km vi gia tng t l lu hnh ca au dy thn kinh sau zona l 9 v 12% ln lt
cc thi im 30 v 60 ngy. Bn trong vng khoanh da (dermatome) b tn thng ngoi au
dy thn kinh ra, BN cn c nhiu bt thng v cm gic, nh d gic (allodynia) mt th tng
cm gic (hyperesthesia) trong mt kch thch khng au (nh chm nh) c nhn bit
nh au. au c th tn ti hng thng v i khi hng nm.
Bin chng ca zona nhng BN c chc nng min dch y gm vim no, vim ty, lit
dy thn kinh s no, dy thn kinh ngoi bin v mt hi chng lit nh na ngi pha i
din mun (Gilden DH, et al. 2000). k nguyn trc khi c cc thuc khng rivt, s lan ta
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
p ng vi tr liu khng virt v hu nh chc chn gy m cho mt b bnh. Vim vng mc
nhng BN c chc nng min dch y t nng hn v thng c th chn ng c bng
tr liu khng virt.
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
l gim nguy c lan ta virt Varicella Zoster.
Liu php khng virt
Ti Hoa K c ba dc cht c chp thun s dng trong iu tr zona l acyclovir,
valacyclovir, famciclovir.

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.
Valacyclovir 1000mg 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
ngha so vi gi dc trong vic gim thi gian ko di ca cn au c lin h n zona, c
nh ngha l s ko di lin tc ca au tnh t lc khi bnh n lc lnh bnh hn (Wood MJ,
et al. 1996). Trong s nhng BN m tui i thp nht l 50, thi gian trung bnh khi cn
au l 41 ngy so vi 101 ngy nhm gi dc; v t l au tn ti n 6 thng l 15% so vi
35% nhm gi dc (Wood MJ, et al. 1996).
Valacyclovir, mt tin cht ca acyclovir, sn sinh nng acyclovir huyt thanh cao cp gp 3
5 ln nng t c nu dng acyclovir ng ung. Trong mt nghin cu ngu nhin
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
nhanh vic lnh so trong mt nghin cu c i chng gi dc (Tyring S v CS 1995). Trong
mt phn tch nhm ph ca cc BN tui trn 50 v vn tn ti au sau khi lnh da, thi
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
ngoi khng c vai tr g trong x tr ca bnh zona.
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
bc s nhn khoa c kinh nghim v x tr cc bnh l gic mc thm khm v nh gi
(Liesegang TJ. 1999).
Zona nhng BN c huyt thanh HIV dng tnh
Bnh zona nhng BN HIV (+) cng tng t nh bnh zona nhng ngi c chc nng
min dch y , d rng vi im khc bit nh ti pht thng xuyn v cc tn thng
khng in hnh c m t k lng (Glesby MJ, et al. 1995). Acyclovir ng ung c hiu
qu trong iu tr zona BN nhim HIV (Ganann JW, et al. 1998). Valacyclovir v famciclovir
cha c nh gi mt cch c h thng, mc d kinh nghim truyn khu m ch chng c
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
Zoster khng acyclovir gy ra c bo co nhng BN AIDS giai on mun, buc phi
iu tr vi cc thuc thay th khc (nh foscarnet) (Safrin S, et al. 1991). Sau khi iu chnh
theo tui, t l ca au dy thn kinh sau zona nhng BN HIV (+) khng khc bit ng k so
vi t l khi dn s c chc nng min dch y (Glesby MJ, et al. 1995; Gnann JW,
1998).
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
BN c nguy c b nh hng bi c tnh do corticosteroid (v d nhng BN tiu ng hoc
vim d dy). Liu php kt hp valacyclovir hoc famciclovir vi cortico-steroid c cho l c
hiu qu tng ng, nhng cha c nghin cu trong cc th nghim lm sng. Khng c
khuyn ngh s dng corticosteroid trong zona m khng c liu php khng virt song hnh.
iu tr triu chng
BN nn gi cc tn thng da c sch v kh nhm gim nguy c bi nhim vi khun. p
mt ming bng v khun, khng bt hi, khng dnh, ln khoanh cm gic da (dermatome) b
tn thng s bo v cc tn thng khi tip xc vi y phc. au thn kinh c th rt nng v
c th b nh gi thp. Thuc chn giao cm c th lm du tm thi nhanh chng cn au
nng (Wu CL, Marsh A. 2000). i vi cn au dai dng, cc opioid (thuc gim au trung ng
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).
au thn kinh hu zona
Vic iu tr au thn kinh hu zona phc tp, i hi mt tip cn nhiu mt.

Chn la iu tr chng au hu zona
Thuc Liu khi u Bn lun Nhng tc dng
ngoi c th c
Opioids
(cc dn
xut ca
thuc
phin)
Oxycodone
5mg ung mi
6 gi*
Liu ton b 80mg
mi ngy (hoc cao
hn) cho nhng BN
c cn au d di.
C kh nng cn n
Gy ng, bun
nn, chong vng,
bn, quen thuc,
lm dng thuc
Chng
trm cm
ba vng
Nortryptylin
hoc
desipramin 10
25mg ung
lc i ng*
Liu ton b ln n
75 150mg mi
ngy, amitriptyline
cng c hiu qu
nhng c th km
dung np ngi
gi; t c kinh nghim
vi cc cht c ch
ti thu hi serotonin
chn lc
Gy ng, l ln,
cc tc dng
khng Cholinergic
(kh ming, m
mt, bn, b tiu)
Gabapentin 300mg ung
mi ngy
Tng liu dn khi cn
trong khong thi
gian 4 tun l, n
mt liu ton b
hng ngy l
3600mg (chia lm 3
Bun ng, chong
vng, tht iu,
rung git (nhn
cu)
ln)
Capsaicin
(dng kem
0,025
0,075)
Thoa ti ch 3
4 ln mi
ngy
Ch thoa ln vng da
nguyn vn, lnh;
bt u vi ch
phm nng thp,
nu dung np c
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
Kch thch da ti
ch v cm gic
rt bng lm hn
ch vic s dng
nhiu BN
Lidocain
(bng dn
5%)
Dn ln vng
b au; c th
dng cng lc
3 bng dn
trong mt thi
gian ti a l
12g
Ch nn dn ln vng
da lnh nguyn
vn; c th ct bng
dn cho hp vi kch
c vng da, gim
au nhanh
Kch thch da ti
ch; c tnh ton
thn do vic hp
thu qua da ca
lidocain nhng rt
him gp
* Cc thuc khc cng c th s dng c

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
hoc kt hp vi nhau. Cc tc dng ngoi ca nhng thuc ny c th hip lc, c bit
nhng BN gi nua. Dng bng dn lidocain hoc kem capsaicin ti ch c th mang li s d
chu cho mt s BN (Bernstein JE, et al. 1989: Galer BS, et al. 1999). Trong mt nghin cu
trn cc BN au dy thn kinh hu zona khng khi, tim vo khoang di mng nhn ca ty
sng myehyl prednisolon acetat mt tun mt ln trong 4 tun lm gim au ng k (Kotani N,
et al. 2000). Cn c thm d liu chng thc nhng kt qu bc u y ha hn ny.
Nhng lnh vc cha xc nh
C phi mi BN zona cn tr liu khng virt?
Nhng BN c nguy c cao nht b bin chng l nhng ngi gi, nhng ngi b zona mt v
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.
C th d phng chng au dy thn kinh sau zona?
Mc du nhiu nghin cu cho thy liu php khng virt lm gim thi gian au, nhng thuc
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
cng tng v nhng BN b tn hi min dch. Chn on thng c xc lp trn lm sng,
nhng mt xt nghim nh lng min dch hunh quang trc tip c th c ch trong nhng
trng hp khng in hnh. Acyclovir, valacyclovir v famciclovir c chp thun trong iu tr
zona. Nhng thuc ny dung np tt v tng t nhau nu xt ring v hiu lc ln tnh an
ton. Tuy nhin, do c cc c im dc ng hc c ci thin v ch liu dng n
gin hn, valacyclovir v famciclovir l nhng thuc c a chung hn cho iu tr zona.
Nhng BN ln tui, c bit l nhng ngi trn 60 tui au d di lc n khm, l nhng
ngi c nguy c cao b bnh nng hn v c bin chng, nn c iu tr khng virt, ging
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
lm gim thi gian ko di v nng ca cc triu chng cp tnh, c th xt n mt liu
php b sung vi corticosteroid nhng BN ln tui nu khng c chng ch nh no. Tim
nng b au nghim trng nhng BN zona khng nn nh gi thp v thng s phi cn
n cc loi thuc gim au mnh. Khng mt n tr liu no c chng t c hiu qu trong
iu tr au dy thn kinh sau zona. Thng l phi cn n mt liu php kt hp v hi chn
vi mt chuyn vin v iu tr au.
BS. Nguyn Hong Tun dch theo John .Gnann, Jr: Herpes zoster, N Engl J Med 2002,
347:340 346

12. THUC BI NGOI DA

BS Bi Khnh Duy
1. i cng :
Thuc bi iu tr ngoi da rt phong ph, a dng v c cc ngun gc sau:
+ Ngun gc ho hc:
- V c: kim loi, mui kim loi, kim v cc dn xut ca chng nh cc oxyt, axit.
- Hu c: cc cht bo, cht thm, aldehyt, axeton, phenol, axit...
+ Cc cht tho mc.
+ Cc cht tng hp, bn tng hp.
2. C ch tc dng ca thuc bi ngoi da:
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
t mu, gim vim. Ngc li c loi thuc bi lm bt da, hn ch bc hi m hi, lm tng
xung huyt da.
2. 2. nh hng ti tun hon da, gy gin mch hoc co mch.
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.
2.4. Cn ch n tc dng l ho hc ca thuc:
+ Thuc lm thay i pH ca da.
+ Thuc c th nh hng n qu trnh oxy ho kh trong t bo, do s dng thuc
kh oxy hoc nhng oxy.
+ 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.
Nh vy, thuc bi ngoi da c c tc dng ti ch v ton thn, ch nh v s dng thuc
bi ngoi da cn ht sc cn thn.
3. S hp thu ca thuc qua da.
3.1. Lp "phim m" trn da c i tnh vi nc , do cc cht nc vn c th ngm qua da
c, nhng cc cht ho tan trong m (cc mui thu ngn, mui ch) d ngm hn.
3.2. Lp sng ng vai tr mt mng hu c l tr ngi chnh i vi s hp thu cht nc,
m bo mt s hp thu tt qua lp sng, cn ch pH ca thuc (pH ca lp sng th toan
r rt: pH = 4, pH ca trung b th hi kim).
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.
Tm li: s hp thu ca thuc qua da ph thuc vo trng thi lp sng, lp m bao ph ln
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
thu ca da v tc dng ca cc loi thuc bi ngoi da.
4. Cc dng thuc bi:
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.
T dc thng c dng l: nc, cn, vaselin, lanolin, bt...
Khi chn t dc cn ch tc dng l, ho hc ca hot cht, tnh ho tan v tng k.
4.2. Cc dng thuc bi thng dng nht gm:
+ Dng dung dch (solutions).
+ 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).
- Gc, ngm, tm.
4.2.1. Dung dch (solutions):
Hot cht c pha trong t dc (thng l cc dung mi lng) thnh mt cht lng ng u,
khng vn, khng ta.
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
nhng dung dch keo.
+ Dung dch trong cn: thng dng loi cn 30- 70.
- Dung dch trong cn li hn dung dch trong nc l ngm su hn v d bc hi hn, nhng
nu dng loi cn mnh c th gy kch thch da v kh da do ty m qu nhiu.
- Cn c dng ho tan mt s mui khong, nhiu cht hu c, tho mc, cn lm c c
albumin c tc dng st trng.
+ Mt s dung dch:
- 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.
+ Mt s cch s dng dung dch nh sau:
- p gc: ph ln vng tn thng 8- 12 lp gc, lin tc ti, gi dung dch thuc vo to
mi trng m t dung dch thuc trong vng 24
h
- 72
h
. p gc c tc dng lm gim vim n,
chng xung huyt, chng chy nc, st khun, chng nga, sch m, b vy tit.
- Gc lnh: Cho cht thuc vo nc un si ngui, dng gc thm nc p ln 5 -
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.
4. 2.2. Thuc bt (poudres,powder):
C tc dng lm mt da, chng xung huyt, gim vim, ht nc lm kh da, lm gim cm
gic ch quan (nga, nng...).
T dc thng dng l hai loi bt: bt tho mc v bt khong cht.
+ Bt tho mc thng dng l bt go, bt m, bt v canh ki na, bt than . Bt go mn hn
bt m, c tc dng ht nc rt mnh. Bt cy canh ki na c tc dng se da, st trng, ht
nc mnh. Bt than c kh nng ht nc, chng thi rung kh tt.
+ Bt khong cht: thng hay c dng hn.
Nhng loi bt khong cht chnh l:
- Bt tan (talc) tc magi silicat t nhin, hay dng ln vi km oxyt, tc dng ht nc v cch
nhit.
- Bt kaolin, tc alumin silicat t nhin c tnh ht nc.
- Bt magi cacbonat c tnh ht nc rt mnh.
- Bt dermatol tc bismuth sous gallat l loi bt mu vng.
Cc hot cht c hoc lng c trn ln d dng vi cc bt ni trn, to thnh mt thuc bt
ng u, mn mng.
Thng dng thuc bt rc ln trn tn thng ang vim nhiu, cp tnh hoc ang chy
nc. Thuc bt cn dng rc vo vt lot lu lnh.V d : bt talc menthol 1% chng nga
(menthol 1 gam, bt talc, oxyt km va 100 gam.
4.2.3. Thuc m ( pommade,oitment):
+ L dng thuc bi ngoi da quan trng v ph bin nht.
+ T dc l cc cht bo (vaseline, lanonine...),t l bt hot cht<30%.
+ Thuc m lm tng kh nng hp thu ca da, ngm su hn cc dng thuc khc nhiu,
mm da, nhng , lm tr ngi s bi tit ca da ,gy bt da, hn ch bc m hi, gy xung
huyt.
Khng dng dng thuc m trn cc tn thng ang giai on cp tnh hoc chy
nc.Thng dng dng thuc m cho tn thng giai on mn tnh.
Cc t dc thng dng l:
- M ln (axonge) : d dn mng, d ngm, t gy kch thch da, lu tr thnh toan c mi kh
chu, bo qun bng cch cho thm axit benzoic.
- M len cu(lanoline) : mu trng ng vng, c mi c bit, chy 40
o
C, c i tnh vi nc,
hp th mt khi lng nc ln, rt d ngm qua da, thng trn vi vaselin thuc mm v
d dn ln da hn..
- Vaselin: l cht thng dng nht, chit xut t cn ct du ho, mu trng, trong sut, mm,
chy 35
o
C, 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.
-T l bt hot cht trong cng thc m < 30 %.
+ V d v thuc m:
- M whitfield (cn gi m benzosali):
axit benzoic 6 gam.
axit salicylic 3 gam.
Vaselin va 100 gam.
C tc dng bong sng, dit nm.
- M arievitch:
axit salicylic 6 gam.
axit lactic 12 gam.
Vaselin va 100 gam.
C tc dng tiu sng, dit nm, bng vo mng b nm.
4.2.4. Thuc h (ptes).
+ 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,
thng dng cho tn thng da giai on bn cp.
+ V d:
- H Brocq:
Km oxyt 30 g.
Lanoline 30 g.
Vaseline 40 g.
-H saloxil 3% dng trong eczema bn cp.
Ichtyol 3 gam.
axit salicylic 3 gam.
oxyt km 15 gam.
Bt tacl 15 gam.
Vaseline va 100 gam.
4.2.5. Thuc kem (cremes,cream):
+ C th coi kem l mt loi thuc m c thm glycerin v nc.
Thnh phn gm vaselin, lanolin, glycerin, stearat.
C tc dng mt da, bo v da, ngm va phi.Thng dng dng thuc kem cho tn
thng da giai on bn cp.
+ V d: kem dalibour st khun da.
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.
4.2.6. Thuc du (huiles,oil).
+ Cht pha trong t dc l du oliv, du lc trung tnh, du u ta, du vng, c th thm
bt 30- 40%.
+ 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.
C th cho thm rivanol 1%, hong ng 3% tng tc dng st khun.
4.2.7. Ngm tm (bain):
S dng cc dung dch ni phn trn.
Ngm: thng dng cho cc tn thng u chi, mi ngy ngm 1-2 ln.
Tm cho trng hp tn thng ton thn.
5. Mt s bit dc thuc bi ngoi da thng dng:
5.1. Thuc st khun
- Dung dch thuc st khun dng ngm ra, p gc cc thng tn da trt lot, nhim
khun, chy dch, c m vy tit nh chc ly, Eczema cpnhim khun.
Dung dch Rivanol 1
o
/oo , dung dch (dd) yarish( c Axit boric3g, glycerin 40ml, nc ct 1000ml)
dd becberin ,dd NaCl 9
o
/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
metyl 1% , dd xanh metylen 1% , dd Cestellani, dd Milian
- Kem m khng sinh bi vo cc tn thng bnh l cn nguyn do vi khun , hoc nhim
khun khi tn thng se kh : m Chlorocid 1% , m Tetracylin 1%, kem Silverin, kem
Fucidin, kem Bactroban
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).
5.3. Thuc tr nm hc lo, nm lang ben, nm k chn
- Cn BSI 1,2,3%
- Cn ASA, m Benzosali ( Whitefield).
M Clotrimazol 1%, kem Nizoral, kem Lamisil, kem Daktarin.
5.4. Thuc tr Eczema, vim da.
- Cc dung dch ngm ra, p gc ( ni trn) dng cho Eczema cp trt lot, chy dch,
nhim khun 3-5 ngy u.
- 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 m Corticoid + khng sinh: m Diprogenta, m Celestoderm- neomycin, m Flucort-N
Kem m Corticoid + khng sinh + chng nm
M Gentrison, Triderm, m Endix, m Ecodax
5.5. Thuc tr trng c
Eryfluid, Erythrogel, Dalacin T
Metrogylgel, m Panoxyl 2,5 - 5- 10
Kem Eclaran, Kem RetinA, m Locacid, kem Erylik, kem Differin, kem Isotrex
5.6. Thuc tr vy nn
- M Salicylic 2%, 3%, 5%
- Gudron, Coaltar
- M Corticoid ch nn dng 1 t 20 - 30 ngy bi ngy 1 ln khng bi ko di qu. Khng bi
loi mnh, khng bi din tch qu rng trnh tc dng ph
- M Daivonex, Daivobet.
-Tazaroten
5.7.Thuc bi tr mn cc
Dung dch Duofilm, dd Collomark, dd Podophylin ( ch bo v vng da quanh tn thng bng
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 ) .
5.8. Thuc bi chng virus dng cho cpt, zona.
Kem m Acyclovir, m Varrax
5.9. Thuc bi iu tr rng tc lin quan Androgen
Dung dch Minoxidil
Cn Chloralhydrat Salicylic 3%
5.10. Thuc bi chng xm da , nm m
M Leucodinin B 10%
Kem Renova( bi ti ngy 2 ln).
6. Mt s im ch khi dng thuc bi.
6.1. Thuc bi khng nhng c tc dng ti ch m cn c tc dng ton thn, thuc bi ngm
vo da, ngm vo mch mu, tc ng vo thn kinh, qua tc ng ln ton b c th (v d:
bi m salicylic din rng nn bnh nhn thy chng mt, nhc u...).
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.
6.6. Cn lu mt s thuc bi c in (goudron...) vn c tc dng tt, mt s bit dc mi
c th c tai bin tc dng ph cha c nghin cu y , cha c nhiu kinh nghim s
dng trn lm sng.
6.7. Theo di k bnh nhn trong thi gian dng thuc c th iu chnh kp thi.
6.8 Theo di phn ng da ca tng bnh nhn v thuc bi c th gy d ng.

13. THUC IU TR BNH NM
PGS Nguyn Ngc Thy
1. Cc thuc nhm polyene.
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
thuc ph thuc vo cc ni i, y l thnh phn k nc gn kt vi mt s cht sterol trong
c ergosterol l mt thnh phn c bn trong mng ca nm, to ra cc knh ( chanal)
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)
Amphoterincin B do mt loi actinomyces a kh, streptomyces nodosus sn sinh
ra.Amphotericin B c 7 cu ni i trong phn t, nhng cu ni ny lm cho thuc hp thu
mnh tia cc tm (UV) , do nhy cm vi nh sng. y l mt loi thuc rt c nn gn
y c dng bc thu gia hai lp phospholipid lm gim c tnh.
Ph tc dng: thuc c tc dng vi candidiasis, cryptococcosis, histoplasmosis, blastomycosis,
paracoccidiomycosis, coccidiomycosis aspergillosis, sporotrichosis da, mucormycosis, thuc
cn c tc dng vi leishmaniasis th da- nim mc nhng ch dng trong nhng trng hp
bnh khng vi thuc nhm antimoan.
c tnh : cc phn ng c th chia thnh cp v mn . Phn ng cp tnh c th c st, gim
huyt p, kh th , rt run, thng gim 4 gi sau ngng thuc, c th phng nhng phn ng
ny bng cch dng corticoid ngay khi bt u truyn dch. Phn ng mn tnh gm tng nit
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.
3 .Nystatin (fungicidin, mycostatin, monoral, nystan).
Nystatin c tng hp t loi x khun streptomyces noursei. L thuc nhm polyene c c
ch tc dng nh amphotricin B. Thuc c tc dng vi nm men, c ch ng trong nhng
trng hp candidiasis da, nim mc.
Khi dng ti ch thuc dung np tt nhng i khi gy tng mn cm . Khng dng iu tr nm
h thng do thuc khng tan trong nc., khng hp thu vo t chc v rt c khi dng ng
tim.
4. Pimaricin (natamycin):
Pimaricin c sinh tng hp t loi streptomyces natalensis. Thuc c tc dng lm h mng
t bo nm. Dng iu tr cc bnh nm nh: candidiasis, aspergillosis, c tc dng vi c
trichomonas, thuc c dng dng vin, tim, aerosol, m.
5. Candicidin.
Candicidin c sinh tng hp t streptomyces griseus. Thuc c tc dng tng t nh
nystatin dng trong iu tr cc bnh nm gy ra. Thuc c dng vin, kem v arosol.
6. Khng sinh chng nm ngun gc nm mc- griseofulvin :
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.
C ch tc dng: thuc c ch qu trnh phn chia ca t bo nm, c l l lm ri lon n
qu trnh phn cc ca vi ng ( microtubule) v tn thng thoi phn bo ( mitotic). Thuc c
tc dng dit nm, l mt khng sinh iu tr nm da. Theo cc tc gi griseofulvin c tc dng
lm qun si nm, lm thoi ho nguyn sinh cht, lm ri lon h thng men ca t bo
nm dn n lm ngng s pht trin ca nm.
Ph tc dng: c tc dng vi nm da,khng tc dng vi lang ben, candidiasis da v nm h
thng. Vi nm mng thucc c tc dng km. Ph tc dng hp ca griseofulvin c cho l
thuc ngm km vo t bo nm c bit l nm men nh candida.
Tc dng ph : hay gp nht l au u, ht sau khi ngng thuc vi ngy, cc tc dng ph
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.
Ph tc dng: candidiasis, cryptococcosis v cc tn thng chromomycosis nh, thuc lm
tng cc tc dng ca amphotericin B trong iu tr asperrgillus v sporotrichosis ngoi vi.
C ch tc dng : cc nm nhy cm thuc s chuyn ho 5-fluorocytosine thnh 5-fluoracil,
sau thnh 5 - fluorouadylic axit, cht ny kt hp cht ch vi RNA hoc chuyn ho thnh
5- fluorodeoxyuradylic acid moniphosphate, mt cht c ch thymidylate synthetase mnh,
men ny c vai tr quan trng trong sinh tng hp DNA.
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.
8. Thuc dn cht Imidazol ( azole).
Tc dng chung ca dn cht imidazol :
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
candidiasis,cryptococcosis,coccidioidomycosis,pseudallescheriasis,tinea versicolorr, ringworrm.
Trn ng vt thuc c tc dng vi asperrgillosis v sporotrichosis, itraconazole c th tc
dng trn bnh nhn mc hai bnh trn. Khng ging nh nitroimidazol thu khng c tc dng
vi vi khun, thu c tc dng vi Leishmania majorr v Prototheca.
C ch tc dng : thu nhm azole gn vi phn heme ca cytochrome P450, lm ri lon cc
chc nng oxy ho, qu trnh demethyl ca lanosterrol b c ch dn n tnh lu -14 methyl,
sterol, hai tc dng ny lm tn thng nghim trng mng t bo v lm nm ngng pht
trin. Vi nng cao hn thuc c tc dng ditnm.
9. Nhm biazole : gm cc thu nh ketoconazole, miconazole, clotrimazole, econazole...
10. Ketoconazol:
Bit dc nizoral , dng vin 200 mg, kem hoc fungicid vin 200 mg.
Ketoconazol thng c s dng nhiu trong iu tr cc bnh nm da, nm men v cc bnh
h thng.
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...
Thuc thng s dng cc dng kem, bi ti ch v vin ung.
10. Clotrimazol : bis- phenyl- ( 2- chlophenyl)- 1- imidazol methan). Bit dc canesten ,
calcream.
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
nm mc, vi nng 10 microgam / 1 ml th clotrimazol c tc dng dit nm.
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.
Thuc c cc dng dung dch, kem, dng bt, dng sa bi da.
Tc dng vi nm da, nm men, vi khun gr (+).
12. Miconazol :
[ 1- ( 2,4- dichloro- b ( 2,4 dochloro benzyl) oxy- phenyllethyl- ] imidazolnitrat.
Thuc c tc dng mnh vi nm da. candida, vi khun gram (+). Thuc c t dng mnh, nng
ti thiu c ch nm ngoi da l 0,1- 1mm / 1 ml, nng 10 mm/ ml thuc c ch nm
candida. C dng thuc kem. Thuc dung np tt, i khi thy kch ng da ti ch, cm gic
bng, nga tng ln khi dng kem m o.
S dng iu tr cc loi nm da, nm men thng dng dng kem 2%.
Cc bit dc: miconazol ointment 2% dakatrin dng bt, dng kem v dng gel.
12. Chlormidazol:
Cng thc cu to : 1-(p- chlobenzyl)- 2 methyl- benzimidazol:
Tc dng vi cc chng nm da, candida v mt s vi khun gram (+).
S dng dng kem 5% bi ngoi da.
13. Itraconazol (sporal):
Tc dng nh ketoconazole nhng t c hn v t tc dng hormon hn. Tc dng in vitro
mnh hn 10 ln so vi ketoconazole nhng nng mu ngoi vi li kem hn ketoconazole
10 ln do tc dng iu tr tng ng, tuy nhin itraconazole c tc dng tt hn
ketoconazole trong cc bnh sporotrichosis,asperrgillosis, cryptococcosis.
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:
Bit dc diflucan vin 150 mg.
Tan trong nc pH trung tnh.
Ph tc dng: c tc dng iu tr candidiasis nim mc ming, thc qun, thuc t hn
ketoconazole nhng hp thu tt hn trn nhng bnh nhn AIDS c bnh l d dy, thuc
cng c tc dng trong nhng trng hp cryptococcosis trn bnh nhn AIDS, c th dng
iu tr ngay t u nhng amphotericin B tc dng nhanh hn nhng trng hp co git hay
c nhng triu chng tin lng xu, sau khi bnh nhn n nh, c th dng amphotericin
B, dng fluconazole ko di v duy tr.
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.
Viriconazol l mt triazole mi. Ph t dng rng: bao gm c nm men, nm si v nm lng
dng, c gi tr trong iu tr aspergillosis v candidiasis su, thuc tc dng vi c nhng
trng hp candida khng fluconazole v c itraconazole. Thuc c mt s tc dng ph cn
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
ng ung, ng tnh mch.
4. Thuc iu tr nm da thuc nhm allylamin.
Thng ngi ta s dng hai cht terbinafin v naftifin iu tr cc bnh nm da. Trong
terbinafin c dng ph bin hn vi bit dc l lamisil. Thuc c ch squalene epoxidase,
mt bc quan trng trong sinh tng hp ergosterol ca thnh t bo nm. Thuc c nhiu u
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.
Terbinnafin c ch nm da nng 0,01mm/ ml in vitro. Thuc dung np tt, mt vi bnh
nhn thy kh chu d dy, rut nhng khng phi ngng thuc.
So snh iu tr terbinafine 250 mg / ngy vi ketoconazol 200 mg / ngy bnh nhn nm
thn thy c hiu lc cao hn (t l 95% so vi 78%) v bnh nhn c dng terbinafine khi
bnh nhanh hn trong tun u c 10% khi, cn nhm iu tr ketoconazol cha c bnh
nhn no khi trong tun u tin


14. TRNG C

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.
- Danh php cn gi trng c thng thng (Acne vulgaris).
2. Cn nguyn sinh bnh.
Tuyn b c hu khp cc vng da ca c th tr lng bn tay, lng bn chn, mt mu ngn
chn v mi di, tuyn b thng tp trung nhiu vng mt, ngc, lng, phn trn cnh tay.
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.
Hin nay ngi ta cho rng cc yu t cn nguyn sinh ra bnh trng c gm c:
- Th a da du, tng tit cht b (c tnh cht t bm di truyn, gia nh).
- Dy sng c nang lng lm cht b b vt tc, khng thot ra ngoi c.
- Vi khun Propionibacterium acnes (P.A).
- Nng dihydrotestosteron tng cao m.
Do c th a da du tuyn b to ra, tng ch tit cht b, cht b tit ra nhiu m khng thot
ra c do c nang lng b dy sng hp li to thnh nhn trng c (comedomes), vi khun
Propionibacterium acnes phn hy cht b to thnh cc axt bo t do ngm ra t chc xung
quanh to nn cc sn vim, nu bi nhim thm t cu, lin cuto nn sn m,mn m.
Ty theo mc v cch x tr cc sn, mn m khi khi c th to so mt thi gian hay vnh
vin.
- La tui thng gp nht l 10 - 25 tui c nam v n.
- Cc yu t nh hng:
+ Yu t ni tit
+ Yu t xc ng thn kinh c th lm nng thm bnh.
+ Mt s thuc c th gy trng c hoc lm bnh nng thm: Lithium, hydantoin, bi corticoid,
ung vin trnh thai, isoniazide, iod
+ Yu t ngh nghip: tip xc du khong
+Trng c do dioxin.
3.Triu chng lm sng
3.1.V tr: thng gp vng mt, ngc, lng (nht l vng lin b), phn trn cnh tay.
3.2.Tn thng c bn:
Ty theo tn thng c bn v mc bnh ta c th quan st thy
- Trng c u trng: trn da mt thy cc im trng 1-2 mm di da, chnh l nhn
trng c.
- Trng c u en: c mt im en l chn lng, l cht b phn trn b oxy ha.
- Trng c sn vim: c cc sn vim 1-3mm ng knh, nn ra nhn trng c l mt si
cht b mu trng ng vng.
- Trng c sn m, mn m: c sn m, trung tm l m v nhn trng c, c qung vim
bao quanh, kch thc 1-5mm.
- 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
4.1.Trng c thng thng
- Khng vim: u trng, u en.
- C vim : sn, mn m, vim ty, nang bc
4.2.Vim nang lng do Pityrosporum ovale
Sn ,nh, vim r, hay vng lng, 50% s ca tm thy Pityrosporum ovale.
4.3. Trng c do steroids: do dng steroids ngn hoc di ngy. Tn thng l sn mu
ng nht, cc sn m ri rc mt, lng, c v cnh tay. Thng khng c nhn trng c.
4.4.Trng c do m phm: thng do bi kem lm m da.
4.5.Trng c so li (Acne kelodalis): trng c khi lnh li so li.
4.6.Trng c hoi t: c qu trnh hoi t to so lm.
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
- Chiu n Wood nu c mu da cam l cho bit c s hin din ca P.acnes.
- Nu c mn m nui cy xc nh vi khun bi nhim v th nhy cm khng sinh.
-nh lng hormon nhm Androgen.
6.Chn on
6.1.Chn on xc nh: ch yu da vo lm sng, v tr vng mt, ngc, lng; tn thng l
cc nhn trng c (u trng, u en), sn vim c nhn trng c gia, mn m, vim ty,
nang bc.
6.2.Chn on phn bit
- Vim nang lng do t cu
- U mm ly (Molluscum contagiosum) sn hnh trn bn cu, trn nhn, c im lm gia,
nguyn nhn do virus.
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
Benzoyl peroxyde c tc dng chng vi khun, co hiu lc hu ht vi cc loi trng c c vim
nh trng c sn, trng c mn m, trng c nang bc v trng c c nhn. Tc dng thng
gim bnh sau 4 tun. Bi thuc ngy 1-2 ln, ln u bi thuc nn th 1 vng sau 15 pht
lau ra i, nu khng c phn ng g ngy hm sau bi thuc, sau 30 pht - 1 gi lau ra i,
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.
- Cc thuc trc lt da v chng da nhn
Cc thuc ny lm lt da nh v chng da du, lm cho cc nhn trng c thot i c nn
bnh. Thnh phn thng c lu hunh (sulfur ), Salicylic acid, resorcinol v benzoyl peroxide
loi 10%, bit dc kem Fostex ( thnh phn c lu hunh,Salicylic acid, resorcinol).
Sulfoxyl - Strong ,Sulfacet -R ,Novacet v benzoyl peroxide 10%.
- 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%).
7.2.Thuc ung ton thn
-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
(Minocin) 50mg-100mg 2vin/ngy.Thng dng mt t 10 ngy, ngi ta cho rng c th
dng tr liu di ngy. Tetracyclin 0,25g 2 vin/ngy trong vi tun n mt vi thng, ngoi tc
dng chng P.acnes c nghin cu cn cho l dng liu thp ko di Tetracyclin c tc dng c
ch s ch tit ca tuyn b.
-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.
- Spirolactone 100-200mg/ngy trong 3-6 thng cho ph n ngoi 30 tui.
- Isotretinoin (Accutane vin nang 10, 20, 40mg) Isotretinoin (13_cis retinoic acid) l thuc thuc
nhm retinoid (vitamin A acid) c tc dng hiu qu cao iu tr trng c, nhng phn no c
hi v tn km, ch nn dng cho cc trng hp trng c nng, dai dng (trng c vim ty,
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
m bo khng c thai, v mt trong nhng tc dng ph l thuc c th gy qui thai. Liu
dngbt u 0,5mg/kg/ngy sau tng ln 1mg/kg/ngy, c th dng thuc ny trong vng 4-
5 thng.
- Biotin 5mg 2vin/ngy, c th dng hng thng.
- Vitamin A 50.000-100.000 iu/ngy.
7.3.Cc phng php khc
- 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
thuc gy t b mt vng da chch nn trng c.
- Tho b nn nhn trng c bng keo cyanoacylate: bi keo cyanoacylate vo mn trng c
dng que nha dnh vo ch , sau 1 pht nhc ra ko theo nhn trng c b dnh cht vo
que thy tinh hay tm plastic.
- 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
c nang lng nhn trng c thot i c.
- Xoa bp da mt: hng ngy ch nn ra mt 2-3 ln, ra mt bng tay nh nhng trnh lm
xy xc da, xoa bp nh nhngda mt gip lu thng cht b.
- C th ra mt ngy 2 ln bng x phng Acne aid bar c tc dng ty bt cht b nhn da.
- Trnh cng thng thn kinh
- Hn ch n nhiu ng, S-c-la.
7.4.Gii quyt so trng c
Cc tn thng trng c thng li so nh, mm nng, sau mt thi gian mi ht. Mt s
trng hp b so li, so ph i hoc so teo lm c bit l so hc lm to nh h bng.
Vi cc trng hp trng c so li c th gii quyt bng tim Triamcinolone acetonide vo
di so li.
Vi cc trng hp so hc lm ngi ta c th la chn mt trong cc phng php sau:
.Ht, bo da(Dermabraion)
. Cy Silicon vo da: cy polymethylsiloxane c tnh do, 300centristrokes.
.Cy collagen vo di da cha so mm nng v su. Cy collagen da b tinh khit
ha tan, tim s lng nh 1 thng 3 ln. Tuy nhin cch ny khng c hiu qu vi so hc
lm to.

15. U MM LY

Do Batchman m t t 1817.
L mt bnh ly, tim truyn c, gy nn do mt virut tn (Poxvirut mollusci) xuyn
lc,biu hin bng mt u nh trn da.
Ri rc t hoc nhiu trn mt vng da no , th ng gp nht l vng sinh dc, mt, l ng,
ngc.
Tn th ng l nhng hnh bn cu, mu trng c hoc hi hng, chc bng ht k, ht u
nh, c c im ni bt l gia lm hnh rn ( tr nhng sn non mi mc). Dng hai ngn tay
nn mnh nhng sn gi c th ra mt cht ln nhn mu xm, soi knh hin vi l nhng t bo
sng v nhng tiu th hnh trng cchit quang (tiu th u hn).
C bit c tr ng hp ni thnh u ln, mt nhn hoc x x, gia lm, nn ra cc tiu th in
hnh.
ng i tr tui u hn ly c th tn ti dai dng do t ly nhim. Mt s u c th m ng m,
khi lnh li so.
Chn on da vo rn lm v tiu th u hn.
Hnh nh t chc hc kh c hiu: c nhng thu th ng b lng su xung trung b thnh
m ln, trn ranh gii r hnh qu l m u nh hng vo trung tm ca u. T bo trong tiu
thu l nhng t bo gai, hnh dng bnh th ng ngoi vi, nh ng cng vo pha trong cng
kerattin ho v thoi ho r. Nh vy t bo trong tiu thu rt khc nhau: c t bo keratin
ho, c ci to, c ci hnh trng, i toan hoc i kim khng ng nht ging nh nhng qu
trong ci gi. l nhng tiu th " u ho" t ng ng vi t bo b vi rt lm thoi ho.
Theo Van Reyen vi rt gy u hn ly l loi vi rt to nht gy bnh ng i (0,35 micron). Ch
a nui cy c trn phi g.
iu tr:
No sau chm cn it hoc t in, laser, nha podophyllin.
i vi tn th ng rng c th dng sunfamit (sunfapyridin, sunfadiazin), aureomycin,
terramycin... c kt qu tt.

16. UNG TH T BO GAI
1.Triu chng lm sng : ung th t bo gai lun lun xut hin trn nhng thng tn c t
trc, nht l trn nhm bnh da tin ung th (Bowen, Paget), him hn l trn nhng vng da
c so, vim mn hoc dy sng ngi gi (kratose snile). Bnh xut hin t nhin, sau
sang chn nhiu ln lp i lp li hoc sau khi iu tr khng thch hp.Thng tn ln ln, lan
rng ra, lp sng dy ln, trn b mt b lot, thm nhim su xung di , b ni cao ln
(nhng n tht), c qung bao bc xung quanh, c khi xut hin dng nh nh sng
(papillome corn).
Theo Degos , c 3 hnh th lm sng.
1.1. Ung th t bo gai lot xi: l hnh dng lm sng hay gp nht .
U li cao hn, to hn v cng mt lc n su, thm nhim hn, gn vo trung b. B mt khi u
khng u , va c nhiu n tht, va lot , lot i khi rt nhiu, ln v b rt thay i, y
khng u thnh vm, t hoc nhiu xi v chy mu, b dy cng v b lt cong ra,s vo thy
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
hp khi u c dng hnh bn cu , vt lot gia c mt b xung quanh dy v khng u
ging nh u sng gai (kratoacanthome ).
1.2. Ung th t bo gai li cao v xi : c 2 dng :
+ 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
tn thng vim mn tnh nh lao da, lot cng chn, so bng...
Qu trnh tin trin c th c lot.
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.
+ Di cn ni tng him gp, thng thy di cn phi , gan, di cn xng t gp hn (gp
trong ung th t bo gai dng vt, m h hoc u, c).
3. Chn on v chn on phn bit.
+ Chn on quyt nh.
Da vo lm sng v m bnh hc: ung th t bo gai in hnh l t bo hnh a gic gii
hn r, nhiu nguyn sinh cht, nhiu ty lp th, nhiu t chc si. C mt, hai nhn bt mu
r v c mng nhim sc. Cc t bo u xp chng cht ln nhau to thnh dng t bo lt ni
vi nhau bng cu ni lin bo.
+ Chn on phn bit.
- Nh bt xi , liken sng, ht cm m, ht cm thng thng c chn, cc u sng xi v nht
l sng ho do nh nng.
- Lao xi, giang mai III , nm su, vim da m xi.
- Nhng th c n nh phn bit vi: u ht trong vim da m, lot do it, Brm.
4. iu tr ( ung th t bo y v t bo gai).
+ Ct b bng phu thut theo hnh elip hay hnh thoi.
Nhng tn thng vnh tai, trn, m u lm phu thut ct b (nhng ch nh c bn l: khi
kch thc trung bnh hoc ln phi ct b cch b 4 milimet, kt qu khi 95% trng hp).
+ Dng laser: p dng i vi khi u thn mnh c kt qu tt v khng li so.
+ Nhng tn thng nhiu v rng dng ho tr liu ti ch: retinoide hoc 5-fluoro- Uracile
hoc tim ti ch vo trong thng tn interferon- a(alpha) v interferon d ( gamma).
+ 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.
K thut c in l quang tuyn X nng lc t hoc khng lc, in th 80-100KV.
- Nu phu thut ri iu tr quang tuyn : ch s dng liu c nht 1500-2000 r .
Nu n thun iu tr quang tuyn: iu tr ko di ( mi tun mt ln) , tng liu 3000 r/ 3 - 4
ln. Nu din tch nh dng my Chaoul in th 50- 60 KV khong cch ngn. Nu kch thc
nh hn na dng tia Bucky in th 12 KV.
Cc trng hp ung th t bo gai rng, thm nhim, b mt xi to cn in th cao hn 200
KV, iu tr bng nhiu t, mi t 3 ln chiu, mt tun mt ln 200- 300 r. Tng liu 4000-
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).
+ Ngoi ra cn dng t in.

17. UNG TH T BO Y

1. i cng.
+ Bnh gp c hai gii nhng nam thng hay b hn n, trn 40 tui.
Bnh gp bt k ch no trn c th, nhng thng thy nht vng u, mt khong 80-
89,3%, i khi c c 5,2 %, thn mnh 3,6%, b phn sinh dc 1 %. Khi khu tr mt,
thng vng mi 20-23%, m 16-29%. Him khi khu tr lng bn tay, bn chn . nim
mc khng bao gi xut hin bnh .
+ Bnh tin trin chm.
2 Triu chng lm sng .
Thng thng xut hin sau mt dy sng ngi gi , n mt lc no dy sng to lan
rng, thm nhim v pha y c mt vt trt. Vt trt c bao ph pha trn va vy da va
vy tit (squame- crufte ), dn dn xut hin cc cc nh ring r hoc lin kt vi nhau. Cc
nh c c tnh ca ht ngc ung th.
Cc hnh thi lm sng ca ung th t bo y.
2. 1. Ung th t bo y phng thnh so.
L loi ung th t bo y thng gp nht. Thng tn bng ht u nh, nm su trong
thng b, c th bng mt da hoc ni cao ln, mu trng , m, b mt nhn hoc hi dy
sng. Cc thng tn rng v ln dn, c mt ch lm phn trung tm, nhiu nm sau to
thnh mt mng. B cc ni cao ln to thnh hnh vng , v sau lin tc xut hin thng tn
mi b v lm cho cc thng tn lm xung thnh so mu trng c, c nhng dn mch
nh, hoc c lot nng. Cc ch lot c th lnh so trn mt vng nhng lot li lan rng ra
ch khc
2. 2. Ung th t bo y lot ( ulcus rodens).
Tn thng c bn l lot , v tr khu tr thng da mt v da u vi tnh cht:
B ca lot hi thm nhim, b thng ng v lun lun c g ,xung quanh thnh vm
.G c to bi nhng ht ngc ung th nh.Vt lot su c th tin trin ph hu nhiu n
su xung cc t chc di, ph hu mch mu hoc n c xng.
2.3. Ung th t bo y nng ( superficieh).
Tn thng thn mnh, bng, c dng mt mng n c hoc c khi nhiu mng. Mng
hnh trn hoc hnh dng khng u .
Da bong vy hoc dy sng c gii hn r.
2.4. Ung th t bo y ni cao ln (saillants).
+ Th xi c n .
U hnh trn xi ln hoc cc nh xi, i khi d chy mu v lot .
+ Th ni u r rng ( forme nodulaire):
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.
2.5. Ung th t bo y dng x cng b ( pithlioma morphiforme ).
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.
2.6.Ung th t bo y nhim sc ( pigment).
C nhiu ht sc t trong t chc t bo ung th, sc t c th nhiu mu nh tng hoc
en xm, hnh thnh vt rng lin kt vi nhau trn gn ton b da ca khi u.
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.
- Da vo m bnh hc : cc t bo khi u c nguyn sinh cht rt t, nhn hnh bu dc hoc
hnh trn, rt kim, c th c 1 -2 nhn trn nh hoc hi di, khng c cu ni, cu trc ca
khi u do tp hp cc t bo thnh tng m hoc tng kch thc thay i. Cc t bo ny
dy c, bt mu kim, gii hn r, trn hoc khng u, thng c nhng n ngang
(bourgeon) trong khi b ca khi u c cc t bo dng ko di hnh tr ging lp t bo y
ca thng b.
5. iu tr: xem bi iu tr ung th t bo gai.

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
thng trc y nh methotrexate, cyclosporin v retinoids c nhiu c tnh v tc dng ph
nn ngi thy thuc cn phi theo di st nhng bnh nhn s dng cc thuc ny. Nguyn
nhn ca vy nn hin nay c chng minh c lin quan n p ng min dch qua trung
gian t bo v du n ca cytokine. V vy, cc thuc iu chnh min dch chn lc vi c tnh
t hn c xem nh mt th h tr liu mi trong vic kim sot v cha lnh vy nn.
II. Nhc li cc yu t lin quan n vy nn
Yu t di truyn:
C hai kiu bnh r rng trong vy nn: kiu khi pht sm v kiu khi pht mun. Vy nn
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
mnh vi tnh di truyn nh loi khi pht sm.
Yu t ngoi sinh:
Nhiu yu t mi trng cng gp phn trong sinh bnh hc ca vy nn. Cc yu t ngoi sinh
nh chn thng, stress, bng nng, phu thut, thuc v nhim trng lm khi pht bnh
nhng ngi c sn yu t di truyn tim tng. Cc yu t ny cn lm bnh nng thm hoc
ti pht nng n.
III. Sinh bnh hc min dch ca vy nn
Vy nn c xem nh mt tnh trng tng sinh qu mc ca cc keratinocyte thng b di
s kch thch ca cc lymphocyte b. C ch chnh xc v dy chuyn tng tc gia cc
keratinocyte v cc t bo min dch vn cha c hiu mt cch y . Tuy nhin, nhiu
bng chng cho thy cc t bo T hot ha l nhng cht iu chnh min dch ch yu trong
sinh bnh hc ca vy nn.
Thot u, cc t bo T hot ha xm nhp vo lp b vng da tn thng nh cc phn t
kt dnh t bo v cytokine tin vim interleukin-8 (IL-8). a s t bo T thng b l loi
CD4+helper. Cc t bo T b kch hot bi cc t bo nhn din khng nguyn. Qu trnh ny
sn xut ra nhiu loi cytokine. Cc t bo T sn xut IL-2 v interferon-y (INE-y) c gi l t
bo Th1 v min dch trung gian t bo. Ngc li, cc t bo T sn xut IL-4, IL-5 v IL-10
c gi l cc th bo Th2 v gp phn trong min dch c th. Cc cytokime Th1 l nhng
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.
iu tr ti ch thng c s dng trong vy nn mc nh v trung bnh. Vy nn mc
trung bnh v nng c th phi s dng quang tr liu hoc thuc h thng.
V. iu tr ti ch
C rt nhiu thuc c s dng ti ch trong iu tr vy nn. Gn y, mt s loi thuc mi
nh tazaroten v tacrolimus cng c hiu qu trong iu tr vy nn.
Bng 1: Thuc iu tr ti ch

Thuc u im Tc dng ph
Corticoisteroid D s dng, tc
dng nhanh
Teo da, gin mch, c
ch thng thn, d ti
pht.
Calcipotriene Dung np tt C th gy kch ng da,
tng canxi mu.
Anthralin Ch thoa 1 ln trong
ngy
Nhum mu da, kch
ng da
Tar C th dng phi
hp vi quang tr
liu
Nhum mu da, chm
tip xc, c mi.
Acid salicylic R tin, d s dng Hiu qu thp, thoa
nhiu ln, kch ng da.
Tazarotene C th thoa mt
v da non
C th sinh qui thai,
kch ng da

VI. Quang tr liu
Bng 2: Quang tr liu

u im Tc dng ph
UVB (Goeckerman) Khi bnh ko di, t
l sch thng tn
cao.
Tn thng da do nh
sng, pht ban nh sng
a dng, tng nguy c
lo ha v ung th da.
PUVA Khi bnh nhanh Tn thng da do nh
sng, lo ha da sm,
tng nguy c

VII. iu tr h thng c in
Bng 3: Thuc iu tr h thng c in

Thuc u im Tc dng ph
Ciclosporin Hiu qu cao t tin, c thn, tng huyt
p, c ch min dch (tng
nguy c nhim trng v c
tnh nu iu tr PUVA trc
)
Methotrexate Hiu qu Gy qui thai, c gan, x ha
phi, c ch ty xng.
Acitretin Hiu qu tng
i
Gy qui thai, c gan, bt
thng lipid mu, rng tc.
Fumaric acid ester Hiu qu Gim t bo lympho, tng
bch cu i toan thong qua,
tng men gan, ri lon tiu
ha, chng bng
Hydroxyurea Hiu qu tng
i
Gy qui thai, c ch ty
xng, ri lon tiu ha, tng
sc t da, ri lon chc nng
thn, lot chn v ming.
Dapson R tin, hiu
qu tng i
D ng, thiu mu tn huyt,
methemoglobin huyt.
VIII. Mt s tuc mi trong iu tr vy nn
Bng 4: Cc thuc sinh hc mi

C ch tc ng Thuc
T bo T hoc t bo trnh din
khng nguyn
Alefacept
Efalizumab (anti-CD11a)
OKTcdr (anti-CD4)
CTLA4-Ig
Denileukin diftitox
(DAB389-IL2)
Cytokine Infliximab (anti TNF-)
Etanercept (anti TNF-)
Adalimumab (anti TNF-)
IL-10
Onercept (anti TNF-)
Anti-IL-12
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
gian gia 2 t ti thiu l 12 tun.
Bnh nhn cn c m lng CD4 trc khi iu tr v mi tun trong lc iu tr. Nu CD4 <
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
v: CD18 v CD11a, LFA-1 ng vai tr quan trng trong vic bt gi t bo T v keratinocyte
v t bo ni m.
Efalizumab ngn chn s kt hp gia LFA-1 vi ICAM-1 (phn t kt dnh gian bo) do tc
ng trc tip ln LFA-1 t ngn cn dng thc dn truyn tn hiu n LFA-1 v mt i
chc nng bch cu.
Efalizumab c tim di da, 1 ln/tun. Liu khi u l 0,7 mg/kg v sau liu lin tc mi
tun l 1 mg/kg.
Thi gian bt u c tc dng v ci thin lm sng i vi Efalizumab thng sm khong 14
ngy. Nhiu nghin cu cho thy iu tr Efalizumab lin tc rt c li trong vic duy tr v ci
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
u, lnh run, st, bun nn.
Etanerceft
Etanerceft l mt phn t ti kt hp bao gm th th TNF-ap75 ca ngi (yu t hoi t khi
u) v on Fc ca IgG1 ca ngi. Etanerceft l mt protein hp cht nh trng c iu ch
t t bo bung trng chut ng Trung Quc v c cng nhn trong iu tr vim khp dng
thp, vim khp vy nn v vim cng ct sng.
Etanerceft hot ng nh mt cht c ch TNF- bng cch kt hp v bt hoi TNF-1, qua
ngn cn s tng tc vi cc th th b mt t bo.
Liu Etanerceft i vi ngi ln l 50 mg/kg/tun. i vi bnh nhi b vim khp dng thp v
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
trn, nhc u v vim mi.
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
thng v mt. Infliximab gy ly gii t bo qua trung gian b th nn xt nghim IDR cn c
thc hin tt c bnh nhn iu tr bng thuc ny.
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,
cch tun. Ging nh infliximab, nhng bnh nhn iu tr vi adalimunab nn c xt nghim
IDR. Adalimunab c th s dng mt mnh hoc kt hp vi methotrexate trong iu tr vim
khp dng thp. Hin nay, hiu qu ca thuc ny trong iu tr vy nn v vim khp vy nn
cn ang c nghin cu.
Pimecrolimus (SDZ-AZM-981)
Pimecrolimus l mt dn xut ascomycin ca macrolactam ang c nghin cu trong iu tr
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
gi. V vy, tazarotene c th l thuc thay th an ton trong iu tr vy nn bng retinoid h
thng i vi nhng ph n tui sinh .
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
nh c tnh cao v d ti pht khi ngng iu tr. Th h iu tr mi tp trung ch yu vo cc
mc tiu chuyn bit trong phn ng min dch qua trung gian t bo. Chng ta c th hy vng
tr liu nh th s gip bnh nhn dung np tt hn v khng cn nhng tc dng ph nghim
trng nh c gan, c thn v c ch ty.
Ti liu tham kho
1. Alice B.Gottlieb. Etanercept for the treatment of psoriasis and psoriatic arthritis. Dermatologic
Therapy, Vol.17, 2004, 401 408.
2. Craig L. Leonardi. Efalizumab in the treatment of psoroasis. Dermatologic Therapy, Vol.
17,2004, 393 400.
3. Emmilia Hodak, Michadl David. Alefacept: areview of the litarature and practical guidelines for
management. Dermatologic Therapy. Vol. 17, 2004. 383 392.
4. Laura S. Winterfield, Alan Menter. Infliximab. Dermatologic Therapy, Vol.17, 2004, 409 426.
5. Toral Patel, Kenneth B.Gordon. Adalimumab: efficacy and safety in psoriasis and rheumatoid
arthritis. Dermatologic Therapy, Vol. 17, 2004, 427 431.
W.Sterry, J.Barker, W.H.Boehncke, J.D.Bos, S.Chimenti. Biological therapies in the Systemic
management of psoriasis: International. Consensus Conference. British Journal of Dermatology
2004; 151 (Suppl. 69): 3-17

BS. Hong Vn Minh BS. V Quang nh
B mn Da liu - i hc Y dc TP.HCM
medinet.hochiminhcity.gov.vn

19. VY NN (PSORIASIS)

1. i cng.
+ Vy nn (psoriasis) l bnh da mn tnh, thng gp v hay ti pht. cc nc u- M, t l
mc bnh vy nn chim 1-2% dn s. Vit Nam, t l vy nn l 5-7% tng s bnh nhn da
liu n khm ti cc phng khm da liu.
+ Cn nguyn - bnh sinh ca vy nn c nghin cu t lu song vn cn nhiu im cha
sng t, ngy nay ngi ta cho rng vy nn l bnh da di truyn, gen gy nn bnh vy nn
nm trn nhim sc th s 6 c lin quan HLA- DR7, B13, B17, B37, BW 57, CW6...
Di tc ng ca cc yu t gy bnh (yu t khi ng, yu t mi trng) nh stress, nhim
khun, chn thng c hc, vt l, ri lon ni tit, cc thuc... gen ny c khi ng dn
n tng sn t bo biu b sinh ra vy nn.
+ Vy nn l mt bnh c c ch min dch, vai tr ca lymph T hot ho, cc cytokines,
IGF1, EGF, TGF , IL 1, IL 6, IL 8, nhm trung gian ha hc eicosanoides, prostaglandine,
plasminogen m hu qu cui cng l dn n tng sinh t bo biu b, tng gin phn sinh ra
vy nn.
+ c im lm sng ch yu l pht ban c dng, trn da c cc m mng kch thc to
nh khc nhau ( t vi milimet n hng chc centimet) , nn cm, thm nhim, b mt ph vy
trng nh nn, khu tr mt vng hay ri rc khp u mt, thn mnh, tay chn. Triu chng
nga chim khong 20- 40% s ca. Bnh thng xut hin nhiu nht la tui 10- 30, t l
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. Cn nguyn - bnh sinh.
Cn nguyn - bnh sinh cn nhiu im cha sng t, song hu ht cc tc gi cho vy nn
l bnh da di truyn, bnh da do gen. Yu t di truyn (genetic factor) c tha nhn, di tc
ng ca cc yu t khi ng (nh stress, nhim khun, chn thng c hc vt l...) gen gy
nn bnhvy nn c khi ng v sinh ra vy nn.
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.
2.5. Chn thng c hc vt l: c vai tr trong s xut hin bnh (14%).
2.6. Ri lon chuyn ho.cho l c ri lon chuyn ho ng,m.
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
400% so vi da bnh thng, (trong vim da cp ch tng 50- 100%), y l mt c im ln
(theo Charpy).
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.
2.9. Vy nn l mt bnh c c ch min dch, ngi ta thy c rt nhiu t bo lymph T xm
nhp vo da vng tn thng, t bo TCD 8 c lp biu b, t bo TCD4 c lp chn b,
thot bch cu a nhn trung tnh t nh b ln biu b, c vai tr ca mt s cytokines, IGF1
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.
Da vy nn xut hin khng th khng lp sng, l loi IgG, yu t khng nhn.
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.

+ Vy trng ph trn nn m , vy mu trng c hi bng nh mu x c, nh mu 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...
+ gp phn chn on vy nn, trc y ngi ta thng lm mt nghim php gi l co
vy theo phng php Brocq (Grattage de Brocq), dng dao m hay curt co nh nhiu ln, t
t trn b mt tn thng s ln lt pht hin cc du hiu sau:
- Du hiu vt nn: co thy bong vy vn nh bt trng.
- Du hiu v hnh (pellicule dcollab) tip tc co s n mt lp mng mng, dai, trong sut
bc c nh v hnh.
- Du hiu git sng mu (cn gi du hiu Auspitz) sau khi bc ht lp v hnh, bc l mt
nn da , rm mu lm tm nh git sng nh, gi l du hiu git sng mu.
+ 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.
+ Tn thng mng gp 25% s ca, bn mng c h lm nh (nh khu th may) hay c
cc ng k theo chiu dc, hoc mng dn vn, dy b t do, 10 mng cng b mt lc.
+ Vy nn da u thng l cc m mng , nn cm, b mt ph vy trng, thng mc
ln ra trn thnh mt vin gi l vnh vy nn, tc vn mc xuyn qua tn thng, mng c khi
dy cm, vy dnh, vng sau tai , c vt nt c khi xut tit, d nhm vivim da da du,
sng lin cu...
+ 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
khp, vy nn da ton thn.
4. Cc th lm sng.
4.1. Vy nn th chm git (psoriasis punctata, psoriasis guttata).
Tn thng l cc chm t 1-2 milimet n vi milimet ng knh, ni ri rc khp ngi, nht
l na ngi trn, mu ti, trn ph vy mng mu trng c, d bong, co vn ra nh
phn. Th ny thng gp la tui tr em v ngi tr tui, bnh xut hin t ngt, lin quan
ti vim amidal do lin cu, vim tai gia, chu tc dng tt vi tr liu khng sinh, c th t
v khi, c khi thnh da ton thn do iu tr khng thch hp.
Cn chn on phn bit vi vy nn th git (c du hiu bong vy ra ton b khi co gi l
vt gn xi) v phn bit vi ban giang mai II dng vy nn.
4.2. Vy nn th ng tin (psoriasis nummulaire):
y l th in hnh v ph bin nht, cc vt m c kch thc 1- 4 cm ng knh, xu
hng trn nh ng tin, s lng cc m c th m c, vi chc m hoc hn na, tin
trin mn tnh.
4.3. Vy nn th mng (psoriasis en plaques). y l th mn tnh tin trin t vi nm tr
ln, c tnh cht c th dai dng.
Thng l cc m mng ln 5-10 cm ng knh hoc ln hn, khu tr vng t (lng,
ngc, xng cng, khuu tay, u gi, mt trc cng chn) cc m mng gii hn r, cm
hn cc th khc, ngc c khi thnh mng rng nh mt ci mc, ci khin ca trng s thi
trung c khi xung trn.
4.4. Vy nn da ton thn (psoriasis erythrodermique exfoliative generalise):
L mt th nng, t gp (1% theo Goerkerman). Da ton thn ti, bng, ph n, nhim cm,
cng, rm dch, ph vy m t, khng cn vng da no lnh, nga d di, cc np k b trt
lot, rm dch m, nt n, au rt.
Triu chng ton thn: st cao, rt run, ri lon tiu ho, suy kit dn dn c th t vong do mt
bnh nhim khun no .
Th ny t nhin tin trin thnh t mt vy nn th git hay do bin chng ca iu tr khng
thch hp nh d ng DDS...
4.5. Vy nn th khp (psoriasis arthropathique) cn gi thp khp vy nn, vim khp vy nn
(psoriatic arthritis). y l mt th nng t gp.
i a s trng hp tn thng vy nn c trc tn thng khp, tn thng da thng nng,
lan to, vy dy g cao dng v s, c khi kt hp vy nn da. Tn thng khp kiu
vim a khp mn tnh tun tin kiu thp khp, bin dng. Cc khp sng au, dn dn i
n bin dng, hn ch c ng, mt s ngn tay, nn chn b cho li nh nhnh gng, sau
nhiu nm tr nn tn ph, bt ng, suy kit, t vong do bin chng ni tng.
4.6. Vy nn mn m (pustular psoriasis).
L mt th nng him gp, chia lm 2 th:
+ Vy nn mn m ton thn Zumbusch (generalized pustular psoriasis) do Zumbusch m t
u tin t nm 1910. Xut hin tin pht hay trn mt bnh nhn vy nn da hay vy nn
th khp (20- 40%).Triu chng lm sng gm: st cao t ngt, mt mi, da c cc m da
lan to, ni chi cht cc mn m ng knh 1-2 mm, cm gic rt bng, v sau xut hin giai
on rc vy l rng ko di nhiu tun, c th rng tc, tn thng mng, xt nghim mu
bch cu a nhn trung tnh cao, mu lng tng cao, cy m khng mc vi khun. Tin lng
nhn chung tt, hay ti pht.
+ Vy nn mn m lng bn tay, bn chn: th Barber (localized pustular psoriasis). Biu hin
bng mn m v khun ni gia nhng m dy sng lng bn tay, bn chn, mn m tin
trin tng t rt dai dng hay gp nht m ci v m t, c khi km theo ph n cc chi, st
cao, ni hch bn, mt s ca chuyn thnh th Zumbusch.
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,
iu tr bng khng sinh c tc dng tt.
5. M bnh hc.
+ Dy sng v sng (hyperkeratosis v parakeratosis): lp sng dy ln r rt, gm nhiu lp
t bo sng (l nhng t bo sng non, cn tn ti nhn) gi cc l sng c nhng khe
ngang cha y khng kh lm vy d bong.
sng l hu qu ca tng gai (hyperacanthosis), phn ln lp gai pha trn cc nh b mng
ch cn 2-3 lp t bo, nhng phn cc mm lin nh dy ti hng trm lp t bo, cc mm
lin nh di ra m xung chn b, phn di phnh to nh di trng, c nhnh i khi dnh vo
cc mm ln cn, lp gai v lp y c biu hin tng gin phn r.
Nh b b ko di ln pha trn v bin dng hnh chy. Nh b v phn trn chn b ri rc c
mt s t bo vim quanh cc mch mu gm lympho v t chc bo.
+ T mao mch vng nh v di nh thot ra cc t bo lymph v bch cu a nhn trung
tnh xm nhp vo cc khe gian bo v lp gai to thnh vi p xe Munro, l du hiu quan trng
chn on m bnh hc i vi vy nn, thng gp tn thng mi, giai on vng bnh.
+ Gim sc t da trong lp t bo y v lp gai.
+ Gin mao mch chn b.
6. Chn on v chn on phn bit.
6.1. Chn on xc nh da vo:
+ V tr.
+ Tn thng c bn: m , nn cng cm, ph vy trng nhiu lp.
+ Du hiu Ko'bner.
+ Phng php co vy Brocq.
+ M bnh hc da.
6.2. Chn on phn bit:
+ vy nn.
+ Vy phn hng Gibert
+ sng lin cu, eczematide
+ Sn giang mai II.
7. iu tr.
iu tr vy nn cn nan gii, mc d nhng nm gn y c nhng loi thuc mi, phng
php iu tr mi c hiu qu cao hn c a ra, cc loi thuc ny lm bnh nhiu hoc
tm khi v lm sng, sau mt thi gian bnh li ti pht, cha c loi thuc no cha bnh
khi hn c.
7.1. Cc loi thuc bi iu tr vy nn.
7.1.1. Thuc bong vy , bt sng.
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.
7.1.2. Goudron : l mt loi thuc kh oxy c 2 loi.
- Goudron ngun gc chng ct phn hu t mt s g c nha ( cy thng...).
-Goudron ngun gc t than .
l mt cht lng c mu nu sm hay mu en, nht vi mi hc c trng. pH c tnh acit,
ha tan trong dung mi hu c, t tan trong nc c dng iu tr bnh vy
nn,eczema dng dung dch cn, bt nho, m v nguyn cht ( goudron pur).
Du cade l 1 loi goudron ngun gc sn phm chng ct t mt loi g cy thng.
Coaltar l 1 loi goudron than .
Goudron l 1 loi thuc c in iu tr vy nn kh tt, c tc gi coi goudron l " vua ca cc
loi thuc bi", bi vo tn thng vy nn lm tn thng ht vy, tan nhim cm v tn
thng bin mt sau t iu tr. Nhc im l mu en, mi hc dy bn qun o v mt s
bi lu ngy c th c vim nang lng.
M Sabouraud 1 cng thc ni ting cha vy nn, thnh phn gm goudron, du cad, dim
sinh, Resorcin...a. salicylic.
7.1.3. Anthralin l mt loi thuc kh oxy c tim nng c ch cc enzymes iu ho vic s
dng glucoza l men 6-phosphate -deshydrogenase ( G6-PDH).
Thng dng Anthralin trong iu tr tip xc ngn (short contact).
Trong 2 tun u hng ngy bi Anthralin, nng 0,1% - 0,3% sau 10-20 pht tm ra
thuc i.
Cc tun sau iu tr duy tr 2 ln/ tun.
Ch trnh hin tng kch thch da, khng tm nc nng sau khi bi thuc trong vng 1 gi,
trnh dy thuc vo mt.
7.1.4. M corticoid ( bit dc m Flucinar, Synalar, Eumovate, Betnovate, Tempovate,
Diproson, Sicorten ,Lorinden...).
u im ca thuc m corticoid l bnh nhanh, tng i sch, bnh nhn a thch. Nhc
im l bi din rng, di ngy c th gp tc dng ph nh ni trng c, teo da, gin mch,
vt rn da... v c hin tng "nhn thuc " hoc " bt bng" v sau bnh ti pht vng bnh
nng hn.
Hin nay ngi ta cho rng nn p dng bi m corticoid nh sau:
- Bi loi m corticoid loi nh v va ( nhm IV, V, VI,VII).
- Bi 1 t 20- 30 ngy , sau ngh thuc 1 thi gian sau nu cn mi dng tip t khc.
- Bi xen k, t ny dng m corticoid, t sau bi loi thuc khc.
- Trnh bi din rng, ko di ngy.
C ch ca thuc l c ch huy ng bch cu a nhn, c ch tng hp DNA pha G1, G2
ca gin phn, chng vim, chng gin phn.
7.1.5. M Daivonex (calcipotriol): l cht ng ng vitamin D3 c tc dng c ch tng sinh t
bo sng (keratinocytess) v kch thch qu trnh bit ho t bo sng, tc dng vo lympho T,
c ch sn sinh IL2, gim s biu hin ca HLA- DR, thuc ny theo s liu nghin cu tt hn
m corticoid, ch ch dng cho cc ca vy nn khu tr, bi ngy 2 ln ( sng v chiu). Ch bi
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)
7.2. Cc thuc dng ng ton thn iu tr vy nn.
7.2. 1. Quang ho tr liu ( photo chemotherapy).
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.
Phng php ny do Parrish v Fitzpatrick xut nm 1974.
Ni dung ca phng php bao gm:
- Ung thuc cm ng nh sng Psoralen.
- 2 gi sau chiu tia cc tm sng A ( UVA) bc sng 320-400 nm ( na n mt).
Tc dng chnh ca phng php PUVA l :
- Hiu qu chng phn bo.
- Hiu qu min dch gim s lng v gim hot ho lympho T ( TCD3,TCD4, TCD8), c ch
tng hp ADN ca lympho, gim cc yu t ho ng ng, gim sn xut IL2, c ch biu l
HLA DR ca t bo sng.
- Lm sch tn thng nhanh chng, c hiu lc trong giai on vng v ti pht bnh.
- Gin n, d thc hin, trnh phi bi thuc.
- Tng i an ton, t c hi.
- Giai on tn cng 3 ln chiu / tun trong 1 thng.
- Giai on duy tr 1 ln / tun trong 2 thng.
Kt qu ca nhiu tc gi ca nhiu nc thu c l bnh 70-95% sau t iu tr PUVA.
Tc dng ph : mt s bun nn, da, nga, ni phng nc, trn thc nghim sc vt c 1
s c nhn mt, gada...
7.2.2. Retinoid ( nhm etretinate- bit dc Tigason-Soriatan).
Retinoid l mt dn xut tng hp ca vitamin A c tc dng tr liu cao v t c tnh hn
vitamin A, c c tnh khng nhim sng (Antikeratisantes) v khng tn to (Antineoplastique)
, 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.
Cng thc ho hc ca etretinate.
Acitretine (Soriatan) c tnh dc c hc tt hn etretinate (Tigason) thi gian bn hu
nhi liu l 50 gi, thi tr ch yu qua gan v mt t qua thn.
C ch tc dng ca Retinoid cha r hon ton nhng c tc dng iu ho tng trng v
bit ho t bo, tc dng trc tip ln gen ca cht keratin, lm chm tng sn biu b v bnh
thng ho qu trnh bit ho t bo sng.iu bin min dch v chng thm nhim vim biu
b trong bnh vy nn, c ch biu hin HLA lp II (HLADR +)
Ch nh.
Vy nn thng thng din rng.
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 :
Vim kt mc, kh mt, kh da (48-78%) .
Rng tc, nga, da mng, vim mi (87-100%).
Kh ming (8-88%), trn ng vt th nghim c tnh gy qui thai (teratogenic), do vy khng
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.
Liu lng v cch dng.
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.
- Tun 2 : ung 3 vin MTX 2,5 mg 1/1/1.
(V d sng th 2: 1 vin , ti th 2 : 1 vin, sng th 3 : 1 vin, cc ngy khc khng ung
thuc).
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
t thun li cho sy thai, qui thai, gim tinh trng...
7.2.4. Cyclosporin A ( bit dc Samdim mun , Samdimmun neoral).
Cyclosorin A l mt polypeptid vng gm c 11 axit amin c kh nng c ch min dch chn
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 th nng iu tr bng cc phng php thng thng khng kt qu.
- Vy nn mn m.
- Vy nn khp.
Chng ch nh.
- ang c bnh c tnh.
- Chc nng thn khng bnh thng.
- Cao huyt p khng kim sot c.
- ang dng thuc c ch min dch khc, x tr liu, ho tr liu.
Liu dng : 2,5 mg/kg/ ngy n 5,0 mg/ kg/ ngy ung chia lm 2 ln ( thng dng nht l liu
4 mg/ kg/ ngy).
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,
coi l tr liu khng c kt qu.
Khng c dng qu liu ti a 5 mg/ kg/ ngy.
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
c th c thay i cu trc thn ( x thn k).
- C th c mt s tc dng ph khc nh chng rm lng, run, ri lon chc nng gan, mt
mi, ph i li.
7.3. Mt s thuc khc.
C th dng mt s thuc khc trong iu tr vy nn nh:
-ACTH
- Thuc an thn tc dng ln h thn kinh trung ng nh bromua.
- Vitamin A,C,B12, Biotin, vitamin H3.
- 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
n thuc : h kh tho, th phc linh ca GS Nguyn Xun Hin v CS.
Thuc sc ht ph c ch, ht u miu ca GS Nguyn Xun Hin , BS Nguyn Thi im.
Thuc bi cao vng ( Dampommade) nghin cu ca GS Nguyn Cnh Cu v BS Bi Khnh
Duy tha k bi thuc ca lng y cha Trng H Ty.
7.4. Phng hng chung v chin lc iu tr bnh vy nn.
Trc mi mt bnh nhn vy nn cn cn nhc k, la chn phng php iu tr nhm t
c mc ch sau:
- Lm sch tn thng, lm bnh nhiu.
- Hn ch ti pht ( ko di th gian ti pht).
- Ch an tan, t c hi.
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
nh k ca bc s chuyn khoa da liu.
* Chin lc iu tr gm 2 giai on:
- Giai on tn cng: lm sch tn thng da ( bnh nhiu, tm khi v lm sng).
- Giai on iu tr duy tr trnh ti pht.
* Ch sinh hot ca bnh nhn vy nn.
. Trnh cng thng thn kinh.
. Hn ch kch thch c ph, ru.
+ 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:
Vy nn mn m lng bn tay chn:
Ton thn dng phng php PUVA, hoc Etretinate (retinoids).
Ti ch bi m corticoid, dithranol, coaltar.
+ Vy nn mn m ton thn (th zumbusch) c th dng tr liu sau :
Retinoids ;Methotrexate; phng php PUVA.

20. VY NN MN M LNG BN TAY
CHN

1.nh ngha: vy nn mn m lng bn tay chn l bnh c c im c nhiu mn m chm
su, kch thc 2- 4 mm, mu vng, mn m v khun nm trn nn dt vim khu tr lng
bn tay chn, bnh c tnh cht mn tnh, hay ti pht.
2. Cn nguyn.
Cn nguyn ca vy nn mn m lng bn tay chn cn cha r.
Thng kt hp bnh nhn c vy nn mt vng no ca c th.
L bnh t gp, thng gp la tui 20-60, n nhiu hn nam ( 3/1).
3. Triu chng lm sng.
+ V tr :lng bn tay chn, m ci, vm lng bn tay, bn chn, mt di ngn, ria gt bn
chn, mt mu bn chn v u ngn tay chn th t hn, him khi lan qu c tay.
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.
Dn dn mn m c dn, mu vng chuyn thnh mu nu ti, mn m kh i trong vng 8-10
ngy. Tn thng da v dy sng c th c vy tit hi ging eczema, khi thuyn gim t
mc mn nc mi, sau thuyn gim nhiu tun hay nhiu thng c th bnh li pht mt t
mi.
Thng khng nga hoc khng au, nhng cng c khi c cm gic nga,au trc khi ni
mn m.
4. Xt nghim:
- Mn m l mn m v khun , cng thc mu bch cu t khi tng.
- 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.
+ Chn on da lm sng v m bnh hc v nht l khi c thy tn thng vy nn thng
thng vng da khc.
Cn chn on vy nn mn m lng bn tay chn khi c biu hin lm sng nh trn, cy
khun m tnh, hnh nh m bnh hc c mn m dng xp.
+ Chn on phn bit :
- Vim da u chi lin tc ca Hallopeau c mn m u ngn , tiu , rng hng mng.
- T a nhim khun.
- Gh nhim khun c tn thng bn tay, c mn m k ngn tay, 1 vi mn lng bn
tay, ngn c tay v cc v tr khc thn mnh.
6. iu tr :
Ti ch bi thuc st khun, bi m corticoid khi c da dy sng.
Ton thn :
PUVA tr liu ( bi hoc ung thuc cm ng nh sng Psoralen kt hp chiu UVA).
Methotrexat 15 - 25 mg mi tun ( sng ung 1 vin 2,5 mg, ti ung 1 vin 2,5 mg 3-4 ngy
mi tun) cho cc ca nng.
Etretinate cho kt qu tt, hn ch mc mn m mi, mau sch tn thng da, ngy 25 mg -
50 mg.
Cyclosporrin A cho cc ca dai dng c th, dng 1 t < 3 thng
21. VY NN MN M TON THN

1.i cng
Vy nn mn m ton thn l mt bnh nng c th e da sinh mng, khi pht t ngt, da
rc lan rng trong nhiu gi, xut hin cc mn m nh trn nn , nhiu mn m lin kt
thnh h m, st mt mi, suy yu, kh chu, tng bch cu mu ngoi vi. l nhng c
im ni bt ca bnh.
Bnh thng xut hin ngi ln 20-70 tui c nam v n, t gp tr em.
- C th t nhin pht bnh hoc trc bnh nhn b bnh vy nn, vy nn th khp.
2.Triu chng lm sng
- Bnh khi pht t ngt, bt u d i nhanh st cao 40
o
C, 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.
Trong vng vi gi, 12-36 gi trn nn da ni nhiu mn m (mn m v khun). Mn m
mc thnh tng t, mn m nh nh k, rt nng, mu trng sa, mc thnh m cm nhng
cng c khi ri rc, mn m c khi phng c khi g cao, xung quanh c qung xm, c
nhng mn m nm ngoi m , xung quanh c qung xung huyt nh. Mn m khng i vi
nang lng. Nhiu mn m lin kt vi nhau thnh h m 1-2 cm ng knh. Do mn m mc
thnh tng t nn c ci kh i ng thi li c t mc mn m mi.
Vi ngy sau mn m v tn thng hi trt chy dch m ri ng vy tit, chuyn sang
giai on rc vy, rc vy kh trn nn da , vy l dy hoc mng thn mnh, chi, mt
nu c thng tn thng rc vy phn. Rc vy ko di mt n nhiu tun sau da nht
dn, dn. C khi li xut hin mt t mn m t bnh khc.
Cm gic da trong giai on mc mn m l au rt, c khi nga t hoc nga nhiu.
- Triu chng ton thn: thng st cao, nhc u, rt run, mt nhiu, kh chu, th trng suy
sp, mt li b nhng khng c tn thng ni tng, v nhim c mch nhanh, th nhanh.
- Cc mng ngn tay chn dy hoc tiu mng, c cc h m di mngdn n bong mng,
v sau c rng tc.
- C th c triu chng khp vim au.
- Tn thng nim mc t gp: vim li trt gai, vim mng tip hp, vim quy u.
3.Xt nghim
- Xt nghim mu thy bch cu tng, nht l bch cu a nhn.
- Tc mu lngcao nht l trong cc ca c km tn thng khp.
- Cy mu thng m tnh
- Mn m thng v khun hoc ch l tp nhim t cu, lin cu.
- M bnh hc da: c mn m xp bo hnh thnh khoang do bch cu a nhn t mao mch
ca lp nh chn b di chuyn ln phn trn lp t bo gai ca biu b, tp trung k gia cc
t bo sng b thai ha, cn gi l mn m Kogoj c hnh ming bt b xp.
4.Chn on.
Chn on xc nh da vo triu chng lm sng ni bt v m bnh hc da.
Cn chn on phn bit vi:
- Nhim khun do t cu.
- Herpes th lan trn.
- D ng thuc bi nhim c mn m.
- Hi chng Reiter.
5. Tin trin
Tin trin rt c bit, cc giai on ban , mn m, rc vy ni tip nhau lm bnh cnh
ngoi da thay i hng ngy lm ta c cm tng nh l khng phi cng 1 bnh nhn. Khi ban
rc, mn m ni nhiu du hiu ton thn nng. Khi giai on rc vy, st h, tnh trng ton
thn hi phc nhanh chng.
Bnh c xu hng ti pht nhiu t, c t ni ban mn m rm r, vng bnh c v nguy
kch, sau dn dn lui bnh. Tin lng ni chung l tt.
6. iu tr
t cp iu tr nh bng nng, nm bung cp cu ring, cho truyn dch, cy mu.
Retinoid l thuc u tay (Etrtinate hoc Acitretin) 0,5-1mg/kg/ngy. Thuc lm ngng mn m
nhanh v cn dng iu tr trnh ti pht.
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.
Methotrexat 15-25mg/tun. Thuc ny c hi vi gan, munn cn cn nhc thn trng

22. VY PHN HNG GIBERT

1. nh ngha:
L bnh cp tnh, t min, c kh nng ly truyn hay gp tr em v ng i tr, c tr ng bi
tn th ng da c hiu, cn ton trng t nh hng .
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
tr em hay ng i gi ( c th tr s sinh hay ngi 90 tui).
3. Cn nguyn ca bnh cha r. V dch t hc v hnh nh lm sng c th ni rng n l
bnh truyn nhim, vng Transvaal c mt thi k ko di t 2- 4 nm , c mt " dch"
t nhin bnh nhn tng vt ( c t 2-4 c th b bnh mt gia nh hoc tr ng hc) nh
ng khng c mt bo co chnh thc no ni v s ly truyn ca bnh. Australia cng c tm
c s lin quan gia cc tr ng hp xy ra ca bnh. T 1892 Lassar quan st thy bnh
c lin quan n mc qun o mi hoc qun o ct i mt th gian. S truyn nhim qua
qun o hoc qua cn trng c tr trong qun o cng cha c chng minh.
Trong bnh s, vi tn th ng thng th ng ( lan to sang bn cnh) tn thng th pht, t
nhin dng li, chng minh n rt ging vi mt bnh truyn nhim chnh cng.
C nhiu tc gi hy vng rng bnh do mt loi siu vi khun nh ng khng c chng minh
v c nm , vi khun , xon khun cng nh vy, cn li l do vi rt, n ng c xem xt v
kh nng nht. C tc gi s b xc nh l do virut Epstein - Barr ( l mt loi virut ADN
thuc h Herps virut ) ( thng th ng th vi rus E-B gy bnh tng bch cu n nhn ). Mt
s tc gi lm ly truyn c bnh qua vy da v qua thanh dch ca mn n c tn th
ng.
S mn cm ca bnh c s lin quan vi cc yu t chung khc nh th a d ng, eczema,
hen, so snh vi nhm chng .
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:
Lc u bnh biu hin khng r 50 % tr ng hp. Bnh nhn cm thy au u, st nh,
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
th ng ko di 5- 15 ngy . C th ngn vi gi hoc ko di 2 thng. Tn th ng ( th pht)
trn lan bt u biu hin sau 2-3 ngy hoc n 10 ngy . Cc tn th ng mi k tip pht
trin vi tun sau. Hnh thi c in tn th ng bao gm: ban m ay xung quanh, mu hng
nh, vy kh xm ph trn. Trung tm tn th ng teo, lm, da nhn mu nu. Sau mt thi
gian tn th ng c tr ng bi cc ng ly tm song song nh xng sn ca cha.
Tn th ng thng th ng thn mnh, c, cn thy cnh tay v cng chn, ch ny
thng dai dng v c mt tn th ng c bit tr em. Tn th ng cnh tay v cng
chn khong 6- 12 %. Tn th ng lng bn tay cng c th c, c hnh nh da bong vy
c mn n c nh. Tn th ng bn nim mc l him nh ng cng phi ch . Tn thng
da bong vy hoc im xut huyt hoc phng n c cng c gp. C c tn th ng m
o.
Triu chng chung khc c th quan st thy nh ng nh, sn nga nh, hoc l c th do
iu tr khng ng. St rt nh, mt mi, hch limph nch c th s ng.
Tn th ng da thng th ng bin mt sau 3- 6 tun , nh ng mt vi tn thng c th
nhanh hn 1-2 tun. Tn th ng pha d i, c th ko di hn. C th li tng hay
gim sc t. Nh ng thng th ng khng li du vt g.
Tn th ng ti pht sau vi thng hoc vi nm sau c th thy 2% cc bnh nhn .
Tn th ng nhiu hay n c c th quan st thy .
Bnh c th dng khng in hnh, bin dng khong 20 % cc bnh nhn. Cc tn th ng
th pht c th thnh m ln, n c th trn lan hay thm ch ch c vi tn th ng. Cng lc
y c th c tn th ng u ngn tay. c bit tr em tn th ng c th dng sn my
ay giai on sm v c vy ph trn , hoc tn th ng tr em dng my ay in hnh
vi im xut huyt, tn th ng xut huyt cp tnh cng c ng i ln. Sn n c, mn n
c v m cng gp. Tn th ng dng sn hay gp Chu Phi hn Chu u. Sn li chen hay
gp ra tn th ng .
Vy phn vn vo v c b vin Vidal ( Pityriasia Circinata et marginata of Vidal), mt i khi
thy hnh thi ny ngi ln. Tn th ng t nh ng ri rc rng, thng th ng n khu tr
mt vng ca c th, c bit nch v bn. N ko di vi thng, hnh thi ny l hnh thi
trn lan.
Chn on :
Khi tn th ng in hnh th khng kh .
Khi khng in hnh, bin dng ( ban my ay, xut huyt , li chen...) th
cn phi phn bit vi :
Nhim c da d ng thuc bng cc xt nghim inVitro.
- Vim da da du c th lm vi cc vy phn . Nu vim da da du tn
th ng th ng chm v vng da u, ngc, l ng , m. C vy m v vy vn, sn chn
lng. Tn th ng s ko di nu khng iu tr.
- Giang mai 2: Phi c cc tn th ng ni khc, tin trin chm c ni hch, c tn th ng
chung v tn th ng nim mc, tn th ng l o ban dt sn, xt nghim huyt thanh giang
mai (+).
- Hnh thi ban ma ay tr em.
- Vy nn th chm git i khi cng d nhm vi vy phn hng dng liken (lichnoi'd )C hai
tn th ng u l sn. Nh ng vy nn c vy trng x c cn vy phn hng l a dng. Mt
i khi c vy mu v ng i tr.
Cc phn da nhim sc kh mt , vim da lin cu, tr em d nhm vi bnh ny.
6. iu tr :
iu tr triu chng l chnh. iu tr mnh ti ch l khng cn thit. Trnh kch thch bi tm
nng, x phng v qun o len. chng da kh, trnh kch thch c th dng crem cocticid.
Ti ch tn th ng c th dng tia cc tm liu d i da.
Bi dung dch Rivanol 1 %o c th cho kt qu tt. C tc gi cn cho ung c Rivanol.


23. VIM B THN KINH
(Nevrodermite)

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,
nga ban u nh v ni thnh cn sau thnh t d di nht l v m.
Dn dn vng da nga b gi nhiu tr thnh sn hi nhn, hi cm, ni nhng sn
dt bng, sau thnh mt m, c xu hng hnh bu dc, i khi thnh vt di c vin khng
u, khng r. nhng m in hnh c th phn bit 3 vng: vng ngoi sm mu hi rp, da
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.
Tu tng v tr , c khi trn mt m vy da xm c, c khi trng nh bt, sng ho
cc np, tn th ng c th hi cht t. bu da cm, sm mu, hn da su, d b cht nhim
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
cng nng cng nh hng n thn kinh ca bnh nhn.
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).
- Ri lon tiu ho, vim lot d dy hnh t trng.
- bu, cn ch pht hin giun kim.
- m h cn pht hin kh h, candida, trichomonas...
3. iu tr :
- iu tr chung: nh chng nga v sn nga ni chung, cc thuc an thn v khng
histamin, thuc gii cm, ch n , ngh ngi, trnh bi quan lo lng u c tc dng.
- iu tr ti ch : nhng thuc bi c tc dng i khi quyt nh.
- M corticoid , ASA, dung dch axit tricloracetic 33 %, hc n nguyn cht.
- 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.
- Vim b thn kinh khu tr : xanh metylen 1 %- 0, 25 % + Hydrococtison + Novocain ln
vim b thn kinh khu tr khi 30/ 70 , nhiu 31.
- in phn dung dch xanh metylen 1 % : Tc gi iu tr 62 bnh nhn vim b thn
kinh khu tr v eczem khu tr chi trn v chi d i bngin phn dung dch xanh mtylen 1%
. Kt qu gim vim, gim nga, gim cm nhanh. 26 bnh nhn khi, 19 .
Ph ng php : - 4 lp gc giy tm dung dch xanh metylen 1 % t trn tn th ng (+)
cc d ng .
- 1 lp gc tm NaCl 1 % ln bn i din (-) cc m. Nu vng h nang ta
t cc (-) ln x ng cng v tht l ng .
Tin hnh : mi ln 20 - 30 pht dng in 0,1- 0,3 Ma/ 1 cm
2
. 3 ln / 1 tun , tt c 15 -
20 ln.
Ngoi ra dung dch xanh metylen cn c iu tr ngoi da bng nhiu cch :
C ch : - Tc dng da trn s c nh trn t chc t bo thn kinh
- Ti ch tn th ng l phng b cc ngoi cm th ca da, lm chm cc phn
x bnh l t tn th ng ln v no do c ch cc kch thch su t tn thng . V vy
cn phc hi thng bng ca v no.
- C tc dng hi phc s oxy ho do tc dng gim vim, gim nga.



24. MN TRNG C

A. I CNG
Mn trng c l bnh thng gp, thng tn vi nhiu mc khc nhau hn 90% thanh
thiu nin. Nhng ch c 10% thc s cn thit s dng thuc v 1% (0,4% n v 3 4%
nam) gp vn kh khn v iu tr.
Mn trng c thng bt u tui dy th. Khng c nhng tn thng nang lng c trng
bo trc ca vic tit b: tit b dy th, thng sm hn dy th sinh dc nht l b gi da
tr nn nhn v ni mn, thng gp trc khi c chu k kinh u tin tui 8 9 tui, nam
xut hin chm hn khong 12 13 tui.
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.
B. PHN LOI NNG CA MN TRNG C
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.
BNG 1: PHN LOI NNG CA BNH

nng Tn thng
Mn nh
< 20 comedones hoc
< 15 tn thng vim hoc
tng s lng tn thng < 30
Mn trung bnh
20-100 comedones hoc
15-50 tn thng vim
Mn nng
05 nt (cc) hoc
tng s lng tn thng vim >
50hoc
tng s lng sang thng > 125

C. NHC LI SINH BNH HC
C 3 nhm yu t gp phn ch yu trong bnh sinh cc tn thng cn bn ca mn trng c:
+ Tng tit b.
+ Sng ha vng phu ng: cha r c ch.
+ Vai tr ca Corynebacterium acnes vng phu ng v cc yu t gy vim khc vng
phu ng: C. acnes tit ra nhng thnh phn gy vim nh lipase, protease, hyaluronidase v
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
Tng tit
b
Tng
sng
Tng sinh P.
acn
Vim
Thoa ti ch
Tretinoin
Adapalene
Tazarotne
Benzoyl
peroxide
Erythromycine
Sulfacetamide
sulfur
Acide azelaic

Khng
Khng bit
Khng
Khng
Khng
Khng
Khng

C
C
C
C (gin
tip)
Khng
Khng
C

Khng bit
Khng bit
Khng bit
C
C
C
C

Khng
C th
Khng
C th
C th
Khng
C th
Ton th
Thuc nga

C (gin
tip)

Khng
Khng

Khng
C

Khng
C th
thai
Erythromycine
Tetracycline
Isotretinoin
Khng
Khng
C
Khng
C
C
C (gin
tip)
C
C

Ti ch

Retinoids
C 3 cht l Tretinoin, Adapalene, v Tazarotene.
a. Tretinoin
+ Tc dng: tiu comedon v ngn s hnh thnh comedon.
+ Thi gian: trong vng 3 thng cho kt qu ng k.
+ Thoa thuc vo bui chiu v dng t nht 6 tun mi thy kt qu r.
+ 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
L mt retinoid th h mi trong iu tr mn trng c ti ch vi c im:
+ n nh vi nh sng v oxygen khng b phn hy bi nh sng v oxygen nn c th
thoa ban m hoc bui sng.
+ Hp thu qua da thp thm vo nang b nhn v hot ng ti v tr mn trng c.
+ Tnh kt hp th th chuyn bit trong t bo sng gip cho adapalene t c tc dng ph.
Tc dng ph ging nh tretinoin, nhng t l gp t hn.
+ C th c hot tnh khng vim.
c. Tazarotene
L mt retinoide tng hp c s dng trn th trng t nm 1997 iu tr bnh vy nn.
Sau khi thoa ti ch s chuyn thnh mt cht bin dng hot ng l acide tazarotenic.
C hai dng ch phm c s dng trong iu tr mn l dng gel v cream, tuy nhin
Tazarotene 0.1% gel c tc dng hiu qu hn nhng phn ng da v kch ng thng gp
hn. Dng cream cng c dung np tt. Tazarotene 0.1% gel c thoa 1-2 ln/ngy, lu
nu thoa 2 ln/ngy th sau 2-5 pht phi ra mt bng nc m.
Mt kho st gn y ti M (2003) so snh hiu qu gia Tazarotene v Adapalene cho thy
Tazarotene c tc dng nhanh v mnh hn Adapalene nhng tc dng ph tng ng
nhau.
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
b, ngoi ra thuc cn c tc dng chng vim v tiu comedons.
Tc dng ph thng gp nht l kh da v nhy cm nh sng. Nn dng thuc bui chiu
lm gim nhy cm nh sng.

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
nhn thy rng iu tr mn trng c vi clindamycine 1% (dng solutions) th c hiu qu tng
ng vi tetracycline 250 mg x 2 ln/ngy (ung). Vi trng c th khng vi khng sinh,
trong trng hp ny s phi hp thuc c th lm gim s khng (v d: Erythromycine 3%
vi benzoyl peroxide 5% hay clindamycine 1% vi benzoyl peroxide 5%). Erythromycine cng
c dng di dng dung dch 2% c km.
Nhng khng sinh ti ch khc nh metronidazole, nhng hp cht c cha sulfur th cng hu
ch trong iu tr mn trng c nht l trong mn trng c .

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
estradiol 0.035 mg. Tc dng ph ch yu ca thuc l bun nn v gii hn ca phng thc
iu tr ny hin nhin l khng dng c cho bnh nhn nam.
Mt thuc thay th cho iu tr mn trng c do hormone n l spironolactone, liu tn cng
200 mg/ngy v liu duy tr 50-176 mg/ngy (ty dung np). Spironolactone c th kt hp vi
iu tr thuc nga thai bng ng ung.

Khng sinh
Tetracycline: (Chlohydrate de Tetracycline 500 mg)
- Liu gim dn:
+ 1,5 g /ngy trong 8 ngy.
+ 0,5 g /ngy trong 1 thng.
+ 0,25 g /ngy trong nhiu thng.
- Hoc liu khng i: 1 g /ngy.
- Hiu qu v khng c hi vi liu 1 g / ngy trong thi gian lu di.
Cyclines th h 2: (Doxycycline 100 mg, Minocycline 100 mg)
- Liu dng: 1 2 vin / ngy.
- Cng c hiu qu nh Tetracycline.
- iu tr ko di t c dung np hn.
- Gi thnh mc hn.
- Theo nghin cu gn y nht, Doxycycline dng liu cao ko di d gy ra tnh trng
Candida m o, au thng v, tn thng thc qun hoc nhy cm nh sng. Ti liu mi
nht (04/2003) s dng Doxycycline liu thp c tc dng chng vim 20 mg x 2 ln/ngy (liu
tc dng khng khun ti thiu ca Doxycycline l 50 mg/ngy) th c tc dng tt trong vic
gim sang thng mn khng vim v vim cng nh tng s lng sang thng so vi
placebo.

Khng sinh khc:
+ Erythromycin: liu dng: 1,5 2 g / ngy.
+ Clindamycin: liu dng: 300 600 mg / ngy.
+ Trimethoprim-sulfamethoxazole: liu dng: 960 mg x 2 ln/ngy.
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
Ty ban nha (94%). khng phi hp gia Clindamycine v Erythromycine rt thng gp
(cao nht l 92% Ty ban nha) so vi khng Tetracycline (cao nht l 26.4% Anh).
Khng tm thy vi khun khng Tetracycline Hungary v . T l Propionibacterium khng
khng sinh da ngi bnh khng iu tr thay i t 41% Hungary n 86% Ty ban
nha. 25/39 Propionibacterium khng khng sinh bnh nhn mn c iu tr.
Nh vy cc thuc thoa Erythromycine v Clindamycine iu tr mn c du hiu khng
rng ri. T l khng sinh Tetracycline ung khng thp tr Thy in v Anh.

Isotretinoin:
Sau hai thp nin nghin cu v retinoid, isotretinoin vn l iu tr c la chn i vi nhng
ca mn trng c nt nang khng tr v th trm trng hn l mn trng c cm. Isotretinoin c
tc dng c ch s sn xut tuyn b, v cng nh c retinoids khc n cng thc y qu
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
na trong 80% trng hp. Liu dng:
+ Tn cng: 0,5 1 mg / kg / ngy trong 4 thng (ty theo dung np).
+ Duy tr: 0,2 0,3 mg / kg / ngy thi gian dng ko di 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.
2. 2. Mn trng c thiu nin:
Chn la phng php iu tr ph thuc vo dng tn thng v nng ca mn nhng
cng cn lu vn tm l.
Mn nh ch cn iu tr ti ch. Benzoyl peroxide, acid azelaic v khng sinh ti ch thng
thng c dng cho mn vim. i vi mn khng vim retinoids thng c dng. i vi
mn hn hp c th dng phi hp retinoids vi cc thuc trn.
Mn trung bnh nng cn thm khng sinh ung. Thng thng s dng tetracycline hay
erythromycine. Doxycycline hay minocycline thng t x dng hn v hp thu km hn v tai
bin nhiu hn. Minocycline t khi cho khng thuc vi P. acnes nhng tai bin ph nng n
c th xy ra. Trimethoprim-sulfamethoxazone s c dng nu nhm thuc trn khng c tc
dng. Benzoyl peroxide phi hp vi khng sinh ung s gim c vi khun khng khng
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
khng n nh. Tuy nhin cn lu tc dng ph ca isotretinoin.
BNG 3: IU TR DA VO DNG MN

IU TR
Mn khng vim Mn nng
Comdon Sn - Mn m Nt kn
Ti ch
Tretinoin
Adapalene
Tazarotne
Khng sinh
Acide azelaic

X
X
X
X
X

X
X
X
X
X

H thng


X

X
Thuc nga thai
Erythromycine
Tetracycline
Doxycycline
Minocycline
Isotretinoin
X
X
X
X
X
X
X
X
X

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.]
E. GIO DC BNH NHN
- Gio dc bnh nhn v bnh l mn.
- Cho bnh nhn bit v cc loi thuc iu tr mn khc nhau v tc dng ph.
- Mun t kt qu tt phi kin tr v iu tr mn lu mi c kt qu.
Li khuyn bnh nhn mn:
Khng c nn mn.
Khng s dng m phm ln mn, cn lu 1 s m phm c th gy mn.
Tia t ngoi c th lm gim nhanh tnh vim ca tn thng nhng n cng d gy ra vt
thm en nht l bnh nhn s dng retinoids thoa.
Ch n ung phi thch hp.
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.

TI LIU THAM KHO:
1. Goueden V. (2003), Guideline for the Management of acne vulgaris in adolescents,
Paediatrics Drugs, 5(5), p. 301-313.
2. Hong Vn Minh (2002), Mn trng c, Chn on v iu tr bnh Da liu bng hnh nh,
Nh xut bn Y Hc, tp 1,xut bn ln th hai, trang 187-198.
3. Liao D. C.(2003), Management of Acne, the Journal of Family Practice, Vol. 52, (1).
4. Ross, J. I. et al (2003), Antibiotic-resistant acne: Lessons from Europe, British journal of
Dermatology, 148,
p. 467- 470.
5. Shalita A (2003)., P 75: Tazarotene Cream versus Adapalene Cream in the Treatment of
Facial Acne Vulgaris: A Multicenter, Double-blind, Randomized, Parallel-Group Study, American
Academy of Dermatology, 30
6. Skidmore R. et al (2003), Effects of subantimicrobial-dose doxycycline in the treatment of
moderate acne, Archives of Dermatology, 139,p. 459-464.
7. Webster G. I (2002)., Acne Vulgaris, BMJ, 325, p. 475-479.

Bc s Hong Vn Minh

25. NM LANG BEN
Chn on nm lang ben da vo.
- V tr: c v cnh tay, ngc, lng. Ch yu 1/2 pha trn.
- Tn thng c bn: Dt trng ( c khi dt hng hoc hi nu, thm mu ) nh bo tm hnh
trn vi mm ng knh, khu tr l chn lng dn dn lin kt vi nhau thnh mng ln, hnh
vn vo nh bn , 10-20-30 cm ng knh.
Nhn k thy c gii hn r hi g cao trn mt da, cao hi bong t vy cm ( khi i nng ng
, g cao, nga rm ran).
- TC c nng: Nga rm ran sau khi i nng hay ngi ch nng ra m hi.
- Soi cy nm dng tnh (kh lm).
2. Chn on phn bit
- Phong v nh dt trng, mt cm gic ,teo c u chi, thn kinh tr, hng kheo ngoi c khi
sng to.
Tm trc khun Hansen.
- 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
hng hi hm, nhn.
- Bch bin (Vitiligo)
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
Bi mt trong cc thuc sau:
Sng cn ASA. Chiu m Benzosali. 15-20 ngy.
Hoc M Clotrimazol 1% 2 ln /ngy trong 20 ngy.
Kem Lamisil bi trong 1 ln t 1-2 tun.
Ung Ketoconazol 200mg 2 vin / ngy x2 -4 tun ( Nizoral).

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. Cc biu hin trn lm sng:
2.1. Nhim phn bn v phn xa di mng (DLSO: Distal and lateral subungual
onychomycosis), l dng ph bin nht gy lon dng mng, thng do vi nm dermatophyte,
i khi cng nhim thm nm mc (mould) th pht.
2.2. Trng trn b mt mng (SWO: Supperficial white onychomycosis), l dng c
trng ca nhim dermatophyte do Trichophyton mentagrophytes, thng khng ph bin.
2.3. phn gc di mng (PSO: Proximal subungual onychomycosis). Xut pht t phn gn
ca mng v thng l th pht ca vim quanh mng mn do cc chng nm men Candida.
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.
3. Cc loi thuc iu tr hin nay:
3.1. Thuc bi ti ch: thng c s dng theo kinh nghim (dng kem, dung dch, sn):
- Nhm azole (ketoconazole, clotrimazole, miconazole, sulconazole, oxiconazole, econazole).
- Ciclopirox Olamine.
- Amorolfine (loceryl).
- Nhm allylamine (natifine, terbinafine).
- Nhm cc acid (salicylic, undecylenic).
- Nhm polyenes (nystatin).
Tuy nhin, a s nhng ch phm trn khng c my hiu qu trn nm mng, ngay c khi s
dng phi hp vi rt mng, do hn ch tnh thm ca t dc vo mng. Do , iu tr bng
ng ung hin c la chn nhiu hn.
3.2. Thuc ung:
- Itraconazole:
Lin tc: 200mg/ngy, trong 6 12 tun
iu tr tng t: 400mg/ngy, trong tun u/thng trong vng 2 3 thng.
- Terbinafine: 250mg/ngy (6 12 tun).
- Fluconazole: 150 400mg mi tun, t 6 12 thng.
- Griseofulvin: 0,5 1g/ngy, (6 12 thng).
B. Cch phn loi mi nh hung iu tr nm mng
1. Tc gi:
BS. Alexey Sergeev - Tng Th k ca Hi Vi nm hc - Hc vin Quc gia Nga.
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
hng t n nn mng, c th iu tr ti ch d dng. Cc dng lan rng hn, thng i hi
tr liu thuc ung mi cho hiu qu v duy tr c kt qu. C vi trng hp, i khi tr liu
n c ng ung cng khng hiu qu.
2.2. rng ca tn thng:
- V tr nhim nm cch mm mng (matrix) bao xa?
- Thi gian tn thng i ra khi mng?
2.3. Mc dy sng bn di mng:
- Thuc bi c n c ging mng (nail bed) khng?
- Thuc khng nm ung c n c bn mng(nail plate) khng?
2.4. V tr mng b nm:
Tc pht trin ca mng khc nhau cng nh hng n kt qu iu tr. Cc mng chn
thng pht trin chm hn cc mng tay. Mng tay ci v chn ci pht trin chm hn mng
cc ngn cn li. S pht trin ca mng chm hn s i hi thi gian iu tr di hn.
2.5. Tui:
Tc pht trin ca mng gim theo tui.
3. Cch tnh ton v sp xp theo tt c d liu lin quan:
3.1. Xc nh mi d liu bng mt tr s.
3.2. Thit lp thang phn loi:

c im Phn loi
1 2 3
Biu hin lm sng
(f)
SWO DLSO PSO
rng tn
thng (d)
< 1/3 1/3 2/3 > 2/3
dy sng (h) Nh (< 1mm) Trung bnh (1
2mm)
Nng (> 2mm)
Tui (a) 15 25 25 60 60 80
Mng nhim nm
(l)
Mng tay II
V
Mng chn II V
Mng tay ci
Mng chn ci
3.3. Cng thc tnh:
Tr s = mc nng tn thng x tc pht trin ca mng
SCIO = [(d/3)
3-f
x (f + h (3-f) x (l) x (a + 3)/3]
1-[(2-f)(3-f)/2
]
4. Dng c c ch s:
Thc o SCIO, dng c kt qu tr s s SCIO m khng cn phi tnh ton, thc c
thang kt qu ch s t 1 30. Tr s SCIO cng cao chng t bnh nm mng cng nng, v
vy i hi tr li ko di hn.
5. Liu php iu tr c ngh theo tr s SCIO:
c tm tt nh sau:
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).
9 - 12: iu tr bng ng ung. Dng phc iu tr cho nm mng chn (Vd:
itraconazole 3 t: 200mg x 2ln/ngy, trong 1 tun/thng).
12 - 16: iu tr ng ung vi liu trnh ko di thm. (Vd: itraconazole 4-5 t:
200mg x 2ln/ngy, trong 1 tun/thng).
16 20: iu tr ng ung phi hp vi ti ch. C th dng thm thuc tiu sng
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.
- Xc nh thi gian iu tr thch ng.
- D on hiu qu iu tr.
6.2. Trong nghin cu:
- a ra nhng tiu chun chn bnh.
- Xp bnh thnh nhm theo tr s gn nhau.
- Hu hiu cho nhng nghin cu nh.
7. Kinh nghim p dng:
Nghin cu so snh hiu qu iu tr ca hai thuc khng nm itraconazole v terbinafine trong
iu tr nm mng. Sau 3 thng iu tr, nhn thy hiu qu iu tr trn nhng nhm bnh nhn
ging nhau (c tr s SCIO gn nhau) l nh nhau

Nhm Itraconazole Terbinafine
S lng bnh 52 46
Tui 51,6 55,4
Gii (nam/n) 29/23 21/25
S mng bnh TB 5,9 5,6
Mng chn ci b nhim 32 (61,5%) 26 (56,5%)
dy sng (nh/trung
bnh/nng)
7/41/4 7/32/7
rng tn thng
(tng ng vi chiu di
ca mng, tnh t b t
do)
< 2/3 > 2/3

< 2/3 > 2/3

25 27 19 27
Ch s SCIO 14,9 14,3
Thi gian bnh nm mng > 10 26 nm > 10 12 nm
Nguyn nhn gy bnh
(% dermatophytes)
82,7 86,9
Hiu qu lm sng (thng
18)
82,6% 78,3%

C. Kt lun:
Da vo tr s SCIO c th so snh c nng ca bnh nm mng gia cc mng bt k
c s khc nhau v biu hin lm sng.
Chng ta hy vng rng h thng ch s mi ny c th h tr chng ta lp nn mt s tip
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.

BS. Trn Th Thy Linh
27. NM TC

1. Chn on nm tc.
- u c cc m hnh trn vi cm nn vim, c vy trng, rng tc.
- Tc rng ch cn li chm en hay b pht gy cch da u 1-5mm chn tc c vy trng bao
quanh d hiu" nhng trong bt" i bt tt".
- C th c m nm (m hnh trn c ranh gii r, c b vin, b c mn nc) da mt,
thn hnh tay chn km theo.
- Nga
- Xt nghim nm dng tnh.
2. Chn on phn bit:
- Rng tc Pe-lt: u c cc m rng tc hnh trn vi cm ng knh, da nhn trng nh mt
ci so.
- 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.
- Rng tc do tt nh tc: tc mc nm chm, vng mc tt vng tha. hi tin s pht hin tt
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
ton u, tc kh x xc hi bc mu. C th suy nhc.
Hi tin s bnh km theo.
3. iu tr:
Ti ch: Nu din rng, nhiu th ct tc ngn n chn dng du gi tr nm nh Nizoral ...
Ton thn: c th dng cc thuc chng nm nh : Ketoconazol (Nizoral), Itraconazol ung
trong vng 4 - 6 tun

28. PHNG CHNG BNH NM

PGS Nguyn Ngc Thy

1. ng ly truyn ca bnh nm da.
Bnh nm da ly truyn theo kiu exogen(yu t ngoi lai) do cc nguyn nhn sau:
Tip xc vi bo t , si nm trong thin nhin, khng kh, t, nc hoc t cc ngun khc
nh thc vt...
Tip xc vi xc vt b nm (mo, ch, tru b...).
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...).
Nm ly truyn cng cn c nhng yu t thun li nh: da b sang chn, m hi lp nhp, lm
b lp sng, c st da lm xung huyt nht l iu kin thiu v sinh, t tm git, cho nha
bo, si nm bm vo da c thi gian ny n v pht trin thnh bnh.
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
khng c s tip xc trc tip gia nm vi cc t bo to khng th ca h lin vng ni mc
nn c th" d on" v mt l thuyt l nng khng th trong dch th s thp hoc khng
pht hin c bng cc phng php huyt thanh hc c nhy thp. Nhng vi cc
phng php xc nh khng th c nhy cao ngi ta vn c th pht hin c khng th
khng nm trong huyt thanh. Ngi ta thy nhng bnh nhn c IgE tng l nhng bnh
nhn cng c test trichophytin (+) trong 30 pht u .
2. Bin php gio dc tuyn truyn v sinh c nhn v v sinh mi trng:
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
(pH ca da khong 4, 5- 5, 5).
+ 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.
+ Trnh mc qun o m t, qun lt khng nn dng vi ni lng v qu cht gy xy xt, b
m hi ( 80% nm gy tn thng da bn, mng, tht lng).
+ 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
hp tc nhn qu th cn gi nhiu ln hn. Khi tc kh v nhiu gu th nn gi u t hn.
Khng nn dng cc loi x phng gi u c nhiu cht kim v n lm tc kh v d rng.
Nn gi bng nc b kt, x phng thm xong x bng nc sch, c th gi bng chanh,
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
nng. Chn chiu phi nh k git gi, trnh m mc.
3.Bin php phng bnh nm da bng k thut.
ch ng trong cng tc phng chng bnh nm da nhiu nc tin tin ngi ta tm
ra cc bin php k thut phng nm. Phng nm k chn nhng ngi i dy dp th
dng hi focmol dit nm hoc rc bt talctamin- boric 10% vo k chn. Qun i M
dng loi bt ( foot powder) c cha axit undecylenic rc vo giy, tt phng nm k cho
binh lnh Nam Vit Nam trc y thu c kt qu tt). c ngi ta dng smotilon A.M
phng nm da bng cch tm dt vo tt. Lin X trc y ngi ta dng mt s
ho cht c tc dng dit nm khng gy hi cho ngi, tm vo si vi ri dt thnh qun o
lt phng nhim nm da, nm men v vi khun. Hungari s dng dung dch
NaPCP(natripentachlorophenolat) 1% kt hp vi km sulfat ( ZnSO4) 1% phun vo cc thm
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:
Axit benzoic 0,2% ( 2 gam trong 1000 ml).
Natri benzoat 0,1%.
Axit salisilic 0,1- 0,2%.
Nipagin.
Nipazol dung dch 1%.
Axit tactric 7 gam / 1000 ml.
Formaldehyt 30 ml + 970 ml nc.
Formalin 1-2%
Iodofor 20 ml + 980 ml nc.
+ 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
khng tm NaPCP v ZnSO 4. Phng php tin hnh nh sau:
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
t tan trong nc.
2 NaPCP + ZnS04 Zn (PCP) 2 + Na 2S0 4.
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
khu vc qun lt, ngi b bnh gan, thn.
Bng phng php trn c th h t l mc bnh nm da t 2,5 n 3,3 ln so vi n v chng
khng nhng thuc. Ngoi ra bin php ny cnc tc dng h tr cho thuc iu tr bnh nm
rt ngn c thi gian iu tr.
Nhc im ca phng php mt s ngi c cm gic nng rt vng h nang trong ln
mc u tin.

29. PEMPHIGIOD BNG NC
1. i cng.
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.
2. Cn nguyn bnh sinh.
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
bo kt hp vi t khng th,c s tham gia ca b th gy phn ng vim li ko bch cu a
nhn v i toan n, c hin tng ng ng v Protein dn n ph hy mng y, lm chia
tch biu b chn b to nn phng nc di biu b.
- Mt s thuc c th gy nn Pemphigiod.
- Mt s thuc c th gy nn Pemphigiod bng nc kt hp vi cc bnh c tnh bn trong c
th.
3. Triu chng lm sng.
- Thng bt u bng ban sn m ay hoc sn, t hn l vim da, eczema i trc bng
nc nhiu tun hoc nhiu thng, sau mi ni bng nc lan trn nhiu ni.
- Cc tn thng thng thng phn b nhiu ni, cc v tr hay gp l : bng di, mt
trong i, bn, nch, mt gp cng tay, phn di cng chn ( thng xut hin u tin).
- Tn thng c trng nht ca Pemphigiod bng nc l cc bng nc ln, cng, mc trn
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.
- Ngoi ra cn c dt , sn mng my ay v bng nc xut hin trn .
- Tn htng nim mc t gp (8-39%) nu c th thng l bng nc nh ming, kh v, t
gy au.
- Triu chng nga thay i t khng nga n nga nhiu.
Triu chng ton thn ch c khi bnh nng, tn thng da lan rng.
4. Cc th lm sng.
C mt vi bin th lm sng t gp ca BP.
4.1. Pemphigiod si : c nhng mng si, mng m bn nch ging Pemphigus si.
4.2. Pemphigoid c :c cc cc dy sng ri rc v mng dy sng trn ni bng nc, chn
on xc nh phi da vo lm sng v min dch hunh quang trc tip.
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.
5.2. Min dch bnh l.
- Min dch hunh quang trc tip gn 90% bnh nhn c lng ng IgG , gn 100% s ca c
C3, lng ng IgG v C3 dc theo mng y l in hnh c hiu cho BP v mt vi bnh
phng nc.
- Min dch hunh quang gin tip 70% s bnh nhn BP giai on hot tnh c khng th
chng mng y lu hnh.
5.3. Huyt hc.
- tng bch cu i toan mu ngoi bin 50% s bnh nhn.
- Tng IgG 70% s bnh nhn.
6. Chn an v chn on phn bit.
- Chn on xc nh da lm sng c tn thng l cc bng nc ln, cng, kh v mc trn
nn da vim hay da bnh thng, bnh nhn 60 tui tr ln, xt nghim m bnh hc v
min dch hunh quang.
- Chn on phn bit vi :
Ly thng b phng nc mc phi.
Bnh Duhring- Brocq.
Pemphigus.
D ng thuc th bng nc.
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.
8.1. Ti ch :p gc dung dch st khun nu tn thng trt lot, bi m khng sinh, m
corticoid khi tn thng kh.
8.2. iu tr ton thn:
- 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.
Phi hp corticoid vi thuc c ch min dch (Azathioprine, cyclophosphamide, methotrexate,
chlorambucil) nht l vi cc bnh nhn khng p ng vi corticoid sau 6-8 tuaanf iu tr. Khi
p ng tt v lm sng th gim liu c 2 loi, sau dng liu duy tr bng corticoid n c.
-Trong cc ca nh c th dng Sulfones (dapsone, S) 100 - 150 mg/ ngy thng p ng
sau 2 tun.
- C thng bo dng Tetracyclin kt hp nicotinamide c hiu qu trong mt s ca.
- Nu c nga cho dng Atarax ( hydroxyzine).
- Nn trnh co gi v tia cc tm.
- Mt s thuc nghi vn nn trnh dng.

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.
- Bnh t min, c t khng th IgG lu hnh trong mu chng li b mt t bo keratinoaftes,
ph hu s lin kt gia cc t bo to ln phng nc trong lp biu b.
- C lin quan HLA-DR4,DQ8 , DR6 ,DQ5.
- Thng gp tui 40-60.
- Nam v n b bnhnh nhau.
- T khng th IgG bm cht vo glycoprotein b mt t bo biu b lm t cc ni dn dn
hin tng ly gai ( acantholyse).
3. C nhiu th lm sng khc nhau.
3.1. Pemphigus th thng thng ( P. vulgaris).
+ Thng tn l mt ci bng nc trn nn da lnh, n dng. Nhng da ny rt d trt ra.
Du hiu Nikolsky (+). Thng c cht ming nht l vm khu ci i trc vi tun, vi thng
do c phng nc d v .
Bng nc phng nc 1 vi cm ng knh, d v, nho.
+ Lm sng : bnh hay sy ra mt cch t ngt mt ngi kho mnh hay ngi c th
tng suy sp.
+ Ch yu l bng nc : xut hin u tin mt ch no trn da hay trn nim mc
mm,hu hng. Bng nc c th nh bng ht u xanh, qu to, qu trng g , bng nc
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.
C trng hp lc u nh sau to dn do hin tng ly gai.
C th bng nc ny lin kt 2-3 ci li bng mt mng ln bng nc c th cng ( ging
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 ny xut hin trn nn da bn ngoi trng bnh thng khng c nn di (
Duhring bng nc trn nn ). Nu bng nc bi nhim th vn c nn di.
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.
Thng mun chn on phi lm t bo Tzanck.
Cc bng nc ny hoc kh i hoc t ln v lan ra c ngi to thnh nhng vy tit. Khi
cy vy tit thy m trt khi li vt thm mu. Cn vt lot c m khi trt da li nhng
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
nc ri th bnh nhn thy au rt. C khi au rt d di nu vt trt lan rng.
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.
Cc tn thng nim mc ny lm bnh nhn cm thy rt au n, n ung kh khn.
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.
Mu : bch cu tng va phi.
Ton trng suy mn c cc tn thng ph tng.
Th dch c ri lon, nht l chuyn ho nc, m, mui.
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.
giai on cui cng tn thng ngoi da c i nhng t vong do tn thng ph tng,
cng c trng hp t khi ? Mt s cho khng phi hay l pemphigus lnh tnh hay mpt th
ca Duhring.
+ M bnh hc : bng nc nm trong lp thng b ch yu trong lp malphighi. T bo gai
xung quanh bng nc b t cu ni chng b ngm trong nc phnh ra hnh trn nhn ca n
to gi l hin tng ly gai ( acantholyse).
C hin tng thm nhim trung b nhng him.
+ V chn on t bo Tzanck : l phng php chn on c gi tr cho php chn on
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.
Nu tn thng ming rt c gi tr chn on ly ko ct bng nc, dng ngi bt
chng u co di y bng nc pht ln lam knh em nhum thng, soi thy t bo gai
hnh a gic.
Nu Duhring khi co em soi khng gp t bo gai m gp mt s t bo trung b.
Tn thng ph tng ch thy c khi m t thi.
Tn thng nhiu ph tng gan, thn, lch, tim, hch tu xng, phi v cc tuyn ni tit
nht l tuyn thng thn.
+ 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.
Xt nghim v m bnh hc thy c hin tng :
- Phng nc trong biu b.
- Hin tng ly gai ( acantholyse) do t mt cc th ni gia cc t bo biu b.
- Hin tng thoi ho mt s t bo thng b do men fermento proteclytique lm tan cc cu
ni t bo gai trn da bnh nhn.
- Thm nhim bch cu i toan.
- Min dch hunh quang trc tip thy IgG v C3 lng ng vng tn thng v da quanh tn
thng.
Mu : pht hin t khng th IgG . T khng th ny chng li glycoprotein 130 K da.
Min dch hunh quang trc tip da thy c IgG v C3.
- 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.
C mt thuyt t nhim c ( autotoxique) c a s cng nhn. Mt thuyt v yu t ni tit
cha r rng. Ngy nay chng minh r y l bnh t min, t khng nguyn l cc th ni (
desmosome) cc t bo gai, t khng th l IgG.
+ Chn on phn bit : chn on khc :
- 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.
- D ng c bit vi iodua: tetioder (+).
3.2. Ly thng b bng nc ( Epidermolysse bulleuse) : alf tt bm sinh gia nh bng nc
mc trn mt nn da bnh thng nhng sy ra vng da t . Thng tr s sinh ra l c ,
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.
3.3. Bnh chc ( Impetigo) : chc do lin cu ,bng nc mc trn mt nn da di vim .
Lc u trong 1-2 gi sau v ra ng li vy tit. Nykolsky (-), th tng t khi b nh hng.
3.4. Hng ban a dng th bng nc ( erytheme polymorphe ):
+ Tn thng c bn l mt sn ph. Trn sn ph gia c bng nc to nh tu xung
quanh mu ti, bng to nh nhiu hay t nc.
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.
Dng ko di phi ch bin chng lot d dy , hi chng cushing trng c.
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).
3.5. Pemphigus th si (Pemphigus vegetant ) do Neumann m t nm 1876.
+ Tn thng c bn l bng nc.
Bnh bt u ging nh pemphigus thng thng bng cc tn thng nim mc ming
hay trn da nhng hay khu tr vo cc v tr c bit : nch, bn, k mng, k di v, quanh
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.
Du hiu Nykolsky vn (+) quanh mng si.
Tnh cht c nng c nga, rt nhng tht thng tr tn thng nim mc ming rt au.
Mu : t bo toan tnh tng cao ( BC i toan tng ).
+ Tin trin bnh: bnh tin trin vi thng n nm tth t vong v suy mn, v bin chng
thn, tiu ho, h hp.
+ M bnh hc : bng nc trong bnh Pemphigus si ging bng nc Pemphigus thng
thng nm trong lp t bo gai nhng y bng nc ch xut hin rt sm giai on u .
V sau cc t bo gai b tng sinh v n tr nn si ln. Cho nn giai on sau khng thy c
bngnc m ch thy nhng tn thng si pht trin n su xung v pht trin b mt ca
thng b. C mt vi ni c cu to thnh nhng p xe nh. Trong nhiu t bo i toan.
trung b c thm nhim gm nhiu t bo i toan v hnh nh n ging vim da m thng
thng hoc ging vim da u chi lin tc Hallopeau.
V chn on t bo Tzanck thy nhiu t bo hnh trn hoc a gic.
+ V cn nguyn sinh bnh hc : l bnh t min. Pemphigus si ch l mt th ca pemphigus
thng thng do n pht trin trn c th c bit trn n si ln.
+ Chn on phn bit :
- Giang mai II si : sn cao hn mt da i khi si nhng sn chc (pemphigus si m vn mm
) ngoi si cn hi chng khc: hc, o ban, rng tc, phn ng huyt thanh bao gi cng (+) ,
son trng (+).
- Lao si ( tuberculose vericose) : c si chn, y tm, c t m khi bp, chm kim ng c
lao n tt xung nh nhng.
- Vim da m si : tn thng lc u l bng nc, m chc, vim da, mm bp ra c m ,
ton tng bnh thng, phi dng chn on t bo Tzanck phn bit l ch yu.
+ iu tr :
Dng coticoide, dng cc loi khng sinh hay dng aureomycin 1 g/ ngy ko di hng nm,
tetracyline, hay dng aureomycin k hp quinacrin.
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 .
3.6. Pemphigus rc vy ( Pemphigus foliac).
+ Tn thng c bn vn l bng nc. Bng nc rt nho nm lp thng b. Rt nng nn
rt d v l ra vt trt nng hoc to thnh vy l. Trn mt bng nc mc ht t ny t
khc, to vy ny chng ln vy kia ( Nikolsky (+) ). Tn thng lan ra ton thn nhanh chng
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.
Ging Pemphigus thng thng c ri lon chuyn ho nc, mui, m.
+ M bnh hc: bng nc hnh thnh ging nh cc loi Pemphigus khc nhng khu tr th
nng hn nhiu gn lp ht, ch yu l nm di lp sng nn phn cn li ca lp nhy 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
nng c hin tng ph nh , c thm nhim do cc t bo vim. Cc t bo toan tnh , i toan
c nhiu trong thng b, trung b , hnh nh t chc hc rt ging vi da bong vy thng
thng.
+ Cn nguyn : ging nh cc Pemphigus khc, cha r rt, a s xp ging cn nguyn ca
Pemphigus thng thng.
+ Chn on khc :
- Lc u cn phn bit vi Pemphigus thng thng v sau bong vy nhiu vy n chng ln
vy kia.
- Duhring : nhiu khi Pemphigus vy l lc u nh bnh Dhring, sau mi c nhiu vy l.
+ iu tr :
- Ti ch : thuc st trng.
- Ton thn : ch yu corticoid.
Thuc st rt tng hp nivaquin, quinacrine trong c nhiu t bo toan tnh.
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.
3.7. Pemphigus da m ( pemphigus sborheique).
Bt u ngi ln, u tin l bng nc hoc cc mng bong vy ging trong vim da
m: khu tr mt v c khi c hnh nh ging lupus. Cng c khi bt u l bng nc to
nh khng u , khng cng v ng ring r. Khu tr c bit vng c nhiu tuyn b nh
ngc, lng, v.
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.
Tn thng thng l ban , vy da, vy tit v I khi l bng nc,t gp phng nc v n
mng, d v nn ch thy cht, vy.
Khu tr nhiu vng c nhiu tuyn b: lng, vai, vng xng cng cnh mi, nch, di v,
da u, cn cc chi t b tn thng hn. Vy y thng dy v bong thnh tng ming.
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
rt ny cng rnh mi, m, cnh mi, trn, vng sau tai, da u.
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.
M bnh hc : c hin tng ly gai. Bng nc nm nng ngay di lp sng, trung b c
thm nhim.
iu tr : corticoid y km tc dng hn cc th Pemphigus khc.
Khng sinh c tc dng nht l aureomycin.


31. RNG TC

( Alopecia).
BsCK2 Bui Khanh Duy
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
thuc vo cc yu t ti ch v yu t di truyn. Bnh thng tc anagen chim 80- 90%,
catagen 5% v tc telogen 10- 15%. Hng ngy c 50- 100 si tc rng, s tc ny l tc c
thay th hng ngy.
2. Phn loi theo hnh thi:
2.1. Rng tc khng so (non scaring alopecia).
- Rng tc androgen di truyn. Androgenetic alopecia).
- Rng tc thnh m (alopecia areata).
- Rng tc kt hp b bnh ton thn hoc h thng.
Rng tc telogen (Telogen effluvium).
Rng tc anagen (Anagen effluvium).
Giang mai (syphilis).
- Do tt nh tc (trichotillomania)
- Rng tc kt hp vi cc hi chng di truyn.
2.2. Rng tc c so (scarring alopecia)
- Khuyt tt di truyn hoc pht trin.
- Nhim khun:
+ Vi khun:vi khun gy m, lao.
+ Nm : nm kerion.
+ Vi rt : zona.
+ Protozoa: leishmania (n bo).
- U sc t.
-Tn thng do ho hc, bng v rng tc do cc chn thng khc.
- Cc bnh c bit c tn thng da u: lupt , li ken phng, morphea, pemphigoid
thnh so.
3. Phn loi theo cn nguyn.
3.1. Rng tc thnh m (alopecia areata).
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
mnh, bc mu nh lng t, ra m c si gy ngn v mp gi l tc du chm than
(exclamation point hairs). Triu chng c nng : khng au, khng nga.
Rng tc vng u, c th rng vng ru cm v vng khc.
+ Chia thnh cc loi sau:
- Rng tc thnh m (alopecia areata).
- Rng tc th rn b (alopecia ophiasis).
- Rng tc ton phn (alopecia totalis).Ton b tc vng u hu nh b rng.
- Rng tc ton b (alopecia universalis).Rng tc vng u, rng c lng my, nch, mi, lng
mu, lng t ca c th.
Biu hin mng: lon dng, a mng c hng trm h lm nh nh" khu""ng t".
+ Tin trin: cc m n nh nguyn nh vy, thng mc li mt cch ngu nhin sau vi
thng, c khi xut hin cc m mi trong khi cc m khc ang mc li. Bnh cng thng ti
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).
Bnh cng thng ti pht.
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
lympho quanh nang lng tn thng ang hot ng.
Xt nghim tc (trichogram): cc si tc anagen lon dng tng t l tc telogen ti 40%
hoc hn (bnh thng < 20%),cc chn tc (hair zoots) hnh di cui, du chm than.
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.
- Cyclosporin: ung lm mc tc, khi ngng thuc bnh d ti pht.
- PUVA tr liu ( quang ho tr liu).
- 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. Rng tc androgen di truyn(androgenetic alopecia- AGA).
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.
T ng ngha: hi kiu n ng, hi thng thng ( common baldness), rng tc c tnh di
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.
Phi hp hiu qu ca androgen ln nang tc c t bm di truyn.
Bnh do di truyn a gien hoc autosome tri nam. Autosome ln n.
Phn ln bnh nhn (c nam v n) c ni tit bnh thng nhng ti ch c tng biu hin
ca cc th th ( receptors) androgen. C ch tc ng ca Androgen ln t bo nang lng dn
n AGA th khng r. Mt s bnh nhn c tng androgen.
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
vi nhau, hi hon ton pha trn, li cn li tc hai mt bn v sau gy thnh mt vnh t
trc ra sau.
n b rng lan to, tc mng tha i . n tr b AGA c cc du hiu nam tnh ho nh c
trng c, lng qu nhiu thnmnh v vng mt , kinh nguyt khng u. Tc vng AGA
mnh hn , ngn hn ,tr thnh lng t v teo hon ton.
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.
2.3.5 Tin trin t nhiu nm n hng chc nm.
2.3.6. iu tr: khng c phng php iu tr c hiu lc cao ngn s tin trin ca AGA.
Dung dch Minoxidil 2% bi ti ch lm gim rng tc v mc li tc, sau 4- 12 thng 40% mc
tc li. Phi hp nng cao minoxidil v retinoid ti ch s c kt qu tt hn.
Khng androgen: spironolactone, cyproteron acetate, flutamid v cimetidine .C ch tc dng
ca cc thuc ny l thuc kt hp vi th th androgen v chn tc dng
ca dihydrotestosteron .Thuc c tc dng n b b AGA,nhng khng dng cho n ng.
Tc gi ( Wig).
Cy ghp tc (hair transplantation). Chuyn cc ming ghp m nang lng t vng g vin
xung quanh( vng tc khng mn cm androgen) ti vng hi u mn cm androgen. Vi
ghp m ny l k thut thnh cng gip tc mc li.
3.3. Rng tc telogen (telogen effluvium ,Telogen defluvium).
3.3.1. nh ngha: l loi rng tc hng ngy tng dn, tc mng tha i.
Tng t l phn trm pha telogen (tc u ty) tc b chuyn nhanh t pha anagen
sang catagen v telogen.
3.3.2. Cn nguyn:
- C thai, sy thai, sinh .
- Chn thng ln, phu thut ngoi khoa ln, mt mu.
- Sau t m c st cao
- Sau n king, st cn trong thi gian ngn.
- Thuc trnh thai, gim nng tuyn gip.
- 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.
Mng c nhng ng hn ngang( ng Beau)hoc rnh, kha bn mng cc ngn tay,
ngn chn.
3.3.4. Xt nghim :
Trichogram (tc ): tng t l phn trm tc telogen(bnh thng t 10- 15%.).
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 Rng tc anagen(anagen effluvium )
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
sang catagen v telogen v rng i,
3.4.2. Cn nguyn :phn ln rng tc loi anagen gy nn do thuc, nhim c v ho tr liu.





Bng danh mc thuc gy rng tc.

Thuc c im rng tc
Cht c ch ACE Enalapril C th rng tc telogen
Thuc chng ng
Heparin
Warfarin
Mt vi thng bo gy rngtc t l thay
i t 19%- 70% rng tc lan to.
Thuc chng phn bo
Colchicine
Rng tc lan to, tng s tc telogen.

Cc thuc chng U
Bleomycin
Cyclophosphamide
Cytarabine
Dacarbazine
Dactinomycine
Daunorubicin
Etoposide
Fluorouracil
Hydroxyurea
Ifosfamide
Mechlorethamine
Melphalen
Methotrexate
Mitomycin
Mytoxantrone
Nitrosourea
Procarbazine
Thiotepa
Vinblastine

Rng tc Anagen
nt
nt
nt
nt
nt
nt
nt
nt
nt
nt
nt
nt
nt
nt
nt
nt
nt
nt
Vinoristine nt

Thuc chng Parkinson
Levodopa
Thuc chng ng kinh
Trimethadione
Thuc chn Beta
Metoprolol
Propanolol
Cc thuc trnh thai
Thuc trnh thai ung


Thuc dng trong iu tr ri lon lng cc
Lithium
Ngun gc nm ca g
(dng trong iu tr prolactin huyt gim)
Bromocriptin
Thuc chn H 2
Cimetidine

C l rng tc telogen

C l rng tc telogen

C l rng tc telogen
C l rng tc telogen

Rng tc lan to (rng tc telogen) 2-3
thng sau khi ngng thuc trnh thai ung.


C l rng tc telogen



C l rng tc telogen
Khi u 1 tun n 11 thng, c l rng

Kim loi nng ( c)
Thallium



Thu ngn v ch.

Thuc lm gim cholesteron
Clofibrate
Cht dit sinh vt c hi
Boric acid


Retinoids
Etretinate

Isotretinoin
tc telogen .

Rng lan to, tc anagen bt thng 10
ngy sau khi ung thuc tc rng hon ton
trong vng mt thng.c tnh r rt l rng
tc pha bn ca u v c lng my pha
bn
Rng tc lan to khi b phi nhim cp v
mn.
Him khi gy rng tc.


Rng tc vng u ton b sau nhim c
cp, vi phi nhim mn tnh, tc tr nn
kh v gy

Tng rng tc v tng tc telogen gim thi
gian pha Anagen
Rng tc lan to c ch c l ging nh
trn.


3.5. Rng tc c so. ( scarring alopecia, cicatricial alopecia).
3.5.1. Mt s bnh c tn thng gy nn so v nu n xut hin vng u nang tc b ph
hu hu qu gy nn rng tc c so ( scarring alopecia).
Rng tc loi ny c c tnh l tn thng c so. Tc b teo v nang tc bi h hi hay hu
hoi, do vim (nhim trng v khng nhim trng) hoc do b bnh l khc v khi khi xut
hin so. C th pht hin cc du hiu lm sng c trng ca bnh chnh vng rng tc.,
vng da xung quanh hoc vng da khc ca c th.
3.5.2. Phn loi rng tc thng so.
- 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):
Ung th t bo y (basal cell carcinoma),ung th t bo gai (squamous cell carcinoma).
Metastatic tumors (cc u di cn), lymphomas, u phn ph (adnexal tumors)
- Tc nhn vt l, ho hc.
Chn thng c hc (gm c do nhn to, tt nh tc trichotillomania),
bng, chiu x, cc cht n da, cc cht ho hc khc, cc thuc khc.
- Bnh da ngun gc cha chc chn v cc hi chng lm sng:luput dng a ( Discoid
lupus erythematosus) luput dng a c th c tn thng trn da u l cc m hnh
trn, c vy da l cc nt sng nang lng sau c teo d agy rng tc c so.
Liken phng ( lichen planus)
Bnhliken phng c th c tn thng vng da u l cc sn mu tm, c dng nt nang
lng v sau cc nt nang lng ny bin mt gy rng tc c so. Lupus mn, li ken
phng, sarcoi'dosis , x cng b: morphea, li ken x v teo, hoi t m i tho ng
(necrobiosis lipoidica diabeticosum), vim da c, Pemphigoi'd thnh so, bnh muxin nang
lng (follicular mucinosis). trng c so li, gi vim nang lng vng ru cm Pseudo folliculiti
barbae thng gp ngi da en, lng un cong mc ngc gy gi vim nang lng nhim
khun th pht, rng lng vng , vng gy chm gy rng tc, vim nang lng vng gy.
Vim quanh nang lng da u ho m ri rc.
- Amyloidosis (dissecting perifolliculitis of the scalp).
3.6. Bnh tc chui ht (Beaded hair, bnh monilethrix).
3.6.1. nh ngha: y l bnh ca tc m hu qu l do cc bin i dy thn tc ln mt cch
u n to thnh cc nt cc tc v c xu hng tc b gy, t on.
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.
C th quan st thy cc si tc dng chui ht bng knh lp.Trong cc ca bnh th nh th
kh pht hin cc si tc ngn bt thng xen k cc si tc di bnh thng, bnh nhn c
th pht hin tc bt thng bng cch s.
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.
3.7. Rng tc do giang mai.
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.
3.8. Rng tc do tt nh tc (trichotillomania).
L tt ca c ngi ln v tr em ,nht l nhng ngi lm vic tr c.
V tr : c ngi nh nh u, c ngi nh pha trc, thng thng hai bn thi dng.
Thng tn khng c ranh gii r rng, tc vng thng tn khng u ch cao ch thp ,cn
chn on phn bit vi nm tc: m vy c ranh gii, tc b gy cch da u mt vi mm,
chn tc c vy bao quanh (du hiu i b tt, nhng trong bt), xt nghim nm dng tnh.
Th nghim ko nh tc ( hair pluck) tng t l s tc Anagen v catagen ( v phn ln tc
telogen bbnhnhn nh i).
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
sinh k hp nu c km vim chn tc.
3.9. Rng tc do nm :
Rng tc do nm thng do chng nm Microsporum hoc trichophyton ngun gc ly t ngi
sang ng ( M ferrugineum, M.audouini, T.violaceum, T. craterioforme) hoct sc vtly sang
ngi ( M. lanosum, M.gupseum, M. equinum, T. gupseum, T faviforme...).
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.
Biu hin bng trnda u c m trn to nh khng u, ranh gii khng ph vy da mu
trng c, xen k gia cc gia cc tc lnh c nhng tc b xn ngn ch cn 1-2 mm, hoc b
xn ct st chn ch cn li im n nh 1 ht than khm vo da u ( trichophytie nng )
hoc thnh tng m rc vy nh da u , gii hn khng r rt, c xu hng lin kt vi
nhau c khi thnh m ln hnh nhiu vng cung ( microsporum c ngun gc t ngi ). Loi
nm tc Trichophyton thm nhim v mng m ngun ly t sc vt sang ngi, u c 1-2
m tn thng ranh gii r, vim mch, nhim cm, trn b mt y vy m l mt cm p
xe nh khu tr xung quanh chn lng cn gi l "p xe nang lng" m nn ra t cc nang lng
ging nh mt trong cc l tng ong cn c tn gi " kerion de celse", cn nu do Microsporum
c ngun gc t suca vt da u thng hcie c 1-2 m ln trn hay bu dc, ranh gii r,
c vy da trng mc nh rc tro. C khi bn cnh m ln c 1-2 m nh hn, ton b tc
trong m b xn ct ch cn cch da u 3-4 mm. im c bit l chn t c cht bt trng
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
r hoc tch ra trn b cc mng vy. Nghin Favus hnh a lm nh u n, trn, va
mm ng knh, g ln 2-3 mm trn da, bao quang mt chn tc, mu vng dim sinh rt c
bit, thc cht l mt khi si nm dy c, mi : chut c" di nghin Favus nn da hi lm,
nhn bng, vim ty t hay nhiu, c th coa lot m, tc b rng hoc tn thng Favus gy
so tri tc vnh vin.
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.
- Khm lm sng, ch tm c tn thng nm vng da khc.
- Lm xt nghim soi nm trc tip , cy nm.
- Soi nh sng n Wood thy nh sng hunh quang mu sng xanh.
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


32. SN NGA DO CN TRNG

1. V tr
Thng vng h:
- Do Rui vng: hai chn, hai tay.
- B cht: Hai chn quanh tht lng.
2. Tn thng c bn:
Sn ph: Lc mi b t l sn tt ( sn ph) vi mm ng knh, gia sn c im chm kn
mm dch hay rm mu, nga nhiu.
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
nga, tn ti lu di, dai dng, kh iu tr.
3. C nng: Nga tng cn nga nhiu
4. Dch t.
3. C nng: Nga tng cn nga nhiu
4. Dch t.
vng c cn trng ( rui vng, b cht ve, dm).
Chn on phn bit:
- Gh nhim khun: k ngn tay, ngn c tay, sinh dc ngoi tn thng l mn nc, ng
hang nga nhiu v m. Nh khu bt c ci gh.
- Vim da d ng c l nga, cy ci, nc sui: v tr vng h ckhi c thn hnh mu da
vim, c mn nc ri rc vt gi cht.
- Vim da m: Tn thng l mn m hay sn vim khu tr nang lng.
5. iu tr v phng bnh.
Ti ch:
- Sn tt ban u nn nh mu ra, chm cn It 1%.
- Sn cht nhim khun bi thuc mu (dd xanh metilen 1%, dd tm metin 1%) khi kh bi m
khng sinh + Corticoid ( Synalar - neomyin - celestoderum-neomycyn).
- 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
cloruacanxi 0.,50 tim mnh mch chm.
- Sn cc mc nhiu c th cho ung 1 t Prednisolon liu trung bnh nu khng c chng
ch nh.
- 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.
-Thuc c ch min dch:
Methotrexa c hi, ch dng cho cc ca 50 tui tr ln m c th kho mnh.
Sandimmun (cyclosporine) A) c hi, t tin:
Retinnids ( Tigason) nhiu tc dng ph c hi.
- 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.
Mn nc phn b ri rc hay thnh m cm.
Triu chng c nng:
- Nga nhiu:
- Hay ti pht, thng ti pht vo ma h.
- Do nga chc gi lm xut hin mn m, vt cht, bn tay chn c kh sng ty nhim khun
th pht, hch nch, bn sng ( t a nhim khun).
2. Th lm sng
- T a th gin n: tn thng l mn nc su v tr trn.
- T a nhim khun: c mn m, cht lot, sng vim ty.
- T a th kh: lng bn tay chn c m rc vy.
3. Chn on phn bit
+ Gh:
V tr k ngn tay, ngn c tay.
Tn thng l mn nc ng hang.
Nh khu bt c ci gh.
Nga nhiu v m.
C tnh cht ly lan.
+ Eczema bn tay, bn chn:
V tr thng mt lng (mu) bn tay chn.
m , nn c mn nc nh, nng chi cht, t v.
m tn thng cht chy dch.
Lu ngy liken ho dy cm.
(t a khng bo gi liken ho).
4. iu tr
- Ti ch:
+ Mn nc n thun bi cn focmolsalicylic 3%.
Mn m, cht bi thuc mu(dd tm Metin 1% , dd xanh metilen 1%).
Khi tn thng kh bi m corticoids (Flucinar, synalar)
Ton thn:
- Nu c bi nhim cho ung mt t khng sinh.
- Khng sinh Histamin tng hp: Histalong 10 mg /1 vin /ngy.
- Vitamin c 0,50 2 vin/ ngy hoc ascorvit 500mg 2ng/ ngy tim tnh mch chm.
- ng y: xng khi thng trut 5 pht ( bn tay, bn chn).
Ch : Gia bn tay bn chn kh sch.
Hn ch x phng.
Trch nhim ngm nc nhiu, bn, phn gio t ct.
- Mt s trng hp t a cn nguyn do nm th cho dng khng sinh chng nm
Griseofulvin 0,502 vin / ngy x 30ngy.
- 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
ban u ( v d s c dc cht huyt thanh, mu hoc m ca mt bng nc, mt mn nc
hoc mt mn m dn n s hnh thnh mt vy tit).
+ Mun chn on bnh ngoi da phi bit phn bit, phn tch tn thng c bn.
+ C nhiu cch phn loi tn thng c bn.
2. Phn loi: thng chia thnh 2 loi :
tn thng c bn nguyn pht v tn thng c bn th pht
2.1.Dt(macule),dt l tn thng thay i mu sc da:
+ Nhn thy c do thay i mu sc
+ Khng s thy c v khng g cao trn mc da.
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.
Nguyn nhn gy ra dt vim, ban (erythema) rt khc nhau, v d ban trong d ng
thuc, o ban (roseole) trong giang mai II cng l mt loi dt vim.
2.1.2. Dt khng vim:
Khng do qu trnh vim, c thay i mu sc da, n knh khng mt dt.
Dt sm mu:nh trong bnh xm da, tn nhang.
Dt bc mu:nh trong bch tng (albinos) v bch bin (vitiligo).
Dt xut huyt (purpura) n knh khng mt dt.
Gin mao mch di da (telangiectasie).
Dt do xm tr vo da (tattoo).
2.2- Tn thng lng:
+ G cao trn mc da, cha thanh dch, c khi c m hoc mu.
+ Hnh trn hoc bn cu.
+ Nng hoc su, d v hoc kh v, khi v li vt trt, ng vy tit, lnh thng khng
li so.
2.2.1. Mn nc (vesicule): kch thc bng u ghim, ht k,1-2mm ng knh, bn trong
cha dch. Mn nc trong bnh eczema nh bng u ghim, nng, t v, san st bn nhau
kn khp b mt thng tn, n t di ln ht lp ny n lp khc. Mn nc trong bnh t
a (dyshidrosis) l mn nc su kch thc1-2mm nh khm vo da.
2.2.2. Bng nc (bulla): kch thc vi mm n 1-2 cm nh trong bnh zna, bnh duhring-
brocq...
2.2.3. Phng nc (phlyctena): kch thc vi cm ng knh, bng qu cau, qu trng g nh
trong bnh pemphigus, d ng thuc th phng nc.
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.
2.3- Tn thng chc:
G cao trn mc da.
Nn chc, chc ra khng c dch.
2.3.1- Sn (papule): l tn thng chc, g cao trn mt da.
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
trung b c ng sn phm bnh l (bnh u vng).
+ 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.
2.3.2- Sn my ay (urticaria, wheal):
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.
+ Mu hng hoc mu da, trung tm c khi nht mu hn.
+ Kch thc vi mm, 1- 2 cm c khi lin kt thnh mng ln vn vo nh hnh bn .
+ Thng km theo nga d di.
+ 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.
Cc vim nh gm giang mai III, thng lot li so.
2.3.5- Gm (gomme):
L cc nhng tin trin qua 4 giai on: cng, mm ra, v m lot v lnh so.
V d: gm giang mai III.
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.
2.4- Tn thng mt da: do mt s ton vn ca da, nng hoc su.
2.4.1- Vt trt (erosion): l tn thng mt da ca biu b nhng khng vt qu mng y,
thnh tng im hay m, mng trt, , rm dch, rm mu do xy xt, ng, hay do tn thng
lng v ra to thnh trt, do bc vy tit, ch nng biu b, khi khng li so .
2.4.2- Vt lot (ulcer): do mt da n chn b hoc h b, do tin trin ca c, cc hoc do
nhim khun da m thnh, khi li so, cn m t nn vt lot, c m hay n tht,b vt lot
c ngc ngch hm ch khng ?, xung quanh mm hay cng,c tm ti khng.
2.4.3- Vt nt n (rhagades), vt rn da (vergeture): do da b cng dn t ngt hnh thnh
ng ,vt nt nng hoc su, rm mu. V d: nt n gt chn, rn da bng ph n cha
.
2.4.4- Vt xc (excoriation): su n chn b nhng thng gn, thnh ng, vt, rm mu.
2.5- Tn thng d rng:
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.
2.5.2- Vy tit (crust): do dch, mu, m mn nc, mn m, vt lot kh ng li m thnh
vy tit, mu vng, sm hay nu en, c khi n cao gi l vy c ( rupia) trong bnh chc
lot (ecthyma).
2.6. Tn thng th pht:
Cc tn thng th pht ni phn trn nh vy da, vy tit, vt trt, vt lot, vt xc, vt
nt, vt rn da. Cn mt s tn thng th pht sau:
2.6.1- So (scar, cicatrix):
Cc tn thng mt da n chn b v h b khi lnh li so, c loi so phng, c loi so
teo, lm nh trong bnh lu pt , c loi so li, so ph i nh trong bnh so li (keloids),
so c cu da ngc ngch nh trong bnh lao da.
2.6.2-Teo da (atrophy): thng b mng i, lp y c xu hng thnh ng thng, da mng,
bng. V d: teo da trong bnh phong, luput mn.
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.
2.6.4- Liken ho (lichenification).
Da dy ln, thm mu, nhim cm, hn da ni r, s cng cm, b mt th rp,l hu qu ca
bnh da nga mn tnh, ch xt, co gi lu ngy. V d: eczema mn liken ho, vim da
thn kinh.
2.6.5- Vt sm mu, vt bc mu: vt sm mu hnh thnh do tng sc t melanin,vt bc mu
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.
+Trn mt bnh nhn tn thng c th n dng hay a dng
+ Cn khm xt t m, ton din, phn tch v tr, kch thc, mu sc, hnh dng, cch sp xp,
phn b, mt ... gip cho chn on chnh xc.

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).
1.2. Gii thiu vi nt v vi nm:
+ Nm l mt loi thc vt h ng, khng c dip lc t nn khng tng hp c cht hu c,
phi sng nh vo cht hu c ca sinh vt khc bng cch hoi sinh hoc bng cch sng k
sinh vo vt ch (pazazita).
+ 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.
1.3. Phng thc ly truyn:
Ngi ta b bnh nm do cc phng thc sau:
+ Nhim bo t c trong thin nhin t ct, khng kh, cy c mc nt...)
+ Ngi bnh ly sang ngi lnh (ng chung, dng chung ), y l vc t chnh.
+ Sc vt (ch, mo) b bnh ly cho ngi.
1.4. iu kin thun li mc bnh nm:
+ Nm d pht trin pH 6,9-7,2 hi kim do ngi ta hay b bnh nm da np k.
+ da b xy st, da kh, ri lon cu to lp sng.
+ Nhit 27-30
0
C
+ V sinh thiu st, mc o lt qun cht.
+Ri lon ni tit (candida), suy gim min dch, dng khng sinh lu ngy, dng thuc c ch
min dch.
1.5. Min dch trong bnh nm da.
+ C th a d "bt nm" (lin quan yu t m hi, tuyn b, cu to lp sng...)
+ 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.
1.6. C cu bnh nm da.
Theo Nguyn Cnh Cu ( 1994) , khm 5663 qun nhn c 2634 ngi b bnh ngoi da (
chim 46,51%). Trong c cu bnh nh sau :
Bnh nm da chim 37,31%.
Bnh lang ben chim 14,12%.
Gh : 13,17%.
Vim da lin cu 11,84%.
Ecema 3,15%.
Cc bnh ngoi da khc 15, 86%.
1.7. Phn loi bnh:da vo tnh cht v c im ca nm gy bnh chia thnh cc loi sau:
- Nm ch gy nhim lp sng (Keratomycoses)
Nm lang ben.
Nm vy rng.
Trng tc.
- Nm da (Dermatomycoses).
Epidermophytie.
Trichophytie.
Microsporie.
- Cc bnh gy nn do nm Candida.
- Cc bnh nm h thng: gy tn thng da,t chc di da, ph tng.
2.Mt s bnh nm da thng thng:
2.1 Nm hc lo: gm nm bn, nm da thng, (tr nm tc, nm k, nm mng). Bnh
thng b vo ma h.
- Cn nguyn: gy nn do Epidermophyton, Trichophyton hoc Microsporum.
- V tr: thng xy ra cc np k ln, thng np bn 2 bn, k mng,tht lng, nch, np
v ph n, thn mnh, cc chi, i khi xut hin c gy, mt.
-Tn thng c bn: ban u khi nhim nm trn da xut hin m hnh trn nh ng xu
ng knh 1-2 cm sau lan to ra, v sau cc m tn thng lin kt thnh mng ln bng lng
bn tay hay to hn na, c hnh a cung.
-Tnh cht: m c b vin ranh gii r, b g cao trn mt da, b c mt s mn nc nh li
ti, gia m tn thng c xu hng lnh, hi bong vy da. Tn thng pht trin li tam dn ra
ngoi vi.
-Triu chng c nng: nga, c bit khi nng, ra m hi th rt nga kh chu.
-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
hin mt s mn m trn m tn thng nm.
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...
Nm da mn tnh: b mt tn thng thm mu, gii hn tn thng km r rt, chn on
kh, c khi xt nghim nm m tnh.
- Chn on cn lm sng:
Cn co vy da t tn thng xt nghim soi tm si nm hoc em nui cy bnh phm
xc nh loi nm.
- Chn on phn bit: cn chn on phn bit mt s bnh da sau:
+ Phong c: v tr h, gii hn r nhng b l c nh, mt cm gic, xt nghim nm (-)
+ Vy phn hng Gibert 1/2 trn, m m, m con, m c gii hn, vin, vy mng ra m.
+ Vy nn: cm , gii hn r, nhiu vy trng
+ Nm da mn vi eczema mn cn chn on phn bit
iu tr :
3.1. Nguyn tc: pht hin sm, iu tr kp thi trnh ly lan trong n v ri mi iu tr.
iu tr phi bi ng phc , thi gian, lin tc.
iu tr nm da 3-4 tun, nm mng 3-6 thng.
-Trnh co da trc khi bi thuc, nu khng dn n d ng v nhim khun ph.
- Khi nm ly truyn trong tp th th phi iu tr hng lot, iu tr t kch
- Bi thuc ng nng d thch hp.
- 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.
- iu tr bi: Cn BSI 1-3% hoc cn ASA 1-3% kt hp vi m benzosali.
ng y : dng cn l mung tru, l cht cht, r cy bch hc 30- 50% iu tr nm hc lo c
tc dng.
2.2.. Nm k chn:
- V tr bnh thng thy xut hin k ngn c bit hay gp k ngn chn.
- Cn nguyn: do cc loi Epidermophyton, Trichophyton gy nn. Bnh hay gp ngi li
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).
Trng hp do loi nm Trichophyton th tn thng thng , rc da gt chn, ra bn
chn, cc k chn, v c khi c mn nc su hoc c tn thng mng, mng s mn trng
vng...
Cn ch chn on phn bit vi cc bnh da khc: sng bn chn, t a th kh, eczema
tip xc...
3.iu tr :
3.1. Nguyn tc: pht hin sm, iu tr kp thi trnh ly lan trong n v ri mi iu tr.
iu tr phi bi ng phc , thi gian, lin tc.
iu tr nm da 3-4 tun, nm mng 3-6 thng.
-Trnh co da trc khi bi thuc, nu khng dn n d ng v nhim khun ph.
- Khi nm ly truyn trong tp th th phi iu tr hng lot, iu tr t kch
- Bi thuc ng nng d thch hp.
- 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.
2.3 Nm lang ben: (Pityriasis versicolor, Malassezia furfure).
- Cn nguyn: bnh do nm men pityrosporum ovale gy nn.
Thng gp ngi tr, thanh thiu nin. Tn thng thng b 1/2 ngi pha trn nh
c, vai, ngc, lng, cnh tay, c khi lan xung i. Tn thng ban u l cc chm, vt hnh
trn ng knh 1-2 mm trng ging nh bo tm, n khp vi l chn lng, thng c mu
trng, hng (nht l khi i nng khi ra m hi th mu thng m hn, i khi c mu nu. Cc
thng tn lin kt vi nhau to thnh cc m c hnh vn vo, hnh bn , gii hn r, khi
co bong t vy cm (du hu v bo).
- Triu chng c nng: nga, nht l khi nng ra m hi hay i nng v, nga rm ran.
- Tin trin:hay ti pht do bo t cn st li trong nang lng,t ly lan.
- Cn lm sng: chn on xc nh cn co vy da xt nghim tm on si nm hay t
bo nm men.
- 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.
iu tr phi bi ng phc , thi gian, lin tc.
iu tr nm da 3- 4 tun, nm mng 3-6 thng.
-Trnh co da trc khi bi thuc, nu khng dn n d ng v nhim khun ph.
- Khi nm ly truyn trong tp th th phi iu tr hng lot, iu tr t kch
- Bi thuc ng nng d thch hp.
- 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.
Phng php Demianovich:
Bi dung dch Hyposunfit Na 30% sau 2-3 pht bi tip dung dch HCL 3% to dim sinh iu tr
lang ben, gh.
- Bi cn BSI 2%, hoc cn ASA kt hp bi m bezosali 15-20 ngy, Mercurobutol thuc bi
mi hiu qu cao, hoc bi kem Nizoral, Trosyd, Lamisil. C th tm x phng Nizoral, Kelog,
Sastid iu tr lang ben.
Trong ng y c th dng ging gi ngm dm thanh bi.
Phng php Demianovich:
Bi dung dch Hyposunfit Na 30% sau 2-3 pht bi tip dung dch HCL 3% to dim sinh iu tr
lang ben, gh.
2.4. Nm vy rng: bnh Tokelau
-Cn nguyn: do nm Trichophyton concentricum hay gp min ni nh ty Nguyn,
Trng Sn
-Triu chng lm sng: khi nhim nm xut hin nhiu vy da, vy bm trn nn da bnh
thng, tn thng da khng vim, khng c mn nc. m da tn thng c hnh trn ng
tm, xp ln nhau nh ngi lp, vy da mng nh v khoai ty, mt b bm vo da, mt b t
do bay lt pht, tn thng thng xut hin lng, ngc, bng, cnh tay.
-Triu chng c nng: nga nhiu lm mt ng dn n suy nhc thn kinh.
-Tin trin: khng bao gi t khi, mang tnh a phng, d ly lan trong gia nh, cn phi
iu tr kp thi.
- Chn on cn lm sng:cn xt nghim vy da tm si nm
- Chn on phn bit: cn chn don phn bit vi bnh da vy c.
iu tr : tm nc x phng cho b vy bi cn BSI 2% hoc cn ASA kt hp bi m
benzosali v ung Griseofulvin 0,25%x4 vin/ngy x 1 thng, c th ung Nizoral hoc Sporal.
2.5. Nm mng:(Onychomycosis).
- Cn nguyn: thng do cc loi trichophyton hoc microsporum gy nn.
- V tr: thng xut hin mng tay v mng chn.
-Triu chng lm sng: b mt mng sau lan dn ra cc mng khc (hng thng). Thng b bt
u b t do ca mng hoc gc mng ra, khi c m nm mu bn tay lan xung. Tn
thng ban u thng c im trng, mng mt bng, im trng c hoc hi vng to
dn, mng trng mn hoc mu vng mn ra nh rut sy. Mng dn dn b n vt, x x bin
dng, i khi tch khi nn mng.
- Chn on cn lm sng: cn co vy mng em soi tm si nm hay bo t t.
- 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
0
C, 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.
+ Ung thuc: Thng I Gricin 4 vin/ngy.
Thng II cch nht.
Thng II : tun 2 l.n
Tng liu 220 vin.
+ iu tr nm mng bng Spozal Ngy ung 2 vin Spozal 0,1 g x 2 ln/ngy, ung lin tc 7
ngy sau ngh 3 tun ung lp li nh trn. Nm mng tay ung 2-3 t, nm mng chn ung
3 hoc 4 t.
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
lc. Khi nhim nm th dc theo thn tc c cc ht nh bng ht vng mu en bm cht vo
thn tc. Cc ht nh chnh l si nm v bo t t to nn rt cng v chc lm gy thn tc.
Nm lan t si tc ny sang si tc khc.
- Triu chng c nng: khng nga nhng lm ngi bnh kh chu.
- 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 :
+ Trng tc: gi u x phng nc m,chi m benzosali, hoc gi u x phng Sastid,
Nizorral hay Kelog.
2.6.2. Nm tc do microsporum hoc trichophyton: Trn da u c cc m , hnh trn, hnh
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 on cn lm sng: xt nghim co vy da hoc nh chn tc em soi tm si nm.
Chn don phn bit: trn lm sng cn chn on phn bit vi cc bnh sau:
- Rng tc pelade.
- Rng tc da du.
- Vim chn tc.
- Chc do lin cu.
+ iu tr : nm tc do Trichophyton, Microsporum th nh si tc bnh, chm cn it 2%, bi
thuc mu v ung Grisefoulvin 1g/ngy x 1 thng, c th bi kem Nizoral, Lamisil,Tryd hoc
ung Nizoral hay Sporal..
3. iu tr v phng bnh nm da:
3.1. Nguyn tc: pht hin sm, iu tr kp thi trnh ly lan trong n v ri mi iu tr.
iu tr phi bi ng phc , thi gian, lin tc.
iu tr nm da 3-4 tun, nm mng 3-6 thng.
-Trnh co da trc khi bi thuc, nu khng dn n d ng v nhim khun ph.
- Khi nm ly truyn trong tp th th phi iu tr hng lot, iu tr t kch
- Bi thuc ng nng d thch hp.
- 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:
Tun 1: cn BSI 2% bi sng, chiu, mt ln
Tun 2: sng bi BSI 2%, chiu bi m benzosali
Tun 3 : m benzosali bi ngy mt ln cho n khi khi, mn da .
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.
3.4. phng bnh:
- Pht hin sm, iu tr kp thi trnh ly lan trong n v nhiu ri mi iu tr.
- Tuyn truyn VSPB, nhc nh np sng v sinh, gi kh cc np k, trnh mc qun o lt
cht...bng ni lon, cn ct mng mng tay, ct tc ngn, gi kh cc np k sau khi tm.
Rc bt phng nm, tm cht chng nm vo qun o....

36. XT NGHIM CHN ON NM GY
BNH

1. Phng php xt nghim trc tip.
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.
Trong cng tc xt nghim nm cn lu iu kin v sinh dng c v khng kh xung quanh
ni lm xt nghim , v trong khng kh cc bo t v si nm tp thng xut hin. Nu khng
ch v sinh sch s d ly nhim nh hng n kt qu xt nghim.
Mt s yu t c lin quan n kt qu xt nghim.
+ 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 m tn ti trn da khin trong vi trng c nhiu ht m kh xem, lm cn tr tm
nhn ca ngi quan st.
+ cc thuc mu lm cho da b nhum mau, xanh hay tm, , lm che khut cu trc ca vi
nm.
+ Ngi quan st soi phi c nh hng trn c s tm tt ca lm sng.
1.2. Xt nghim nm ngoi da soi di knh hin vi.
1.2.1. Bnh phm xt nghim trc tip nm ngoi da c th l tc, lng,vy da u, vy da
mt, chan, tay, bng, bn, k chn, mng tay,v.v... vy da bnh phm c ly t cc ni vim
nhim nghi c nm, bnh phm thng c ly ti phng xt nghim nm.
1.2.2. Dng c phng tin.
Dao u nhn, dao trch, ko, kim, que cy, phin knh sch, lame, gc, bng cn 70
o
C, n
cn t. Knh hin vi.
1.2.3. Dung dch, ho cht.
+ Dung dch nhum gram xt nghim trc tip nhum nm h thng.
+ Dung dch KOH 20% xt nghim nm da.
+ lm tiu bn xt nghim c trong, gi tiu bn c lu di phc v xt nghim v hun
luyn th dung dch KOH c thm glycerin theo cng thc sau hoc dung dch DMSO.
Dung dch KOH 20% :
- KOH 20 gam ; glycerin 20 ml + nc ct va 100 ml.
- Dung dch DMSO.
Nc ct 60 ml. KOH 20 gam. Dimetyslfoxide 40 ml.
1.2.4. Phng php tin hnh .
+ 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 70
o
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
ngn n cn, ta h i h li nh nhng cho nng, khng si bt ri ngui sau em soi.
Ch : khi soi quan st bnh phm phi u khp cc vi trng tm si nm. Si nm , on
si nm hay bo t t c th bc l trn cc m t bo sng ca t chc da hoc ng ring
r tch ri khi t bo da, cn phn bit si nm vi cc si khc. Si nm thng cong queo,
ngon ngoo mm mi c khi phn nhnh v chit quang hn, thnh si nm thng dy trng
ging si " min n".
+ Tr li kt qu :
- Soi c si nm, on si nm hoc c bo t nm.
- Hoc : khng thy si nm, on si nm hoc khng thy c bo t nm.
Trng hp cn xc nh loi nm th phi nui cy phn lp ri nh danh loi nm.
1.3. Xt nghim trc tip nm " h thng".
Nm h thng thng l nm men hay nm si gy bnh trong cc t chc ca c th ngi,
c ly bnh phm ri nhum gram.
1.3.1. Ly bnh phm :
Phng tin xt nghim trc tip nm h thng.
+ Knh hin vi c vt knh du.
+ Dung dch nhum gram gm c 4 dung dch sau:
- Dung dch 1 : crystalviolet
. Crystalvioet 2%.
. Cn etylc 20%.
. Oxaltamonium 0,8%.
- Dung dch 2: Lugol.
. Iod 1,3%.
. KI 2%.
. Polyvinylpyrrolydon 10%.
- Dung dch 3 :Alcol.
. Alcohol etylic 95% .... 50%.
. Aceton.........................50%.
- Dung dch 4 : Safranine
. Safranine.......... 0, 25%.
. Alcohol 95.........10 %.
Du bch hng soi v xy len lau tiu bn.
Thng do cc khoa ly bnh phm trc tip t bnh nhn gi n phng xt nghim nm
trong cc dng c tm bng, ng nghim, phng tin v trng. Bnh phm c th l m,
dch nim mc li, dch hng, dch ph qun, m tai, d mt, dch no tu, phn, dch m o,
niu o , mu hoc cc ni vim nhim khc cc t chc trong c th hay ngoi da.
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 ri soi tm nm.
1.3.4. Kim tra soi tiu bn bnh phm v nh gi kt qu.
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
dng mc chi vi mu tm m. Nu l si nm thng l cc on si mm mi, cong
queo, c khi thy bo t nm.
Ch : cn phn bit vi cc t bo khc c trong bnh phm .
Trng hp nghi ng th phi ch kt qu nui cy. Trong xt nghim nm h thng ngi ta
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.
2. Phng php nui cy nm da gy bnh.
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
thch hp nm pht trin thnh nhng khun lc nm, ri da vo cc c im i th v vi
th xc nh loi. Mt s trng hp phi da vo tnh cht sinh ho hc ca tng loi mi
nh c loi nm theo kho phn loi. Thng ngi ta ly bnh phm nghi nhim nm vo
mt s mi trng nh mi trng matala, mi trng sabouraud, mi trng czapex Dox, mi
trng huyt tng.
2.1. Nui cy nm da.
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 28
o
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
loi nm gy bnh ngoi da ngi ta thng da vo c im hnh dng ca cc c quan sinh
sn v tnh v hu tnh ca nm.
2.2. Nui cy mt s loi dng nm men.
Trong vic xc nh mt s loi nm men nh cc loi candida, ngi ta thng cy bnh phm
vo mi trng sabouraud, mi trng malata, mi trng huyt tng c thm khng sinh,
nhit 28
o
C, thng sau vi ngy nm pht trin thnh khun lc, khun lc dng nm
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
candida albicans chim u th nhiu hn c so vi cc loi candida khc. Gn y chng ti s
dng mi trng huyt tng n gin nui cy xc nh nm men candida nhanh chng v
tit kim c mi trng ho cht.
Thnh phn mi trng huyt tng.
Huyt tng ly t mu ngi 100 ml b xung vo 100 mg clorocit ri ng vo ng nghim v
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 37
o
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".
3. Chn on nm gy bnh bng phng php huyt thanh.
Nguyn l : cng nh vi khun, vi rt trong chn on mt s loi nm gy bnh h thng ngi
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
khng th c hiu ring bit nh cc loi nm candida albicans, aspergillus, histoplasma
capsulatum, blastomyces dermatitidiss, cn i vi nm ngoi da th ng dng phng php
trn cha c ph bin v tnhc hiu ca khng nguyn km, mt khc cn ph thuc vo
kh nng ng thm nhp ca mm bnh.
Trong chn on huyt thanh i vi nm gy bnh thng s dng phng php khuych tn
trn thch ( diffussion) v phng php in di min dch ( Immunoelectrophoressis), hoc
phng php min dch hunh quang gin tip (IFA).
5. Chn on nm gy bnh bng phng php gy bnh trn ng vt.
y l phng php cng c dng trong chn on nm gy bnh. Nguyn tc ca phng
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
trng vi mt t nc mui sinh l 9 %o v trng c cha khng sinh to thnh mt hn dch.
Sau tim hn dch vo mt trong cc c quan ca ng vt nh : tinh hon, tnh mch,
bng, di da v.v... v theo di ng vt mt thi gian, sau m ng vt quan st cc c
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
hng ngy. Nu trong bnh phm c nm da th s gy bnh ngoi da ng vt thc nghim
da

37. CHNG MT (ROSACEA)

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
cn bng mt v v sau l gin mao mch.
- 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.
Cn nguyn cha r, thng c vai tr ca mt s yu t nh:
-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.
- Khi i nng, un bp gn l nng chng mt trm trng thm.
- C th mt thi gian di trc b trng c.
- C khi b chng mt m trc khng c trng c hoc da du.
3. Triu chng lm sng:
V tr : vng m, mi, cm, gia mi, trn.
Tn thng thng gm 4 giai on:
Giai on 1 : c cc cn bng mt ( flushing, blushing), c cm gic nng mt, cm gic
nh ung ru, mt tng lc cn gi l th a Rosacea.
Giai on 2: chng mt, ban dai dng thng xuyn vng m, mi, km theo c dn mao
mch (telangiectases).
Giai on 3: ban dai dng thng xuyn, dn mao mch, c cc sn v mn m, sn
hnh trn 2-3 mm, mn m nh < 1 mm.
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.
Bnh ko di nhiu thng, nhiu nm c th km theo tng sn tuyn b v ph bch mch lm
bin dng mi, trn, quanh mt, tai, cm. C khi b c vng c, ngc, lin b, lng, da u.
c bit c khi thnh mi s t (Rhinophyma) mi to, ,sn si. Tng sn tuyn b vng trn,
quanh mt, cm.
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,
lymphocytes, mt vi t bo khng l, vi cc mn m c bch cu a nhn nang lng ( giai
on 3). Tng sn lan ta m lin kt, tng sn tuyn b, u ht dng biu m, t bo khng l,
khng c b u ha ( giai on 4).
5. Chn on v chn on phn bit :
+ Chn on thng khng kh khn.
Da mi m , gin mao mch.
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.
+ Chn on phn bit:
-Trng c thng: thng c sn vim , nn c nhn trng c, hoc c thm mn m, khi
vim ty, nang bc cha m, cht b.
- Vim da da du : vng rnh mi m, m, gia 2 lng my da vim , cm nh, c vy
m, c th c sn.
- Lupt h thng: ban vng mi m,hi n, st, mt mi, rng tc, st cn, au
khp, tn thng thn, khng th khng nhn (+).
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 :
Ti ch bi Metronidazol gel 0,75% 2 ln/ ngy hoc bi m khng sinh :erythromycin
gel.
- Gin mch ,mi s t t Laser CO2 , t in.
- Th sn m khng p ng khng sinh c th do Demodex folliculosum cho bi kem Eurax,
dung dch Lindane hoc x phng c lu hunh v salicylic acid.
Ton thn :
Metronidazol 250 mg 2 vin/ ngy.
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.
Hoc Doxycyclin 100 mg 2 vin/ ngy hoc Minocin 50 mg 2 vin/ ngy.
( Ung Doxycyclin l thuc c th c hin tng quang c (phototoxic) nn ung v ma h i
nng cn che nng).
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 :
Trnh ung ru v ung nng.
Trnh xc ng cng thng thn kinh.

38. SC PHN V
1.nh ngha:
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 ,
khi khng nguyn vo ln th 2 xy ra phn ng kt hp khng nguyn khng th lm v t bo
mast gii phng histamin v mt s cht trung gian ha hc nh acetylcholin, serotonin,
bradykinin m bnh cnh ch yu l t nhim c histamin.
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.
- Chng vim khng Steroid, h nhit, gim au.
- Vc xin, huyt thanh.
- Ni tit t.
- Mt s loi vitamin
+ Do thc phm : sa, trng , c, tm
+ 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
tin. Liu lng d nguyn xm nhp vo c th khng c ngha quan trng.
- 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 ).
- Trong cc trng hp suy h hp do ph np thanh qun v cy kh ph qun , kt hp vi co
tht d di cc c trn ng h hp dn n ngt, kh th, nim mc ph qun xung huyt v
xut tit, kh c th dn ti ph phi cp.
- Bnh nhn ht hong, bn chn, s hi, da ti lnh, v m hi thm ch co git, ng kinh
lin tc.
- 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.
Ngng ngay ng tip xc vi d nguyn ( nh tim, ung , bi, nh mt, mi ).
Thuc Adrenalin l thuc c bn chng sc phn v.
- Adrenalin ng 1 mg. Tim ngay, tim di da, theo liu sau :
+ 1/2 n 1 ng ngi ln.
+ Khng qu 0,3 ml tr em ( hoc pha ng 1 ml ( bng 1 mg) + 9 ml nc ct thnh 10 ml .
Sau tim 0,1 ml/ 1 kg cn nng ).
+ Hoc Adrenalin 0,01 mg/ kg cn nng cho c tr em ln ngi ln.
- Tip tc tim Adrenalin liu nh trn c 10 - 15 pht / 1 ln cho n khi huyt p tr li bnh
thng.
- m, nm u thp, theo di huyt p 10 - 15 pht / 1 ln.
- Nu sc qu nng , e da t vong , ngoi ng tim di da c th pha long ng
Adrenalin vi 9 ml nc ct ri tim vo tnh mch, bm qua ng ni kh qun hoc tim qua
mng nhn gip.
-Cc thuc khc :
- Depersolon 30 mg x 1 n 2ng tim bp tht hoc tim tnh mch.
- Dimedrol 1 %o x 1 n 2 ng tim bp tht.
Hai thuc ny tim ngay sau khi tim mi Adrenalin u tin.
Ch thng kh , thi ngt , th oxy ,h hp h tr ( bp bng), m kh qun nu cn thit.
- Nu bnh nhn vn cha thot c sc th : thit lp mt ng truyn tnh mch Adrenalin
duy tr huyt p, bt u bng 0,1 microgam /kg / pht. iu chnh tc theo huyt p (
khong 2 mg Adrenalin / 1 gi cho ngi ln khong 50 kg ).



39. ECZEMA

Eczema cp tnh E bn cp Eczema mn
m mu vim vi mm n
10-20cm
Mmn nc nh kn khp b mt
cht,
chy dch.
m mng gim vim ln
da non.
Mu hng bng
m mng thm nn cng cm
x x
A. Chn on eczema
1. V tr: bt k k vng da no cng c th b eczema.
2. Tn thng c bn.
m vi cm ng knh n 10-20 cch mng, ng knh gii hn khng r, n nh. Trn
b mt m c mn nc c c im sau:
- Mn nc nh bng y tm u kim.
- Nng, t v.
- San st bn nhau, chi cht khp b mt thng tn.
- n t di ln ht lp ny n lp khc.
- Mn nc v thnh im cht (ging eczema) nhiu im cht lin k thnh m cht.
Cht chy dch l eczema cp, nu bi nhim c m vy tit.
- Eczema bn cp: m tn thng gim gim kh dn, ln da con.
- Eczema mn liken ho: do nga gi b bnh lu ngy, da dy cm thm mu, hn da ni r,
b mt cng cm, th rp.
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.
Trc ht chn on l mt eczema theo cc yu t ni trn, sau da vo c im ca
tng eczema.
1. Eczema vi khun.
- Thng b cng chn 1 bn hay2 bn.
- Sau vt xy xc da, vt cng trng t sau lan rng dn.
Mn nc, chy dch m, vy tit.
- C kiu v tinh ( chc , nht quanh m eczema).
- C th c ban th pht mt, thn, ,mnh, tay chn, cc m nga lm mn mn nc.
2. Eczema tip xc.
- Vng h: ( mt, 2 tay, 2 chn) c khi in hnh vt tip xc (quai dp...)
- Vim mnh, nn, nn c mn nc c khi c bng nc.
- Ngng tip xc bnh gim, tip xc li, li ti pht.
-Th ng test da vi d nguyn nghi ng (+)
- 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,.....
3. Eczema tr s sinh: t 2 thng tui n 2 tui.
vng m trn c m , hnh mong nga sau lan ra u, thn mnh vim , nhim mn
nc, chy nc mnh, cht , mn, vy tit , cp tnh, nga nhiu.
C khi km ri lon tiu ho a lng tin s gia nh c ngi b eczema.
- eczema tr em 2-12 tui.
- Biu hin bn cp mn tnh c lc cht chy nc, sau kh dn bt u liken ho.
- eczema th a chnh cng t 12 tui tr ln.
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.
Nga nhiu, tin trin mn tnh.
4. Eczema da u .
V tr vng da u mt, u, da c, vng lim b.
m ,nn hi n, hi cm, c vy m ( ring eczema da du kh, khng nhn thy mn nc,
nhng v vi th c mn nc.).
C. iu tr eczema
1. Eczema cp: Vim , cht, chay dch, c m, vy tit.
- 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.
Chlopheniramin 4mg 2 vin ngy hoc Histalong 10mg 1 vin / ngy.
Vitamin C 0,10 10Vin /ngy.
Nu cn m khng c chng ch nh c th cho 1 t Prednisolon 5mg 4 vin / ngy 3/4 ngy
ri gim liu 2/ vin / ngy x 7 ngy ri ngng.
- Chng co, gi ch xt.
2. Eczema bn cp:
Gim vim gim chy nc, bt u kh, ln da non Bi m Cocticoit + khng sinh.
Nh: m Synalar - Neomycin
M Celesytodezem - Neomycin.
Thuc ton thn.
Chng nga chng d ng.
Chlophepniramin 4 mg 2 vin / ngy.
Hoc Histalnog 10mg 10 vin / ngy.
3. Eczema mn liken ho.
m tn thng thm mu, cng cm liken ho, x x th rp.
bi mt trong cc thuc sau:
Goudrar, Coaltar: tan nhim cun.
M corticoids: m Flucinar, m Diprpsali m Demovate, m betnvate.
Ung: khng Histamin tng hp.
Vitamin C1g/ ngy.
Nu cn v khng c chng ch nh cho mt t Prednisolon.

40. GH ( SCABIES, GALE)

1. Cn nguyn.
1. Cn nguyn.
- K sinh trng gh(Scaopte Scabiei hominis)
- KST gh o hang lp sng, trng qua chu k 3 ngy thnh KST gh.
- Sinh sn nhanh trong iu kin thun li sau 3 thng mt KST gh ci c th sinh sn ra mt
dng h 150 triu con.
2. Cch ly truyn:
Ly qua ng chung, qun o, chn chiu.
3. Chn on bnh gh gin n.
* C tn thng c hiu v tr c bit.
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).
* Tn thng c bn: mn nc, ng hang.
ng hang nm ngon ngho hnh ch chi mu trng xm di vi cm u ng hang l mn
nc 1-2mm, KST gh thng c tr y.
* Tn thng ph ( th pht do nga gi to thnh vt gi, vt xc da, vt trt vy tit, so
thm mu ,bc mu.
*Nga nhiu v m.
* Dch t c yu t lay lan trong tp th gia nh.
* Nh, khu bt c KST gh hay trng gh.
4. Chn on gh nhim khun.
Gh nhim khun l gh gin n b bi nhim nn c thm mn m.
(Nh vy trc ht cn chn on l mt trng hp gh).
5. Chn on gh vim da ho.
Trc ht cn khng nh l mt trng hp gh ( 5 yu t chn on gh gin n) cng thm
m Cieem da ho thng vng da mng, (mt trong hai i) do co gi ch xt bng dao,
que, mng tay, m vim da vim 5 -10-15cm ng knh, trn nn ri rc c mn nc ,
vt trt kho hoc vn dch, nga.
am vim da khngc x tr tt lu ngy dn n eczema ho trn nn vim c chi cht
mn nc i t di ln, m tn thng chy dch trong nhiu ngy.
6. Chn on phn bit
- Sn nga do cn trng
- Vim da d ng c cy, nc sui, ho cht.
- Vim da m.
7. iu tr
Nguyn tc:
- Pht hin sm, iu tr sm trnh bin chng.
- iu tr cng mt lc tt c ngi c bnh v ngi lin quan.
- Boio thuc vo bui ti, bi kiu quang du, bi 3 ngy lin mi tm git thay qun o.
(1 Lp mng t c n chn( bui ti KST b ra khi hang) )
Ti ch: dng mt trong cc thuc gh sau:
- Du DEP ( diethylphytalat).
- M dim sinh 10% cho tr em, 30 % cho ngi ln.
- Du Benzyl Bezoat 33% rt tt, dung dch kem Pemethirn 1%.
- Kem Eurax tr gh v sn nga.
- Dung dch hoc kem Kwell rt tt ch cn bi 1-2 ln l khi.
- Phng php Demianovitch.
Bi dng dch Hyposulfit Natri 10% sau 3 pht bi tip.
Dung dch axit Clohydric 6% xy ra phn ng ho hc lm gii phng dim sinh mi c tc dng
tr gh.
- Phng php Diakova:
X phng git 50g
bt dim sinh 125 g
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).
- Vi gh vim da ho vng vin da bi h nc giai on u m corticoid giai on sau vn
phi iu tr gh ( l nguyn nhn gy vim da).
Thuc ton thn:
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)

Tn khc : ht cm thng, mn cm, mn cc.
1.Cn nguyn : Cng vi ht cm dt, si mo g, ht cm thng u do nhim virut gy u
nh tng gai ngi c tn Human papilloma virus (H.P.V).
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.
2. Lm sng : Th ng ni thnh nhiu ci, ri rc lng, bn tay, cc ngn d i rnh
mng, lng bn tay.
+ bn tay v cc ngn tay: ht cm thnh u trn, g cao hn mt da mu xm hoc vng
c, kh cng dy sng. Trn mt c gai, rp mp m, xung quanh khng c qung vim (
khc vi lao da xi lc ban u). Ht cm khng au, tr khi quanh cc mng ly nhim do
gi. Nhiu ht cm c th cm li thnh m, c khi ni thnh dy ht cm di mng i
mng ln, gy au nht l khi chm phi.
+ Ht cm lng bn chn: c th do nhim virus t hoc qua dy, tt ca ng i c bnh.
Hay ni ch t, nh ng c th vng khng t, i li v n vo rt au. Ht cm lng bn
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.
+ mt ( m mt) ht cm th ng c chn, thnh hnh cc si vi mt u dy sng.
3. iu tr: dng cc ph ng php hu hot t chc xi nh chm axit tricloracetic 33%, p
tuyt cc bon, t in , Laser C02, p tinh th thuc tm, bi nha, podophylin 3%.
i vi ht cm lng bn chn : p tinh th thuc tm, t in radio tr liu ( 120 KV , khng
lc L.200 - L. 500 r ), colloma, dudofilm
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..
im c bit trong iu tr ht cm l c th dng tm l liu php mc d l bnh do virus.

HT CM PHNG ( verrus planes)
Tn khc : Ht cm phng ngi tr.
1. Lm sng : L nhng sn th ng b 1- 5 mm ng knh, hi g cao hn mt da, dt, vin
trn hoc a gic c mu sc ging mu da hoc vng xm, mt trn nhn hoc hi rp, c
th nga.
S l ng th ng nhiu, c khi chi cht thnh cm hoc thnh vt do gi.
Hay ni mt, mu l ng bn tay, c khi kt hp vi ht cm th ng . Hay gp tr em, thiu
n, ph n tr. C khi sau vi thng, vi nm, t nhin khi khng li vt tch.
2.Chn on phn bit vi:
-Lon sng nang lng (dyskeratose folliculaire: bnh darier) l mt tt bm sinh, biu hin bng
sn sng c vy xm bn mt, c, bn..
-Lon sn th ng b dng ht cm ( Epidermodysplaire veruciforme Lawandowsky- Lutz) ri
rc hoc khu tr, c nhng sn nh dt, trn hoca gic, mu hoc tm, c vy sng kh
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:
Bi m salixilic 5 %, chm axit trichloacetic 33 %, p tuyt cacbonic, t in Laser CO2 .
Tm l liu php. Theo kinh nghim dn gian c th xoa n c vi nh sau xt kim ni k t i
(mt trong m g).

42. HI CHNG LYELL
(Ly thng b hoi t ti cp)
(Epidermolyse ncrosante Ncrolyse pidermique toxique)
Thc s Nguyn T

1. nh ngha.
Hi chng Lyell l tp hp nhng triu chng da v ni tng rt nng. Bnh thng bt u
trc tin nim mc, nht l nim mc mt, mi, ming. Thng tn da l nhng hng ban,
bng nc, nhng m da b x rch, b lt trng ging nh bng la. Du hiu Nikolsky (+).
Hi chng Lyell bt u nh hi chng Stevens-Johnson nhng khng dng li cc thng tn
hc t nhin m tin trin lan to khp ngi vi da b bc tch ra (detachment of the
epidermis).
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.
+ Do thuc: chim phn ln cc trng hp (77% do thuc, 23% do t pht).
- Do thuc khng vim khng corticoide (43%).
- Sulfamid nht l sulfamid chm (25%).
- Thuc chng co git 10%.
- Cc thuc khc 4%(khng herpes, hydantoine, halloperidol,khng lao).
Bnh thng xut hin ngi ang kho mnh b nh th ng, sau khi s dng cc thuc ni
trn t 10 n 30 ngy, sm nht l 01 ngy, trung b nh 14 ngy, c tr ng hp ti 45 ngy.
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.
+ Do tim vaccin, huyt thanh.
+ Nhim trng km theo bnh d ng.
+ Mt s trng hp khng r nguyn nhn (idiopathique).
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
y in hnh, i khi bn hn m, bnh nhn st cao lin tc 39 - 40 0 C.
+ Tn thng da:
- Dt ging ban si hoc hng ban lan to.
- Hng ban a dng.
- 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 (+ ).
+ Tn thng nim mc:
- Vim gic mc, vim kt mc m.
- Lot gic mc.
- Sng, ph mt, kh m mt.
- S nh sng.
- Vim ming, trt nim mc ming, lot hng hu.
- Trt lot cc nim mc thc qun, d dy, t trng, rut.
- Vim lot m o, m h.
+ Du hiu ton thn:
- St: 39- 40 0 C (bao gi cng c).
- Ngi mt mi, hn m hoc bn hn m.
- Xut huyt tiu ha.
- Vim phi, vim ph qun, ph phi.
- Vim cu thn tng creatinine...
- Vim gan (tng transaminasa).
- C quan to mu: h bch cu, h tiu cu.
- Vim ty.
- Ri lon nc in gii.
4. Tin trin v bin chng.
Nu khng c iu tr kp thi v ng cch c ti 25-100% bnh nhn t vong. Nguyn nhn
dn n t vong a phn do ri lon nc in gii, nhng ch yu do nhim khun huyt,
nhim khun phi, do chy mu d dy rut , khng dung np c glucide v dinh dng km.
+ Cc bin chng:
- Nhim trng huyt.
- Nhim trng b my h hp.
- Cc bin chng gan, thn.
- Bin chng mt:
. Gim th lc, lot gic mc, khng hi phc.
- Hp thc qun.
- Hp m o.
5. Chn on.
5.1. Chn on xc nh da vo
+ Tin s (77% do thuc).
+ Lm sng: bng nc, da phng rp, x rch trn nn , c s bc tch thng b mt cch
t cp tnh... Hnh nh lm sng lin tng n nhng ca bng nng hoc lt da sng.
Nikolsky (+).
+ Tn thng nim mc: mt, mi, hng, sinh dc.
+ Tn thng ni tng: gan, thn, phi...
5.2. Chn on phn bit vi:
+ Hi chng stevens- Johnson.
+ Hng ban a dng.
+ Nhim c da th bng phng nc xut huyt.
+ Ly thng b cp do t cu (Epidermolyse Staphylococique Ai'que- E.S.A) gp ch yu tr
nh di 5 tui. Ngoi ra cn gp ngi ln b suy thn, SGMD. Cn nguyn do t cu type
71.
+ Hi chng Kawasaki (hi chng hch - da- nim mc): bnh gp nhiu ngi Nht Bn.
6. iu tr.
+ Bnh nhn ci trn nm trn ga v khun, nu c m nc th tt nht (bung hu phu,
bung iu tr bng, bung cp cu c n t ngoi, st khun).
+ Ti ch: chm sc ti ch rt quan trng.
+ Truyn dch: cn bng nc in gii.
+ Bo m nng lng v dinh dng (cho n bng sonde).
+ Cho khng sinh ph rng.
+ Corticoide: liu 100-200 mg/24 h (3-3,5 mmg/kg) nn cho ng tnh mch.
Nu tin trin tt (ht st, khng xut hin tn thng mi, ton trng kh) th h liu nhanh
(khc vi iu tr L.E.S h liu chm)
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
(sandimun) c 1/2 s ca iu tr c kt qu.


43. HI CHNG STEVEN JOHNSON

1. i cng.
1.1. nh ngha.
Hi chng S. J thng gp tr em v ngi tr tui nam nhiu hn n, t l 2: 1, vo ma h
ng hoc xun. Bnh khi pht t ngt bt u bng st cao, nhc u, mt mi, au vim
hng ming, nim mc mt v sinh dc v sau xut hin da mn nc, bng nc, ton trng
ngy cng nng c th t vong.
Trc y hi chng S. J c xem l th cp tnh ca ban a dng.Tuy nhin gn y mt
s tc gi cho rng nn xp ring v bnh c tnh cht ring bit.
1.2. Cn nguyn.
Cho n nay hi chng S. J c cho l nhiu cn nguyn trong ng ch l:
+ Do thuc: h st, gim, an thn c bit khng sinh nhm Penicillin, Sunfamides.
+ Do tim vacin, huy thanh.
+ Nhim virut : do Herpes.
+ Cc bnh nhim khun: vim phi, vim mng no, vim no, nhim khun rng ming
+ Cc loi bnh k sinh trng, st rt, trng roi, nhim nm.
+ Bnh to keo : lupus ban .
+ Ri lon ni tit, c thai hoc ri lon kinh nguyt ...
2. Lm sng.
Bnh khi u t ngt st cao 39- 40
o
, nhc u, mt mi au vim hng ming v sau ton
trng ngy cng nng.
+ Vim ming ( Stomatite) l mt du hiu xut hin sm ca hi chng S. J biu hin mn
nc mi, li v nim mc ming hoc xung quanh ming v sau gy vim ming nng km
theo gi mng xut huyt, chy nc bt, lt ming n ung rt kh khn.
+ Mt: vim kt mc hai bn, lot gic mc.
+ Mi (epitaxis): vim mi, xung huyt, chy mu mi.
+ 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,
mi, kt mc, niu o, m o, hu mn).
+ C quan ni tng khc: vim ph qun, ri lon tiu ha.
Tin trin v tin lng
Bnh ngy cng nng bnh nhn mt mi au khp, hn m, lon nhp tim, vim mng c tim,
nhim khun huyt c th t vong. Nu tn thng nng cc hc t nhin c th gy bin
chng nh m la...
Chn on phn bit
- Vim da Herpes.
- Vim da tip xc bng nc.
- Pemphygus.
- Hi chng Lyell.
3. iu tr
iu tr theo nguyn nhn:
Do herpes: dng acyclovir 200 mg x 5 vin/ngy x 7 ngy
Do st rt: iu tr theo bnh st rt...
Nu do thuc: phi ngng loi thuc gy bnh v iu tr vi corticoid. Th nh: 1 mg/ kg th
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
dch betadne (iod long).

44. LAO DA

Bnh lao da l mt trong nhng bnh nhim khun t ng i ph bin gy tn th ng su sc
trong c th. Bnh do trc khun lao (Bacille de Koch- BK) gy ra . Trc khun BK do Robert
Koch tm ra nm 1892, hnh th chiu di t 2- 4 m rng 0, 2- 0,6 m. C mt hnh th trc
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
lao t cc hch c v hch d i hm c a n da qua ng lymph. Qu trnh lao hch
tr ngi cho tun hon lymph, lm cho dch lymph chy ng c chiu vo mt s vng,
mang theo c trc khun lao.
- ng mu : mt s mch mu trong lao ph tng b ph hu lm cho trc khun lao lan
truyn trc tip vo mu, t trc khun chuyn vo khp c th v vo da. ng lan
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
mc mi v mi. Lao thn c th dn n lao da v c quan sinh dc.
Phn loi trc khun lao:
- Trc khun lao ng i (Type human)
- Trc khun lao b (Type bovin)
- Trc khun lao t chim loi ny him ( Type gallinene)
Bnh lao da khng phi l bnh n thun tn th ng da m l mt bnh ca ton c th.
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.
Bnh lao da ph thuc vo 3 yu t:
- Do c lc ca trc khun.
- Do s l ng ca trc khun.
- Do c th ca bnh nhn : trn a a s bnh nhn lao da th hin rt r rng d ng vi
Tuberculin hoc BCG nng 5 %; 10%; 20%, iu chng t trong c th c khng th
i vi trc khun lao. Dng phn ng ny tin l ng bnh. Trong lao nng th phn ng
ny l m tnh. Bnh cn do mi tr ng, yu t dinh d ng bn thn bnh nhn sau nhng
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.
Cc tc gi u phn lm 2 nhm lao nh sau:
Nhm th nht : lao da thc s, luput th ng hoc luput lao , lao hch, lao da ht cm, lao lot
k da v nim mc. Nhm ny c c im tin trin chm, mn tnh, c xu h ng hoi
t v c hnh nh m bnh hc c tr ng .
- c im : xt nghim vi khun trn tn th ng d ng tnh.
- Nui cy v tim truyn trn chut d ng tnh ( mi tr ng Lowenstein)
- M bnh hc in hnh ca nang lao : gia l t bo khng l, vi trc khun Koch, xung
quanh l t bo lymph ngoi l t bo bn lin).
- Phn ng tuberculin (+ +) km theo phn ng ti ch.
- Th ng c lao cc b phn khc km theo.
Nhm th 2 : lao gm lao sn hoi t, lao dng liken, lao da cng.
C tc gi cn phn loi thnh lao sn cc, lao sn k, lao sn hoi t. Nhm ny c c
im l mn tnh tin trin t c xu hng hoi t.
c im :
- Xt nghim trc khun khng thy th ng xuyn.
- Nui cy v tim truyn t khi thnh cng.
- Hnh nh t chc hc tht th ng khng c nang c hiu.
- Phn ng vi tuberculin (+ , - ) tht th ng.
- C th c hoc khng c cc lao cc b phn khc .
Cc hnh th lm sng.
2. 1. Luput lao: l mt th lao da th ng gp nht 50 - 70 %. Lm sng a dng, tin trin dai
dng , iu tr lu di, kh khn c khuynh h ng lot ph hoi t chc, nu sc khng tt
th c th t lnh. Phn ln cn nguyn do trc khun t ni tng do ng mu gy ra hoi t
t ngoi vo. Tr con hay b hn ng i ln.
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
nu chm kim th st.
Tin trin ca c lao : cc c ny lin kt vi nhau thnh m lan dn ra pha ngoi, ln so
gia mu trng. C khi ngay trong lng so li pht ra c lao mi. B ni cao ln mt da khng
u, khc khuu. Cc c lao d tm thy trn b hoc gn b. Luput lao tin trin lu c th
10- 20 nm.
Phn ng vi Tuberculin 86,6 % (+).
Tn th ng khu tr th ng mt, mi trn 70- 75%, t gp hn t chi nh bn tay, bn chn,
mng. Rt him khi gp u. Nu gp b phn sinh dc hoc hu mn th thng th ng t
lao rut lan ra.
Cc th lm sng ca luput lao : c 2 th chnh :
- 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
lao lot c khi kt hp vi tn th ng x ng lm mt ngn tay gy tn ph. Nu tn th ng
hng c th lm thng vm ming lm thng ln mi.
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.
Bin chng ca luput lao :
- Vim qung (Erysipl ) th pht.
- Vim cc mch bch huyt, ph chn voi ( lphantiasis)
- Ung th (Cancers)
Chn on phn bit :
- Giang mai th c: c to hn, mu ng, thm nhim, so su hn so lao, xt nghim
giang mai (+).
- Phong th c : tn th ng c ri lon cm gic.
- Nm su .
2. 2. Lao cc ( Tuberculose verruqueuse)
Lm sng th ng tn trn da l nhng mng xi, lc u l nhng sn mu nht cng, n
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
quanh c mt vng thm nhim mu tm sm c bao ph vy m v vy da. Ngoi cng c mt
vin xung huyt mu .
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.
C khi kt hp vi lao phi, lao rut hoc t lao x ng sang .
Tin trin nhiu nm cc mng lan rng chm c th li so , khng c tn th ng mi
trn so, khng c s ph hu t chc.
Bin chng vim mch bch huyt, s ng hch.
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.
- Mn cm : sn ni cao xi tng gai.
- Liken phng si : c nga xi bn cnh c sn a gic bng.
2.3. Lot lao : (ulcer tuberculosis)
Th ng l lot tin pht xut hin trn nhng ng i lao phn ng tubeculin m tnh.
Lm sng : Triu chng u tin l nhng sn bng bng u inh ghim, lot nhanh, cc sn
lin kt vi nhau thnh vt lot ng knh 2 cm b lm chm khc khuu ng thnh hm
ch, b nht nht hoc hi tm, y ca vt lot khng u, c nhiu im xut huyt, y th
ng nng, dc theo b c nhng ht mu v ht Trelat, m rt t. Nn vt lot mm hoc ch hi
thm nhim cc hch trc thuc c th b vim .
Tin trin chm hng thng .
V tr tn th ng th ng nim mc mi hoc bn trong m, l i, xung quanh ming, hu
mn tng sinh mn, b phn sinh dc th rt him.
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.
Cn c lot lao th pht ( do gm lao lot ra ).
Chn on phn bit :
Lot giang mai l lot nng, thm nhim, x cng, xt nghim c xon khun.
Sn giang mai b lot.
Lot h cam.

iu tr bnh lao da
Phi iu tr ton thn, ti ch ch c tnh cht st khun.
1- Phc khuyn co ca hip hi chng lao v bnh phi quc t
Phc 2RHZ
4 RH
- 2 thng v 4 thng.
- Rifamixin 300 mg liu nh hn 50 kg - 450 mg/ ngy.
Ln hn 50 kg - 600 mg/
ngy. Tr em 10 mg / 1 kg / ngy .
- INH ( Isoniasit nicotinit hydradit).
Liu 300 mg/ ngy bt lun cn nng.
Tr em 5 mg / kg cn nng.
- Pyradinamit - Z.
Liu < 50 kg - 1,5 g/ ngy.
> 50 kg - 2g / ngy
> 70 kg - 2,5 g/ ngy
Tr em 35 mg/ kg.
Hng ngy cho ung c 3 loi mt ln vo lc i.
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.
Hoc Streptomyxin tim bp tht ngy 1 ln ( nh hn 50 kg - 0,7 g; > 50 kg - 1 g ; hoc 60 tui
cho 0,5 g. Tr em 10 mg/ kg khng vt qu 0,75 g/ ngy ).
Hoc l Etambutol, tr em v ng i ln 25 mg/ kg / ngy , khng bao gi vt qu 25 mg/ kg
trong thng u. Nu tip tc sau 2 thng th liu phi gim 15 mg/ kg. Trnh dng cho tr nh
v lm gim th lc.
2S . HRZ / 4 RH.

45. LUPT BAN H THNG

( Systemic lupus erythematosus ) ( SLE).
BS CKII. Bi Khnh Duy.

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
thng thn, tim, phi.
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).
T l mc bnh trong cng ng 40-50/100.000 dn. Bnh c t l n/nam = 10/1 ,8/1.
2.Cn nguyn v bnh sinh.
- Cn nguyn cn nhiu im cha r.
- Cc bin i v di truyn, yu t gia nh gp 5 - 10% trong s cc trng hp .
Cc tc gi quan st thy c s thay i HLA b8 DR2, DR3,DRW52, DQW1, DQW2. Thiu
ht C 19, C2.
- Nguyn nhn do thuc: mt s trng hp bnh xut hin sau khi dng Hydralazine, thuc
chng co git, isoniazide, procainamide, gi l hi chng lupt do thuc.
- Do tc ng ca nh nng: 1/3 s bnh nhn bnh xut hin sau khi phi nng, nh
nng lm trm trng , nng bnh thm (36%).
+ Ri lan h thng min dch : lymph T khng kim sot c lympho B dn n ri
lon sinh ra cc t khng th (Autoantibodies) lng ng cc m nht l m lin kt c
collagen gy ra hin tng bnh l.
+ S v cn nguyn sinh bnh ca SLE.

+ Yu t ni tit : Lupt ban h thng ch yu n chim t l 9/1 so vi nam, cc thuc
nga thai cng c th l yu t khi pht bnh, c thai, sinh , thi k tin mn kinh bnh tin
trin nng hn.
+ Yu t tc nhn virt.
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
Epstein- barr, Herper zoster virus,cytomegalovirus.
3.Triu chng lm sng.
Lupt ban h thng l mt bnh tn thng a h thng, tn thng thng gp l da,ton
thn, cc c quan ni tng.
3.1. Tn thng da: ban da l triu chng thng gp ( 70-80%).
- 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
vai, thn mnh, chn tay.
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.
- C th gp cc tn thng khc nh cc m mng hnh trn dng a (discoid) c dy
sng nang lng tng im v teo da trung tm m tn thng. m tn thng dng a c
th gp mt, tay nu u gy tri tc do c teo da, so.
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.
Trong Lupt h thng c th gp ban quanh mng, lng bn tay.
Lot cng chn c th gp v lnh rt chm.
-Vng u tc rng lan ta, tc kh x xc, ng mu ru ng, nu c tn thng lupus dng a
u th thy rng tc thnh m trn, nn c da, dy sng, teo da lm rng tc khng mc
li c.
- 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
tay hai bn, cc u ngn tay nht nht, lnh, v cm s thiu mu cc b ny ko di t mt
vi pht n mt vi gi ri xanh tm xut hin,au, bng rt, sau mt thi gian tun hon bnh
thng c ti lp,ngm tay nc m lm thuyn gim nhanh chng. Trong cc th tin
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).
- Gin mch : gin mch (Telangiectasie) l mt c im ni bt ca bnh m lit kt. Gin
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.

3.2. Tn thng ton thn v ni tng.
Triu chng th cht ton thn.
Mt mi gp hu ht cc bnh nhn SLE cha c iu tr, mt mi nhiu, nhiu khi l du
hiu u tin ca bnh, mt mi gp 98% s ca SLE.
- St cn c khi st 5-10 kg.
- St ( 96-100%) st 38-39- 40
o
, c khi st ko di. St l mt du hiu gip ch cho chn
on.
- Kh chu.
- Rng tc : rng tc l mt c im ln ca SLE, chim t l > 20% s ca ,c th xut hin 2
dng: rng tc thnh so v rng tc khng so.
Rng tc thnh so u thng l do trn u c ban dng a ca lupus , c m
hnh trn, c vy sng gn cht ( dy sng tngim nang lng) sau c teo da to so ,nang
lng b ph hy, rng tc hu nh khng hi phc.
Rng tc khng so thng l rng tclan ta trong SLE u c ban , vy hi ging kiu vim
da da du, tc rng tha lan ta khp u tc ng mu hi nu, kh, x xc nh mu ru ng,
d gy rng nht l vng trn.
- Vim khp v au khp : ( 15-90%).Xut hin hu nh khp tt c bnh nhn SLE . au
nhiu khp khng c bng chng vim, hoc vim khp c sng,au, c khi trn dch mt s
bnh nhn c khi vim au khp i trc vi tun, vi thng trc khi bnh biu hin r.
Thng vim hai hoc nhiu khp ngoi bin nh bn ngn tay, c tay, ci tay, u gi, mt c
chn, c th nhm vi thp khp cp.
- 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
vng thc, ri lon h thn trung ng.
- Gan, lch : gan to 30 - 35% s bnh nhn, him khi c vng da, lch to ( 20%).
- Hch to 50% s ca, thng nhiu ni.
- 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.
4.1. Bt thng v huyt hc.
Bt thng v huyt hc ( 1 hay nhiu ch s) gp hu nh tt c bnh nhn SLE.
- Thiu mu tan huyt vi phn ng Coombs dng tnh v tng hng cu li.
- Gim bch cu t hn 4000/mm
3
.
- Gim lympho bo t hn 1500 /mm
3
.
- Gim tiu cu t hn 100.000 / mm
3
.
- Phn ng VDRL dng tnh gi.
- Mu lng tng cao.
4.2. Ri lon min dch hc.
T bo LE (cn gi l t bo Hargraves)dng tnh 85% s bnh nhn c tn thng a h
thng.
T khng th SS-A (Ro).
Khng th SS-B (La) tn ti 50% s ca.
Khng th khng nhn ANA dng tnh (> 95%).
Khng th khng nhn Ds DNA dng tnh ( 60-80%).
Gim b th C3.
AntiSm. Anti (n) DNA.
4.3. M bnh hc da:
Teo biu b, thoi ha ha lng ng tip gip biu b chn b, ph n chn b, thm nhim
vim lymphocytes v thoi ha dng fibrin m lin kt v thnh mch mu.
-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.
Chn on da vo tiu chun chn on SLE ca hi bnh thp Hoa K (American
Rheumatism Association ARA) 1982.
5.1. Ban vng m : ban vng mi m hnh cnh bm.
5.2. Ban dng a (discoid) ban g cao, gii hn r c vy sng dnh cht kh cy, dy sng
tng im nang lng, c teo da.
5.3. Mn cm nh sng ( Photosensitivity): c tin s mn cm nh sng hoc thy thuc quan
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
tim, trn dch mng tim, ting c mng tim, bin i in tm .
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.
5.9. Ri lon huyt hc :
- Thiu mu tan huyt c tng hng cu li.
- Gim bch cu < 4000 / mm
3
.
- Gim tiu cu < 100. 000/ mm
3
.
5.10. Ri lon min dch :
T bo LE dng tnh.
Anti DNA (+).
Anti Sm (+).
VDRL dng tnh gi.
5.11. Khng th khng nhn.
Khng th khng nhn Ds DNA.
SSA ( Anti Ro).
SS B ( Anti La).
Nu c > 4 tiu chun , bnh nhn c chn on l SLE.
chn on SLE cn c th da vo cc triu chng lm sng v xt nghim sau(theo kinh
ngim lm sng v theo cc sch,ti liu):
- Ban vng mi m hnh cnh bm.
- St.
- Mt mi.
- St cn.
- Rng tc.
- Vim khp.
- Tn thng thn.
- Mu lng tng cao.
- Bch cu gim < 4000 / mm
3
.
- T bo LE (+).
- Khng th khng nhn (+).
- Gii : n.
Chn on phn bit : cn chn on phn bit SLE vi mt s bnh sau:
- Vim da tip xc, vim da mn cm nh sng cng thng b vng h ( mt, 2 cng bn tay
).
- Vim da c (dermatomyositis) : ban ph n quanh mt, mu tm ( heliotrope), c sn
gottron cng tay, mu ngn tay, yu c, thay i men c in c,sinh thit c.
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.
- Thuc c ch min dch cho dng ng thi vi corticoid : Azathioprine hoc
cyclophosphamide.
- Thuc chng st rt: Hydroxychloroquine, hu ch cho ban da SLE mn tnh v bn cp 300
mg/ ngy. Trc v sau khi dng thuc chng st rt tng hp th chc nng gan, khm mt v
theo di v mt, khm vng mc, theo di 6 thng v mt.
- Bi m corticoid vo vng da tn thng 2 ln/ ngy.
Bnh nhn SLE khng nn c mang,sinh v lm bnh nng ln.
Cn lu mt s thuc lm bnh nng ln hoc kch pht bnh.

46. LUPT BAN MN TNH

(Chronic cutaneous lupus erythematosus ) (CCLE).
BS CKII Bi Khnh Duy
1.i cng.
- Cn gi l lupt mn tnh dng a ( Chronic discoid lupus erythematosus) (CDLE).
- Bnh c c im l c cc mng gii hn r, trung tm c vy v teo da thng xut hin
vng h ( mt,tai, u), bnh da mn tnh v khng au.
- Bnh do Cazenave pht hin v t tn nm 1851.
Nm 1872 Kaposi tch lupt mn dng a (CDLE) khi lupt h thng (SLE).
2. Cn nguyn dch t hc.
- Thng b la tui 20- 45.
- Bnh thng gp n > nam , 1, 5/1 ; 2/1.
- Cn nguyn cha r, cc tc gi c nu mt s yu t c vai tr trong cn nguyn nh :
+ Yu t di truyn gia nh.
+ Thuc loi bnh t min dch ( autoimmune).
+ nh sng lin quan n s xut hin bnh hoc lm trm trng bnh.
3. Triu chng lm sng :
3.1. V tr : thng b vng mi, m ,hnh cnh bm, vng mt, u, trn, tai, cng tay, mu
bn tay, ngn tay, ngn chn v t hn l thn mnh.
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.
Trn b mt m mng nht l trung tm c vy da, vy dnh cht kh cy ( bn cht ca
vy da dnh cht kh cy l do m tn thng lupt mn c dy sng tng im nang
lng, to thnh cc nt sng gm su xung,kh cy, khi cy ln trng nh ci gai, ci inh
bm thm.)
trung tm m tn thng nht l tn thng lu ngy c mu ti trng do c hin tng teo
da, da thp lm xung c th thnh so do cm mng vng mi m, c teo da lm thp
trung tm , c tc gi v von nh b mt con ch si (Wolflike) v t lupus cng mang
ngha ny.
Nu tn thng lupt mn tnh trn da u gy tru tc vng c tn thng lupt do m
tn thng c teo da, thnh so gy rng tc.i khi c hin tng mu sc hi loang l, m
tn thng lupt mu sng, trung tm c teo da, so mu trng, xung quanh m tn
thng c tng nhim sc mu nu, thm da. Phn b cc m tn thng ri rc, ring r
tng m.
c im ni bt nht ca m tn thng lupt mn tnh dng a l:
- Khu tr vng mi,m hnh cnh bm, vng h.
- m tn thng mu sng c th c gin mao mch.
Dy sng tng im nang lng, vy dnh kh cy, teo da trung tm m tn thng.
- Tn thng nim mc : 5% s bnh nhn c tn thng mi nh dy sng, ban , so
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 :
- Him khi gim bch cu < 4500 t bo / mm
3
.
- Khng th khng nhn (ANF) dng tnh 33 % s ca.
- 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,
thoi ha trong lp t bo y. Chn b ph n, mch mu nh dn rng, thm nhim vim vi
cc lymphocytes v m bo quanh nang lng v phn ph ca da.
5. Chn an : Chn on xc nh da vo :
- V tr vng h, vng mi m hnh cch bm.
- m mng da, c dy sng tng im vy dnh kh cy, teo da trung tm.
- Khng nh bng m bnh hc da.
Chn on phn bit :
- Vim da tip xc, dy sng do nh sng.
- Vy nn th mng.
- Nm da vng mt.
- Liken phng.
- Ban a dng do nh nng.
6. Tin trin v tin lng.
- Lupt mn dng a c tn thng khu tr 1 s vng th 50% s thuyn gim nhiu, cn
c loi tn thng lan ta t l thuyn gim < 10%.
- Khng 1- 5% lupt mn tnh dng a chuyn thnh lupt h thng (SLE).
7. iu tr:
- Trnh nh nng, i nng i nn m rng vnh, bi kem chng nng.
- Ti ch : m tn thng bi m corticoid ,cc tn thng nh c th tim trong da
Triamcinolon acetonide song cn thn trng ch nh.
- Thuc chng st rt tng hp :
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.
Retinoid c th dng etretinate 1 mg/kg trng lng c th.

47. LI LNG ( HAIRY TONGUE)

Li lng l mt bnh l do cc nh biu m b mt li di ra v dy ln, n thng nhim
sc " mu en" l do 1 loi vi khun to sc t gy nn.
+ Dch t hc:
- Tnh thng gp : hay gp ( common).
- Tui : thng ngi ln.
- 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.
+ Khm : cc nh biu m b dy sng ging nh c bao bc mt lp o. V tr gia b mt
li.
+ iu tr :
Khi tm ra nguyn nhn v loi b th bnh khi. Tuy nhin bnh nhn khi c th dng cc
nc sc ming c tc dng st khun v dng cc loa thuc nh rng lm bong i cc cht
bm mt li.

48. BNH NM ASPERGILLOSIS

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.
Phng thc gy bnh ca Aspergilluss l u tin c th gy bnh da sau tin trin gy
bnh h thng hoc ngc li. Trong mt s trng hp nm gy bnh c hi c khi c iu
kin thun li nh ngi nhim HIV/AIDS. .
2. Triu chng lm sng:
+ Gy vim da: Tn thng l nhng m , i khi hnh thnh cc dt trng bong vy cm
nh lang ben, hoc c hnh a cung nh nm da. Trong mt s trng hp xut hin cc gm,
si, p xe hay vt lot da. Ngi b AIDS thng hay b A.fumigatus v A.flavus gy bnh nm
da v u.
+ Nm tai : nm thng gy bnh ng tai, ng tai sng n, vy xut hin nhiu, hi m, rt
nga. Nm c th lan ra vnh tai, hoc lan vo trong mng nh, nu khng iu tr kp thi s
gy thng mng nh. Nm Aspergillus cn gy bnh vim xoang.
+ Nm mt : Aspergillus thng gy vim hc mt ri lan ra nhn cu gy vim lot gic mc,
vim kt mc v tuyn l.
Nm gy bnh h thn kinh : thng qua cc hc mt hay hc s, nm c th xm nhp vo
bn trong gy vim tiu no, no.
Nm gy bnh li vi bnh li " lng en", nim mc li thng c mu en vi cc nhung
mao en.
Nm gy bnh tim: thng gy vim mng trong tim, vim c tim.
Nm gy bnh xng : vim xng, vim mng xng.
Nm gy bnh h tit niu: ch yu l gy vim bng quang, vim niu qun.
+ 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
trin trong mt hang sn c to thnh bu nm (funguns ball) ph.
Hen d ng do Aspergillus: khi ht phi bo t trong khng kh thng gy ra cc triu chng
hen ph qun d ng nh kh th, st, ho khan, st cn, phi c ran.
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 45
o
, 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.
Thnh phn mi trng Czapek - Dox:
NaNO3 3 gam.
K2HPO4 1 gam.
MgSO4H2O 0,5 gam.
KCL 0,5 gam.
FeSO4 0,01 gam.
ng knh 30 gam.
Thch 15 gam.
Nc va 1000 ml.
Nui cy nhit phng, thi gian 7 ngy.
4. Chn on phn bit : da cn chn on phn bit vi sn nga do cn trng, vim da m
v cc bnh nm da khc. Bnh nm Aspergillus h thng cn phn bit vi cc bnh nm h
thng khc nh blastomycosis, histoplasmosis, coccidioidomycosis...
5. iu tr: thng dng cc thuc ung nh ketoconazol, itraconazol voriconazol , ngoi ra c
th dng amphotericin B iu tr bnh nm h thng. Ti ch tu trng hp c th bi kem, m
c cha dn cht imidazol.

49. BNH NM BLASTOMYCOSIS NAM
M

PGS Nguyn Ngc Thy

Tn khc: paracoccidioidomycosis. Bnh do Lutz (1908) pht hin ln u tin vi tn bnh l
Lutz - Spendora- Almeida, n 1912 tqcs gi Spendora tm hiu r cn nguyn gy bnh .
Bnh xut hin nhiu cc nc Nam M nh Brasil, Chil, Achentina, Urugoay, bnh cng
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.
2. Triu chng lm sng.
+ 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.
Nm P.brasiliensis cn c th gy bnh ng tiu ho nh rut tha,manh trang, trc
trng, hay gy vim xng hoc vim thn kinh trung ng. Khi nhim nm ton thn bnh
nhn c th t vong sau vi thng, khi b da, nim mc, hc c th sau vi nm nu khng
pht hin v iu tr kp thi.
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.
Nui cy : y l mt loi nm lng dng (dimorpphism) nn ta c th nui cy bnh phm
hai nhit khc nhau. Khi nui cy mi trng sabouraud, mi trng thch mu, mi trng
socola nhit phng sau 20- 40 ngy khun lc dng si mn pht trin, c mu trng sau
chuyn sang mu nu, quan st vi th thy trn cc si nm c bo t c cung nh cch si
nm, kch thc bo t 2,5-6 mm. bo t mng dy cng xut hin, i khi mt khun lc hi
nhn v thnh thong to mu , sau mt thi gian mt mu. Khi nui cy nhit 37
0
C
nm mc chm, c dng khun lc nm men, kim tra vi th t bo nm c hnh trn, ng
knh 10-16mm, xung quanh t bo "m" ny c cc "t bo con" ny chi gn vo, in hnh 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 :
Thng s dng amphotericin B. Ngy nay c th dng itraconazol, thuc c tc dng v t c
hi hn.

50. BNH NM CRYPTOCOCCOSIS

1. Cn nguyn.
Nm cryptococcus neoformans, l loi nm men c nang (capsule) dy. Bnh cn c mang
tn bnh nm blastomycose chu u.Cryptococcus neoformans c hai chng l C.
neoformanss var.neoformans vi cc typ huyt thanh A v D, C . neoformans var. gattii vi cc
typ huyt thanh B v C.
Nm c th gy bnh ngi v ng vt, xy ra trn khp th gii. Bnh c pht hin lin
quan n suy gim min dch trong HIV, neoplasma- N, sarcoidosis v nhng ngi dng
thuc c ch min dch. Nm thng gy bnh da, phi, h thn kinh.
Nm thng gp nhiu trong phn chim nht l phn chim b cu do C.neoformans c kh
nng s dng creatinine trong phn chim lm ngun nitrogen.Trong phn chim b caua tch
lu lu ngy c nhiu nm v nm c tnh chu kh tt, ngc li phn chim mi t gp nm
do cc vi khun thi ra lm tng pH, C. neoformans ngng pht trin.
2. Triu chng lm sng:
+ 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.
- Tn thng l dng sn cc ri rc kiu u ht, m si hoc u cc gm, thng gia lm, b
c g cao, thng c vy tit en nht ph trn vt lot c rm dch v mu, gm ging nh
trng c hoi t. Nhng ngi nhim HIV th tn thng dng herpes hoc nh u mm ly.
- Tn thng dng p xe mng m, d v to so cu, nhn nhm nh trng c cm.
+ 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.
+ Vim mng no:
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
s, ph n, hn m, gy t vong. Ngoi ra, nm cn c th gy bnh vim mng bng, vng
mc, gan, xng.
3. Xt nghim chn on:
+ Xt nghim trc tip: nhum bng mc tu vi cc bnh phm dch, m t tn thng ra hay
cn ly tm ca dch no, ty hoc da sinh thit nhum vi muciramin... c th pht hin t bo
nm men ny chi kch thc 8- 12 mm , c v dy kch thc c th gp i t bo nm
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, 37
0
C
khun lc dng kem soi c nhiu t bo nm men vi nhiu chi nh.
4. Chn on phn bit:
Cn chn on phn bit vi lao, cc bnh nm h thng khc v ung th.
5. iu tr:
Thng phi hp amphotaricin B vi 5 fluorocystosin, c th dng fluconazol , itraconazol ,
ketoconazol. c bit fluconazol hay c dng dng vin v tim iu tr bnh nm
cryptococcus gy vim mng no nhng bnh nhn b nhim HIV.


51. BNH NM PENICILLIOSIS

1. Cn nguyn .
Do mt s loi penicillium gy nn nh P.minatum ; P.citrorosum; P.lengues; P.glaucum ;
P.album ; P.mucedo ; P.racemosus; P.exitrosus... thng gy vim da, mng tay, vim tai,
ng h hp,phi.
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.
Bnh thng gp vng ng Nam , gn y c nhng thng bo ca bnh nam Trung
quc , Hng Kng, Lo, Indonesis ... Vit Nam cng gp mt s trng hp bnh nhn AIDS
mc bnh do P. marneffei.
2.Triu chng lm sng.
Cng nh nm lng dng c th gy bnh li ni m h thng bnh nhn HIV, nm gy
vim da, to nn da nt sn c nt sng trung tm ging nh bnh histoplasmosis.
nhng ngi d nhy cm b nhim nm th st, gim trng lng, ni hch, gan to, lch to, ho
kh th, vim mng tim, v vim mng bng c th xy ra.
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.
nhit 37 C hoc trong t chc: nm c dng nm men hnh oval ( trong t bo m
v i thc bo),nhng t bo ny mm rt c bit c vch ngn gia,y chnh l im
khc vi nm men thc.
Nui cy trn mi trng sabouraud 25 C khun lc ban u gn nh dng bt mu xm,
sau thnh mu xanh vng hoc hng xm, mt di ca khun lc th c mu khuych
tn vo mi trng. Khi soi di knh hin vi th trn nhng si nm c vch ngn s c bo
t hnh thnhnh trn cung dng hnh chai.
Loi nm ny c nhiu c t v c th gy bnh trong phng th nghim, cho nn ngi ta
cn lu s nhim ca nm ny.
4. Chn on phn bit : cn chn on phn bit vi cc bnh nm khc, sn do cn trung,
lao da.
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.

52. BNH NM SPOROTRICHOSIS

Cn gi l bnh gardener (bnh ca ngi lm vn).
1.Cn nguyn : do nm Sporotrichum schenckii. y l mt loi nm lng dng (dimorphism)
. Trong t nhin nm thng sng trong t c trn cc cy v th d gy bnh ngi lm
vn, lm rung v ng vt gm nhm.
Bnh c m t ln u tin M nm 1898 bi Schencki, sau Beumann(1903) v
Ramond pht hin Chu u. Nm 1912 Beurmann v Gougerot m t chi tit hnh dng ca
nm. Bnh xut hin khp ni trn th gii,ch yu M, Mehic, ngoi ra cn thy
Php, Lin X , NamPhi. Vit nam cng xut hin bnh ny, thng gp min Bc .
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
nhiu trng hp ly nhim trong phng th nghim.
2. Triu chng lm sng.
+ Th da- bch huyt: l th hay gp nht. Khi da, nim mc b xy st, sang chn nm d c
iu kin xm nhp vo da lan truyn theo ng mu hay ng bch huyt. Bnh gp mi
la tui. Thi gian bnh thng 20-90 ngy. Thng tn da xut hin l nhng gm, cc
sn ni g trn mt da nhng v tr khc nhau, nhng phn ln vng da h cng chn, cnh
tay. c bit gm sn mc trn ng bch huyt. Nhng gm, sn cc pht trin nhanh, lc
u th cng di ng khng au. Sau th mm thnh m, thng au v khng di ng. S
ho m bt u t b mt v im gia ca gm dn n gm mm nhn gia cn b vin
xung quanh th hi cng. Khi chch nn c t m hi qunh, mu hi vng, khng c kn ngi
nh vim da m, y cng l hnh nh c trng ca bnh. Tn thng c th tin trin thnh
p xe nh hoc p xe ln nm su di da, c mu hng nht, kh t v m. Khi chch nn th
thng c qunh nh du vi mu vng chanh.
+ Th da n thun: tn thng da c dng si nh ht cm, hay mn cc, c th thnh u to
nhng khng lan ra mch bch huyt.
+ Th nim mc: tn thng thng l u nh dng mn cc c m, lot thng xut hin nim
mc mi, hng, ming, khi d nhm ln vi vim da do vi khun.
+ Th xng khp : bnh nhn thng b au, vim, cng khp, ch yu khp ln nh khp
gi,khuu, c chn, c tay, khp hng v khp vai t b.
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 20
o
C- 26
o
C, nm pht trin
sau 3- 7 ngy, khun lc dng si c mu thay i t kem n mu en. Soi di knh c
nhng si nm mnh,c vch ngn, pha trn c cc bo t nh hnh cu hay hnh oval 2-3 x
3-6 mm ng thnh m trng ging nh bnh cm hoa. Trn mi trng thch dch chit tim
c 10% mu v 37
o
C nm c dng nm men t bo ko di 8- 10mm , khi nhum gram bt
mu en c hnh dng c bit gn ging iu x g.
+ Chn on min dch: test da: dng 0,1 ml khng nguyn sporotrichin c pha long gp
2000 ln lm test da, c kt qu sau 48 gi,ng knh nt sn ln hn 3 cm l dng tnh.
Cng c th dng phn ng ngng kt , kt ta hoc phn ng c nh b th chn on.
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.
53. BNH NM BLASTOMYCES BC M

(Bnh gilchrist).
PGS Nguyn Ngc Thy

1. Cn nguyn : nm Blastomycess dermatitidiss, l mt loi nm lng dng. Theo Denton,
Ajello v mt s tc gi khc th loi nm ny sng trong t nhng rt t khi phn lp c nm
ny t t.
Bnh c Gilchrist m t u tin nm 1894, n nm 1896 Gilchrist v Stokes phn lp xc
nh mm bnh l nm Blastomyses dermatitidis. Bnh c th xy ra mi la tui, a s gp
ngi trn tui 40, nam gp 10 ln n. Bnh xut hin M , ch yu vng thung lng sng
Misissippi, cn gp cc nc Bc M nh Canada. Bnh cng xut hin chu Phi.
2.Triu chng lm sng.
Bnh chia ra: th vim da v th ph tng.
2.1.Th vim da:
Triu chng lm sng: nm thng xm nhp gy ra cc tn thng vng da h nh
chn,tay,trn,mt.Tn thng trn da thng l mt sn hay sn m nng khi b lot hay v ra
lm chy dch c ln mu v m ri ng thnh vy tit.Tn thng c th lan rng thnh m u
gai c ng knh vi cm.Vin tn thng thng trn hnh cung hay vn vo, b r, g
cao,thnh b th dng ng,mu tm.
B mt ca m tn thng si, c nhiu gai nh ging nh ht cm.Thnh thong c cc tht
si mm nm xen k nhng ng rnh, nn ra m.Vng trung tm dn dn thnh t chc so
cn vng ngoi b tn thng vn lan rng v c nhng cc,nhng mn m dng trng c.Tn
thng tin trin mn tnh khng gy nga, khng gy au, ko di hng chc nm.
+ Tn thng trn da c th xut hin nhiu m vt trn c g cao,u ht thng l du hiu
ca bnh blastomyes ton thn v h thng.
+ Tn thng nim mc t gp.
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
sng,xng sn, vo cc ph tng khc,tr ng tiu ho. y l im khc vi bnh nm
blastomyces nam M v bnh nm histoplasma.Bnh khng c iu tr tch cc thng dn
n t vong sau vi nm (90% cht sau 2 nm).
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
nhng si nm hnh tn la v c bo t dnh bn cnh si nm.
+Test da v phn ng c nh b th t c gi tr trong chn on.
+Xt nghim t chc hc trong nhng t bo khng l dng langerhans c t bo nm dng
nm men.
4. Chn on phn bit.
Chn on phn bit vi bnh nm blastomyces nam M,histoplasma, lao,
leishmania,carcinoma(ung th t chc lin kt), paracocidioides brasilensis.
5.iu tr.
Thng c iu tr bng amphotericinB liu ti a 50 mg/ ngy, iu tr t 4-8 tun. C th
s dng cc thuc nh:iconazol (sporal),ketoconazol (nizoral).

54. BNH NM MYCETOMA (
MADURAMYCOSIS)

PGS Nguyn Ngc Thy

L mt nhim trng t chc di da do mt s loi nm v vi khun gy ra khi chng nhim
vo sau mt chn thng nh. Cc tc nhn ny pht trin chm, to thnh mt m an kt
cht ch vi nhau thnh cc ht( granule), c th lan vo t chc lin kt (xng).Tn thng
thng gp chn v c gi l " Madurafoot".
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
nhng bo t khng kh hay gai xm nhp vo c th. Bnh thng gp chn, c th
tay, ngc, mng.
1. Cn nguyn:
Cc loi vi khun: Actinomadura madurae, A.pelletieri, Streptomyces somaliensis,
Nocardia asteroides, N.brasiliensis, N.otitidisvarum, Nocardiopsis dassonvillei.
Cc loi nm thc : Madurella mycetomatis, M.grisea, Pseudallescheria boydii, Acremonium
kiliense, A.recifei, Leptosphaeria tompkinsii, L.senegalensis, Exophiala jeanselmei,
Neotestudina rosatii, Pyrenochaeta romeroi, Curvularia lunata, Aspergillus nidulans, A.flavus,
Fusarium monniliforme, F.solani, Corynespora cassicola, Cylindrocarpon destructans,
Plenodomus avaramii, Polycytella hominis.
2. Triu chng lm sng:
Khi da chn b xy st nm d xm nhp gy nn tn thng. Khong 70% trng hp bnh
chn, chn tri nhiu hn chn phi. Tn thng c bn l nhng m ht, cc to nh khng
u, g gh trn mt da km theo sng,ph n vng da tn thng, sau dn dn xut hin
cc l d chy dch vng ln m c. i khi c cc ht mu vng, trng, nu, en hay hi
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
cycloheximid, nui cy nhit 25 v 37
0
C, tt nht l ly c bnh phm sinh thit lp
su trnh tp khun. Cc nm gy bnh thuc lp nm bt ton ( Fungi Imperfecti) hoc
nm ti (Ascomycetes0, nm mc chm, to bo t ti v bo t nh ( conidia) moi trng
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 37
0
C.
4. Chn on phn bit : vi lao da, u da, cc bnh nm khc.
5. iu tr :
Nu mm bnh l vi khun Actinomycetes sng khng sinh nh sulfonamide,dapson, co-
trimoxazole,streptomycin. Cc dn xut penixilin hay sulfadiazin 3-8 gam/ ngy trong 3- 4
thng. Nu mm bnh l nm Eumycetes dng cc thuc chng nm nhm imidazol nh
ketoconazol, itraconazol, voriconazol. Trong mt s trng hp kt hp ngoi khoa ct b phn
hoi t, thm ch pah ct ct chn kt hp dng thuc.

55. BNH PAGET

1. i cng : l mt bnh him gp do Paget m t t nm 1874, thng ph n sau 40 tui
vi tn thng da, v v quanh nm v. Hin nay cha r tn thng da do lan t tn
thng su v ln hay t tn thng da s lan xung su. Cc yu t thun li cho bnh pht
sinh v pht trin: nt n, sang chn, vim quanh u v.
2. Triu chng lm sng : lc u tn thng l mt vi vy tit nh hoc t chc si sng ho
quanh v. Vy tit gn cht kh hoc hi t, nga t hoc nhiu, bc lp ny lp khc li
n ln. Sau mt vi nm tn thng ging mt m eczema lan khp u v, vt qu qung
sm mu quanh nm v, tn thng c ch kh ch t ng vy v hi si. Tn thng
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.
3. Chn on quyt nh v chn on phn bit :
+ Chn on quyt nh:
- Da vo hnh nh lm sng.
- Hnh nh m bnh hc : m bnh hc kh in hnh vi cc t bo gai to, trn hoc bu dc,
nguyn sinh cht sng c nhn qui n hoc 2 nhn, nh gai di v cong queo, cc t bo
ny gi l t bo Paget chng ng ri rc ho thnh cm.
+ Chn on phn bit vi chm vi khun, nm candida, vim da mn tnh do lin cu.
4. iu tr v d phng.
+ iu tr : ct b tuyn v sm, c hch bch huyt ln cn.
+ Phng bnh : iu tr nhng nt n v v nhng vim da quanh v nht l trong giai on
cho con b.

56. BNH PHONG

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.
1.3. Tnh hnh bnh phong trn th gii v Vit Nam.
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.
Vit Nam : 12- 14 vn bnh nhn ( 120.000 - 140.000 ).
1.4. Quan nim v bnh phong.
C cho l bnhnan y, khng cha khi c , s hi, i x tn bo vi ngi bnh .
Mi : cho l bnh ly, c th khng ch ct c ly lan, cha khi c, i x nhn o vi
ngi bnh.
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 .
2.1.Tc nhn gy bnh.
Trc khun Hansen (BH) tn khoa hc Mycobacterium Leprae do nh bc hc ngi Na Uy
Armeuer Hansen pht hin 1873.
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.
Trn tiu bn da trc khun phong ch yu nm trung b nng v gia, ri rc hay
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).
Phong th L ly nhiu hn th phong c (thT),ly gin tip qua nc, t, vt dng l ph
bin,ly trc tip phi trong iu kin sng thn thit ko di.
3. Triu chng lm sng.
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.
3.3.Thi k ton pht.
3.3.1. Triu chng ngoi da :
Vt hng hay gp, i khi vt dt trng bc mu hoc t hn na l dt sm mu, iu kin
l tn ti lu v gim , mt cm gic.
+ Dt , gii hn r hoc khng r, khng g cao trn mt da.
+ mng c : m mng , gii hn r ,c b g cao, b c c nh hoc c to lm tm
bng u tm, ht , ht ng li so. Thng gp trong th phong c(LT).
+Mng cp ( u phong), m sm g cao trn mt da, bng, gii hn khng r, n vo cp
ln, hay n vo lng my, trn, gi l b mt nh s t ,gp trong th phong u(LL).
3.3.2. Triu chng thn kinh :
+ Gim, mt cm gic au v nng lnh trn m tn thng, dt , mng c hay mng
cp,u phong hoc mt cm gic au hai cng bn tay, cng bn chn, pht hin bng chm
kim th cm gic v p ng nc lnh,nc nng.
Cm gic su nhn bit t , p lc thng cn.
+ 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.
3.3.4. Triu chng c ng :
+ 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.
3.3.5. Triu chng ri lon dinh dng.
Hng mng ,da seo bng,
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.
Rng lng my l triu chng hay gp v qu gi,
Ct, rt ngn tay, ngn chn.
3.3.6. Lon chng bi tit: da kh hoc m qu.It tit m hi ,Da m do ri lon ni tit
3,3,7 Triu chng ph tng v ng quan:
+ Tn thng mt(50%),vim gic mc(30%) c th dn n m lo tn ph.
+ Vim mi,vim hng khn ting , hch sng.
+ Vim tinh hon, vim xng, gan, lch to, c th c tn thng ton th cc c quan v l
bnh ton th.
4. Cc th lm sng theo Madrit v phn nhm theo vi trng.
4.1. Phn loi cc th phong theo Madrit.
4.1.1. Theo hi ngh chng phong quc t ( 1953) Madrit, bnh phong c chia lm cc th
sau y:
+ Th I : tc th v nh, l giai on sm ca bnh.
+ Th T: tc th c.
+ Th B: tc th trung gian.
+ Th L: tc th u ( trc y hay gi l th c tnh ). Bng tm tt cc c im ring ca tng
th nh sau :



c im I(v nh) T( th c) B( trung gian) L( phong u)
Lm sng Dt Mng c Mng thm nhim U, cc
Vi trng m tnh hoc dng
tnh nh
m tnh Dng tnh Dng tnh mnh
Phn ng m hoc dng tnh Dng tnh m tnh hoc dng m tnh
Mitsuda mnh tnh nh
M bnh hc Khng c hiu Nang phongc
hiu
Xm nhim lan to gm
bn lin, m bo
Xm nhim lan to gm
t chc bo, t bo bt.

4.1.2. Phn nhm theo vi trng.
tin li cho vic p dng a ho tr liu, chia bnh phong ra lm 2 nhm, nhm t vi khun
(Pauci Bacilary-PB) v nhm nhiu vi khun (MultiBacilary-MB), mi nhm c mt phc iu
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):
+ C s phn loi: da vo min dch trung gian t bo (CMI).
+ 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:

+ ENL(erythema nodosa leprosum) ban nt do phong thng gp trong th phong u (LL)
ang iu tr thuc c hiu.
+ RR(reverse reaction) phn ng o ngc ln cp - chuyn th gn v pha phong c khi sc
khng, min dch mnh ln bnh chuyn dch v pha th c TT.
5. Tin trin v bin chng.
Bnh ko di c lc nh ng yn, thoi lui, t gy cht ngi nhng tai hi l gy tn ph.
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.
+ Sng mt s dy thn kinh ( TK tr) nhnh c nng, hng khoeo.
+ Da c dt, c, mng cp tn ti lu mt cm gic.
+ Teo c u chi.
+ Xt nghim tm trc khun Hansen dch mi, da.
chn on bnh phong ngi ta lm xt nghim tm trc khun Hansen da v nim
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.
Chn on phn bit :
- Phong u tn thng l ban mng cp thng mt mi, trn tai c th nhm vi d ng
thuc, chn on cn ngh n bnh phong th cm gic au v lm xt nghim tm trc khun
Hansen.
- Phong c cn chn on phn bit vi bnh nm hc lo v cng c m mng , c b
vin, gii hn r nhng trong bnh phong c m mng b l c sn nh, mt cm gic
au v xt nghim tm trc khun Hansen dng tnh, cn trong nm hc lo m mng
hnh a cung, b vin r, b c mn nc, nga. xt nghim nm (+) tnh.
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.
+ Xu hng th gii l xo b khu iu tr phong.
+ iu tr nh cc bnh nhn khc ti bnh vin.
+ ng li chng phong ca Vit Nam l " iu tr ti gia nh", thanh ton bnh phong tng
vng.
+ a ho tr liu ( Multidrug therapy) thay th tr liu n ho tr liu
(DDS n thun ) trnh nhn thuc, khng thuc
+ 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.
7.2. a ho tr liu l ch trng ca t chc y t th gi thay th tr liu c v DDS sinh ra
khng thuc, m bo cha khi bnh. Phc ca t chc y t y th gii 1982.
- Nhiu vi khun (MB).
Rifampicin 300 mg x 2 vin ( 600 mg/ thng ln , c kim tra).
Clofazimin 100 mg x 3 vin ( 300 mg/ thng 1 ln c kim tra).
Clofazimin 50 mg / ngy t ung.
DDS 100 mg / ngy.
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).
Rifampicin 300 mg x 2 vin = ( 600 mg/ thng 1 ln, c kim tra).
DDS 100 mg / ngy t ung.
Thi gian 6 thng sau ngng thuc theo di 3 nm.
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.
Clofazimin ( lamprene B663) c tc dng dit khun,tc dng ph l lm sm mu da vng c
nh sng chiu vo.
Ethionamit v prothionamit.
7.3. Cc phng php iu tr khc.
+ 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
phng bin chng mt.
7.4. D phng.
+ Theo di pht hin, iu tr sm.
+ Cha sn xut thnh cng vc xin phng bnh phong.

57. BNH RAYNAUD

L bnh ri lon vn mch tay, chn, pht trin sau khi b lnh lm co nhiu ng mch nh.
Co ng mch lm mch tnh mch.
Thng bnh pht trin qua 2 thi k k tip :
- Thi k ngt ( Syncope) gy thiu mu.
- Thi k ngt Asphyxie gy tm u chi.
1. Lm sng :
Nhng cn co tht hu nh thng xuyn bt u mt bn sau sang bn kia, c trng hp
khu tr mt bn.
Cc ngn chn t b hn, gt, mt c ngoi , mi c th mc nhng rt him. C thng bo c
bit cho bit bnh c th lan ra c 4 chi.
Bnh chu nh hng ca lnh: nc lnh, khng kh lnh. Th ng xy ra v ma ng. Cc
chn ng v tm thn cng nh hng n bnh.
Cc triu chng lm sng th hin qua 2 giai on :
1.1. Giai on 1 : ngt ti ch , y l giai on bt u ca bnh.
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
hnh nhnh li.
Hin tng thiu mu ny ch khu tr vo 1- 2 ngn tay hoc lan ra c hai bn ngn tay, c khi
lan ra c cnh tay.
1.2. Giai on 2 : ngt ti ch .
Th ng tip ngay giai on ngt 1-2 pht hoc hn.
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.
Thng km theo s lng cc ngn tay nhu di trng.
Bnh pht trin thnh tng t, sau mi t cn au gim bt.
Thm tm u chi trong mt thi gian ri cng gim , cn ngn nu trnh c lnh.
2. Tin trin :
Rt thay i mi cn xy ra trong vng vi tun n mt thng, thng ch xy ra vo ma rt...
Thng cn ngt cng nng ln ko di, pht ra c ma nng dn n ri lon dinh d ng
chi. Ri lon dinh dng xy ra sau cc cn ko di hoc b nh hng ca ri lon kinh
nguyt nh mn kinh.
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
dng cc u ngn , c th c so trn, lm xen k cc vng mt sc t.
- 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.
Th cp tnh c th thnh so d dng nhng c khi ph hu c xng bn ngn.
- X cng u chi c th n c, c khi km hoi t. Da u chi tr nn kh, bng, hoi t. T
chc da gim i, t cui co li , mng b nh h ng, ngn tay nh li u. Da dnh vo bnh
din di , hnh nh ging nh x cng b u chi ( Sclrodactylie) nhng tin trin chm
hn.
3. Chn on : cn chn on phn bit :
- 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.
- Vim ng mch u chi (Artrite des membres) gy tc mch, thiu mu dn n hoi t
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.
- Th khng kh lnh hoc l khng kh lnh la vo gy gy nn co mch.
- Hoc ngm lnh sau ngm nng.
- Chp ng mch khi co.
- o huyt p.
- o nhit thy nhit cc ngn gim nht l sau ngm lnh.
- Lm sinh thit khng cho kt qu r rng.
4. Cn nguyn :
Raynaud cho l do ri lon co tht ng mch.
Cc cn co tht ng mch gy hin t ng ngt ti ch ch l cn sinh l nhng ko di v
tng mnh ln gy bnh l.
Hin tng ngt ti ch.
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.
Cn s dng bin php :
- Trnh lnh , eo gng tay, trnh nc lnh, gi lnh.
- Tho mi v tinh thn v th lc.
- Khng ht thuc , ung ru v cc gia v kch thch.
- Thuc an thn ung lu.
- Vitamin B6, nng c th tim 1 gam/ ngy x 1-2 thng.
- Cc thuc lm gin mch : Rserpin. Achtylcholin , Grisofulvin 500 mg - 1 gam / ngy ( lm
gin mch nh).
- Phong b Novocain vo cc hch giao cm.
- Phu thut .



58. BNH THAN (ANTHRAX)

Bnh sinh v bnh cn : l mt bnh nhim khun c bit do Bacillus Anthracis gy nn .
1876 R.Koch phn lp vi khun than trn mi tr ng nhn to v pht hin ra bo t.
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 :
- Th dinh d ng d b dit bi cc yu t l ho bnh thng.
- Th bo t c sc khng cao, trong t tn ti vi chc nm. Bo t b ph hu nhit
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 :
- V l yu t c lc quan trng gip cho vi khun khng b thc bo.
- c t : c ngoi c t, l " yu t t vong" c tnh xm l c t gip vi khun khuych tn
nhanh. Ngoi c t vi khun than c tnh khng nguyn yu nn khng dng ch gii c
t c.
1. 2. 2. Gy bnh cho ng i: ng i mc bnh trong cc tr ng hp qua vt xy xt ngoi
da do tip xc vi cc cht thi ca ng vt m hoc khi lm tht cc ng vt cht v bnh
than. Ngoi ra cn gp trong cc trng hp n tht b nhim khun ch a nu chn, hoc mc
bnh khi ht phi vi khun t bnh nhn mc bnh th phi, hoc cc thao tc khng m bo
quy nh cc phng th nghim gy bn cc canh trng ra ngoi. ng ly bnh than ch
yu ng i l qua da (94- 95%), qua n ung (0,5 - 0,7 % ), qua kh dung (aerzon ) (0,3%).
Min dch: ng i khi bnh c min dch lu bn, b li rt him .
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
huyt. ng vt mc bnh do n c ung n c nhim bo t than. Ngoi ra cn c th b do
cn trng t. ( rui tru, mui, vt ).
ng vt th nghim cm nhim vi trc khun than nht l chut lang v chut nht trng.
Pakistan n , I Ran, Trung , Mng c, Nam Phi, bnh ny gp nhiu hn. Australia,
Trung M, Chu u v M bnh gp t hn v c pht hin sm khng b b st . tng
vng nht nh, ng i b nhim trng trc tip t gia sc v gy bnh cp tnh nguy him ngay
c tr em cng b bnh ny. Bnh c th ly truyn qua cn trng ( cn ch a c khng
nh). ng u s ly truyn qua ng vt l him. Nh ng i khi thy ng i bn tht. Mt
s tr ng hp ly nhim t da, m, o lng cu nhp t n , Pakistan, Chu Phi bnh c
bit nguy him nhng ng i khun vc , cng nhn trong cc ni ty u, hoc nhng ng i
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
si gelatin. Vi khun tng sinh s l ng ln da v t nhim vo mu v gy nhim trng
ni khc .
Lm sng : Tn th ng da l cc mn m khc th ng hay gp vng da h c bit mt ,
c, tay hoc cnh tay, c th mt ch hoc nhiu ni b bnh. T 1- 5 ngy sau nhim trng da
pht trin vo vng ln cn, phng n c v ra v to nn vy mu ,xung quanh l v ph c
th c mn n c nh xung quanh. Hch limph s ng v c th mm ra, b mt da trn hch
bng lng. Nhiu tr ng hp b mt tn th ng lm sng l a dng v c khi ch yu l
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
th trung bnh bnh ko di t 1- 3 tun.
T l t vong th lot da hoi t t 5- 20 %. Ph n v nhim trng huyt l yu t tin l
ng. iu tr khng sinh sm. Tin l ng bnh s tt hn.
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.
- Ph ng php phn lp: Bnh phm cy vo :
Mi tr ng thch mu 5 %.
Mi tr ng thch thng.
Sau 18- 24 gi t m 37
o
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 :
Lm phn ng Ascoli: l phn ng kt ta ca vng iu kin m trong ng nghim nh. Th
ng d pht hin khng nguyn than lng, da hoc ph tng ng vt nghi ng v bnh than.
Phn ng tin hnh nh c khng huyt thanh c hiu ch sn .
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.
4. Chn on phn bit :
Nhim khun t cu trng, Blastomycosis, Sporotrichosis Bc M rt ging vi Anthrax
trong cc thc nghim nhim cu trng vng trung tm tn th ng l vy tit mu mu en
vng xung quanh l ph n v da, tin trin cp tnh, khng c biu hin vim ng bch
mch iu l khc vi Anthra.
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 .
Vc xin c th c s dng cho nhng ai tip xc vi nhng yu t c kh nng gy bnh.
Nh ng tt nht l kim tra cht ch cc bnh ca ng vt v cc sn phm ca n.

59. BNH GII LEO ( HERPES ZOSTER)

Tn th ng gi : Zna thn kinh , gii leo.
1. i c ng.
Bnh th ng gp vo ma xun - thu v mi la tui ( tr tr s sinh ), nh ng xy ra ng i
ln nhiu hn ( 3/4 s bnh nhn zona trn 45 tui ). c bit ngi suy gim min dch ( c 8
- 11% bnh nhn nhim HIV b zna).
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.
Tr c khi tn th ng mc 2-3 ngy th ng c cm gic bo hiu nh : rt dm dt, au vng
sp mc tn th ng km theo triu chng ton thn t hoc nhiu nh mt mi, au u...
Hch ngoi vi ln cn c th sng v au.
+ V tr : th ng khu tr tp trung nhng v tr c bit v ch c mt bn ca c th dc
theo cc ng dy thn kinh , nh ng c bit c th b c hai bn hay lan to.
+ Tn th ng c bn: thng bt u l cc mng , n nh, g cao hn mt da, hnh trn,
bu dc ln lt ni dc dy thn kinh , ri rc hoc cm li thnh di , thnh vt, sau 1-2 gi
trn mng xut hin nhng mn n c cha dch trong, cng kh v, cc mn nc tp
trung thnh cm ( nh chm nho), v sau c, v, xp li so ( nu nhim khun).
Tr c hoc cng vi mc tn thng da th ng ni hch sng v au vng t ng ng v
l du hiu quan trng chn on.
4. Cc th lm sng.
V tr tn th ng l yu t tt nht chn on, th ng mt bn ca c th dng t ngt
ng gia, dc theo ng phn b thn kinh (c bit mi c nhng mn n c lc lng).
+ Zna lin s n v ngc bng th ng 1/2 ng i c khi lan xung mt bn cnh tay ( ngc,
cnh tay).
+ Zna c ( m ri c nng) v c cnh tay c tn th ng c, vai, mt ngoi chi trn.
+ Zna gy c : c tn th ng gy, da u, vnh tai.
+ i khi gp zna hng, bng, sinh dc, bn, x ng cng, ngi, i, cnh tay...
+ i vi thn kinh s no: hay b nht l dy III.
+ Zna mt ( nhnh mt ca dy thn kinh III) gy tn th ng trn, mi trn dc trong mt,
cnh mi, k c nim mc mi... c bit nghim trng c th gy bin chng mt t vim
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.
+ Zna hm trn v d i ngoi vng da t ng ng cn c c tn th ng nim mc ming,
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.
+ Zna u: tn th ng nhiu dy thn kinh s no, hch no tu, c khi tn th ng c no.
5. Tin trin : th ng lnh tnh, khi sau 2-3 tun.
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 :
- Giai on cp : h n c, dung dch thuc mu nh xanh metylen ; cestellani timethyl nu c
nhim khun.
M khng sinh....
+ Ton thn : khng virus Acyclovir 0,2 g ( 0, 8 g) x 5 vin / ngy x 7 ngy.
- Khng sinh chng bi nhim.
- Gim au, khng vim, an thn nh seduxen, nhm Diazepam c bit Neurontin (
gabapentin).
- Sinh t nhm B liu cao.
- Nu au dai dng c th phng b thn kinh v vt l tr liu kt hp.


60. CC BNH NM CANDIDAS

1. i cng v nm candidas.
C rt nhiu loi c ti 300 ging.
+ 1952 : thy c 30 loi c lin quan y hc. Ngy nay : 35 loi.
+ Trong cc loi th C.albicans c c tnh cao nht v hay gy bnh ngi.
+ Ngoi ra cn c C.tropicalis, C.pseudotropicalis, C. parakrusei , C. krusei, C. guillermondi m
trn lm sng cng hay gp.
Nhng loi candida thng tp sinh. Nhng trong iu kin thun li th gy bnh ( gy bnh c
hi ).
1.1. V tr ca canbicans trong phn loi dng nm men : ( lvures).
C.albicans l mt loi nm men sinh sn bng n bo ny chi. bn cnh c th c si
nm gi gm cc t bo di dnh vo nhau bi mt im nh v d gy ( levures= 8).
Theo Lodder c 2 loi nm men l :
+ Men chnh cng: sinh sn bng nang m (ascus) trong in hnh l nm men
saccharomyces.
+ Men khng c nang m : hp thnh h ln cryptococace. V nm candida l mt trong
nhng loi thuc h cryptococcacea.
Tt c cc bnh do nm candida gy ra th gi l bnh candidose ( ngy xa gi l bnh
levures , monilia ).
1.2. Hnh th ca C. albicans khi xt nghim.
+ Soi ti hoc nhum ( theo phng php nhum gram hay nhum PAS) thy t bo trn n
l kch thc 2- 4 m. Trong thnh t bo mng. Bn cnh c mt s t bo ny chi. Cnh
c t bo di, ngn, gn vo nhau bng im yu d gy.
+ Trong phin t chc ( sinh thit b phn mc bnh) cng c hnh si min gi v hnh t
bo ny chi bt mu m. Nu l tp nm khng c t bo ny chi.
+ da c th tm thy t bo ny chi lp : sng, gai, trung b.
Ch : soi ti hay trong t chc nm khi chn on phi :
+ Thy t bo nm men mc chi hnh con lt t, si "min gi".
+ S lng phi nhiu so vi tp khun khc.
+ Nu bnh phm ly t chc kn ( nh ti m, mng no, khoang bng, nc tiu ) m thy
hnh chi ny mm- si " min" coi l dng tnh.
+ 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. a 500 chng ( 78%) , C. pesudotropicaliss 25 ( 39%).
C. tropicalis 50 ( 7,8%) , C. guillermondi 15 ( 2%).
C. krusei 50 ( 48%).
Theo RLEY( 1977) cy 14600 bnh phm t dch m o ca 12365 ph n , nm candida
albicans chim 57,9%, C. krusei 12,1%, Torulops glabrata 8,8%, sacharomyces cerevisiae
3,6%.
2. Cc yu t thun li nhim nm candida.
+ Yu t ni lai:
- Bnh nhim trng cp tnh hay mn tnh.
- Bnh chuyn ho: tiu ng, mp ph.
- Thiu cc sinh t B ( B2, B6, PP v C ).
- S dng cc khng sinh c ph rng ko di.
- S dng cocticoid ko di .
- S dng cc thuc khng t bo ( iu tr ung th).
- Bnh i ng, bng, ung th, nhim HIV/AIDS, thai nghn.
- Sau phu thut thay van tim.
- Bnhnhn suy mn , suy kit .
- Vim sau lu.
+ Yu t ngoi lai.
- Ngi gi, rng rng ht.
- Lot do bng bnh nhn bng.
- Ngi hay tip xc vi ngun nc, hoa tri, thc phm , cng nhn sn xut bia, th git...
3. Triu chng lm sng .
3.1. Candida nng.
3.1.1. Nm candida nim mc ming li hay cn gi l ta ( muguet) hay gp tr em,
ngi gi yu hay ngi b cc bnh khc lm suy nhc c th, hoc dng khng sinh,
cocticoit di ngy.
Triu chng khi b nm nim mc ming , trn hm ch c th c t vt trt nng tp hp li
thnh m trng nh sa ng li, ly ra d dng. Hay khu tr vo li, vo mt trong m, c
khi lan xung c hng, thc qun, c khi km im lot, hoi t. nhng ngi gi yu, tr
em suy dinh dng, c th phi hp vi t cu, lin cu lm cho nim mc sn si ln.
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).
3.1.3.Nm candida trong cc k: thng gp cc k ln nh bn, nch, di v, khoeo, khuu
v ngn tay, k ngn chn. Thng tn l nhng vt ,ranh gii r, hi g cao, c vy, c khi
c mn nc hoc mn m. B mt thng tn v t.B khng u, nham nh, xung
quanh c mt vin vy mng d bong.Tn thng thng khu tr vo cc k.y ca k
thng thnh vt nt chy nc, k chn do i giy dp b m t nhiu, cho nn tnh trng
bt da (maceration) tng ln thnh tng mng, di da trt ti, d b nhim trng ph lm
cho tn thng c m, v vy tm nm rt kh. Tn thng cn lan ln c mt mu ca cc
ngn.
3.1.4.Nm candida da u: t gp. Trn da u c nhng vng c tc thy nhng m vim
chn tc (folliculite) c m. Trong m y va tm thy c t cu v c nm men. Tc b rng v
khng mc li. si tc khng b tn thng, tm khng thy si nm cng nh bo t nm.
3.1.5. Vim mng do candida .
Thng tn bt u thng l vim quanh mng, c khi c m c khi khng. V sau mng dy
ln c ng nt, i khi li thnh nu, nhng khng mt v bng v khng gy. Bn di
mng khng c vy vn nh trong nm mng khc. Cng c khi mng dy tr nn c v di
mng cng c nhng mng vy lm cho kh chn on phn bit, i khi c dch m gc
mng.
3.1.6. Nm candida m h, m o: Triu chng ch yu l nga. Da m h v nhn. Trong
k mp c bt da (macation) trn ph mt cht nh kem mu trng. Bn di l tn thng
ti hoc sm, b khng u, nham nh, xung quanh c vin vy da.
m o khi nhim nm th c nhng nt trng nh ta, dnh vo thnh m o c khi khng
thy r v c bi tit nhiu cht nhy, ln m. i vi ph n c thai, cm gic nga tng ln
lm rt nh phi bng, kh h ra nhiu.
Tn thng c th lan ra c bn, nht l nhng ngi b bnh i ng. Bnh rt dai dng,
c khi ht triu chng lm sng nhng nm vn tn ti trong m o v trong iu kin thun li
no y, li pht trin ln. Cc triu chng ln sng thng khng ph thuc vo s lng nm
tm thy trong m o.
3.1.7. Vim qui u do candida: hay gp ngi c v b vim m o do nm men.
Tn thng bt u bng mn nc, mn m, khi v li cc vt trt trn,ban ri rc
hoc lin kt thnh m mu ti, c vin biu b, c cht b trng, c khi c vy kh,
thng nga.
3.2. Candida su:
3.2.1. Granulome monoliasique: t gp.
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.
3.2.3. C khi li thnh nhng p xe lan to khp ngi.
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.
+ Bnh nhn ho nhiu, m c, dnh trong c nhng ht ln nhn cu to nn bi cc t bo
bong ra trn ln vi nm, khng mu.
Ton trng t b nh hng.
+ Nghe phi c ran rt nht l y.
+ Chiu X quang ch thy hnh nh ca vim cung phi.
+ Xt nghim m tm thy c nhiu nm men.
4.2. Nm candida phi ( candidose pulmonaira).
+ Ho nhiu v au ngc, st mch nhanh.
+ m lc u t, sau nhiu v dnh, c t tia mu. C khi nhim trng ph lm cho m ln
mu.
+ Nghe v X quang c th thy nhng tn thng ging vim phi mt hoc c hai ph
trng.
+ C th do C. albicans hoc C. tropicalis.
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.
4.5. Bnh nm candida hu mn.
4.6. Vim ni tm mc do candida.
4.7. Vim phc mc v tit niu do candida .
4.8. Nhim khun huyt do candida .
4.9. Nhim candida h thn kinh ( candidose ).
5. Nhim nm candida cc gic quan ( candidose).
5.1. Vim tai do candida .
5.2. Nhim nm candida mt .
6. iu tr bnh nm candida.
+ Candida nim mc ming, li th ra, sc ming bng dung dch natriccbonat hoc chm
dung dch glycerinborat 3 % v bng Daktarilgel.
+ Candida m o ra bng dung dch nabiccbonat, t thuc chng nm nh : nystatin,
clotrimazol, polygynax, tergynan, miconazol, kt hp ung thuc chng nm nh nizoral, sporal
hoc fluconazol.
+ Vi candida da c th bi thuc mu nh gientian 2%, milian, castellani, fungizon hoc kem
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.
+ Trong iu tr nm candida cn tng cng ung vitamin B cc loi, cn gim lng ng
trong ch n, khi b bnh.


61. U TRNG SN LN DI DA

1. i cng: l mt bnh mn tnh c tn thng da, c, no... cn nguyn do cc u nang
sn ln (trong c u sn) gy nn. Biu hin lm sng tu theo v tr khu tr ca nang da nh
hng ti thm m, no c th gy ng kinh, gim tr nh hoc ri lon vn ng nh
hng nghim trng n cht lng cuc sng.
2. Cn nguyn bnh sinh :
Sn dy ln c khp ni trn th gii, nht l nhng vng c phong tc n tht ln sng,
cha nu chn hoc qun l phn cha tt. Sn dy ln di t 2- 3 mt (thm ch 8 mt), u
nh, hi trn, ng knh khong 1 mm, c b phn nh ln, c 2 vng mc (22- 32 mc) v 4
gic 4 gc. C t c mnh, c t thn trng thnh, c t gi. Mt t sn gi c th cha
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
trng, c mu u sn vi 4 gic v 2 vng mc.
Ngoi ln cn c ch mo hoc ngi u c th l vt ch ph ca sn dy ln. Khi ngi n
phi trng sn dy ln t ngoi cnh (theo thc phm, rau qu) hoc nguy him hn l
nhng ngi ang mc sn trng thnh k sinh rut non v mt l do no nh say tu,
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.
3.Triu chng lm sng: ty v tr u nang m c cc tn thng
+ da : cc nang nh, bng ht hoc ht d, trn, chc, khng au, di ng trn nn su
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
nm s b vi ho, lc ny c th pht hin c bng X quang.
+ no: biu hin nh mt u nang trong no hoc c th gy nn nhiu triu chng lm sng
a dng khng c hiu: tng p lc s no, cn ng kinh, suy nhc tr nng, ri lon tm
thn. Bnh nhn c th b lit , c th b t t .
+ mt: nang u trng c th nm trong hc mt, mi mt, trong kt mc, thu tinh th, tin
phng...gy gim th lc hoc b m tu theo v tr ca u trng trong mt.
+ c tim: c th lm tim p nhanh, ting tim b bin i, bnh nhn b ngt xu.
4 Xt nghim:
+ Chc ht ti u nang c mt t dch trong.
+ Trn c s da vo bnh sn dy ln ng rut (xt nghim phn tm t sn v trng
sn), c biu hin lm sng u nang sn di da.
+ Sinh thit u nang da tm u trng sn ln.
+ 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.
5. Chn on phn bit : vi cc u nang b, u m, u sarcoidose.
6. Tin trin v tin lng
+ Tn thng da lu ngy c th vi ho nh hng ti thm m.
+ Tn thng no ph thuc vo v tr ca u nang .
7. iu tr v d phng:
7.1. iu tr bnh sn ng rut.
+ 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.
+ Niclosamide (yomesan) 0, 5 cho ung 4 - 6 vin (1 liu), thuc khng c, hiu qu
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.
7.2. iu tr bnh u nang sn ln no.
Hin nay vn l mt vn nan gii. C th dng praziquantel, methifolat, DEC. Cha
bit ht c ch tc dng ca thuc cng nh phn ng ca c th v c bit l no(c trng
hp sau khi iu tr bnh nhn c th b m hoc t vong) nn phi hp vi corticoid v thuc
chng ph n no.
7.3. iu tr u nang da.
+ C th phu thut khi tht cn thit v yu t thm m hoc cc u nang chn p cc dy thn
kinh.
+ Tim ht dch u nang, bm 0,5 ml nc ct vo u nang tiu dit u sn ln.
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.

62. BAN MY AY V PH MCH

( Urticaria and Angioedema )
BsCK2 Bi Khnh Duy
Ban my ay v ph mch gm cc sn ph, mng ph nht thi thng nga v cc vng
ph ln ca da v m di da ( ph mch Angioedema ), hay ti pht, cp tnh hay mn tnh.
T l 15 - 23 % dn s tng b tnh trng ny trong i sng.
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. Cc kiu c hiu .
1.1.1. Min dch .
- Trung gian IgE : th ng c nn th a d ng khng nguyn thc n ( sa, trng, c hi ),
thuc men : Penixilin, k sinh trng.
- Trung gian b th , phc hp b th hot ho gy nn tn ht t bo Mast.
1.1.2. My ay vt l :
Chng da v ni (Dermographism ): 4,2 % , dn bnh thng c n.
- My ay do lnh thng tr em v ngi tre, chn on bng test " cc ".
- My ay do nh sng mt tri ph 290 - 500 nm, histamin l mt trong cc trung gian ho hc.
- My ay cholinergic khi vn ng cc bi tp th lc tng tit m hi, sn nh.
- Ph mch : p sut , rung chn ng, tin s s ng ln sau chn ng, khng histamin khng
hiu lc, corticoids th c ch.
1.1.3. M ay do thuc gii phng t bo Mast.
- Phn ng khng dung np ( Intolerance ) vi salicylates, thuc nhum Azo v benzoate.
1.1.4. M ay kt hp vi bnh t min m lin kt - mch mu . Vim mao mch m ay l
mt dng ca vim mao mch da ( cutaneous vasculitis ) tn thng m ay ko di hn 12 -
24 gi, c th kt hp vi ban xut huyt hoc c th thy nhim sc t do hemosiderin, th ng
kt hp gim b th mu v bnh thn.
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.
1.1.6. Hi chng m ay - ph mch tng bch cu i toan ph mch nghim trng, c m ay
sn nga mt , c, chi, thn mnh ko di 7- 10 ngy. C st tng cn (10- 18 %) do gi dch.
Cc c quan khng tn th ng, tng bch cu i toan, tng bch cu 20 .000. - 70. 000. Tin
lng tt.

. Sinh bnh hc.
- Tn th ng m ay cp trung gian IgE do cc cht hot tnh sinh hc t t bo Mast v t
bo i kim c gii phng do khng nguyn gy nn, cc t bo mn cm khng th IgE
type I tng mn cm loi qu mn.
- 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.
- Trong m ay mn tnh histamin c tit ra t t bo Mast da l cht trung gian ch yu.
Cc cht trung gian khc gm eicosanoids v neuropeptides cng c th c vai tr mt
phn trong s to thnh tn th ng nh ng o trc tip cc cht ny khng thy c thng
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.
M ay to ra do cht trung gian khng phi cytokine m trng l ng phn t ln hn 1 triu
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
vo cc d i ni lin IgE ca th th hp dn cao lin k. Nh vy t khng th khng IgE
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.
1.2. Cc kiu chung.
1.2.1.
M ay cp ( < 30 ngy ) th ng l m ay ln ph thuc IgE, c nn tng Atopic, lin quan
thc n, k sinh trng, thuc, thng kt hp ph mch.
1.2.2. M ay mn ( > 30 ngy ). t ph thuc IgE, cn nguyn khng r, 80 - 90 % cho l t
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 .
- Thi gian xut hin tn thng : nhiu gi.
- Cc triu chng da : chng nga, au khi i ( chn b bnh ) ng , rt bng v th kh
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 .
- Cc sn m ay nht thi - nhiu sn nh 1-2 mm th in hnh cho m ay Cholinergic,
chng nga - sn m ay loi nh 1,0 cm n to 8 cm cc mng ph.
- Ph mch mt vng rng mu nh mu da mt phn ca mt ( quanh mt, mi, l i ) hoc
chi.
- Mu sc : hng vi cc tn th ng rng c vng trng trung tm bao quanh bi qung .
- Hnh dng bu dc , hnh cung, hnh vng, a vong, kiu hnh c pt v kiu hnh dng k l.
- Phn b : hnh vng, hnh vng cung, ng vt.
- Khong thi gian nht thi, nhiu gi.
- Phn b khu tr tng vng hoc trn lan.
- V tr hay gp : v tr t , vng h ( m ay do nh sng ) thn mnh, bn tay v bn chn,
mi, tai.
4. Chn on phn bit .
Ban m ay : cn trng t, phn ng thuc, vim da tip xc c m ay, vim mao mch m
ay.
5. Xt nghim v khm nghim c bit :
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
mch ch yu lymphocytes, T helper, HLA- DR d ng tnh. Trong cc sn ph c cht tit
Selectin E v ICAM I t bo ni m mch mu, VCAMI t bo quanh mch.
- Huyt thanh hc :
Kim tra khng nguyn vim gan kt hp
nh gi h thng b th.
nh gi khng th IgE bng k thut RAST
- 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.
- Nghin cu b th : cht c ch chc nng.
- Siu m chn on sm tn th ng rut, ph rut.
- K sinh trng hc : xt nghim phn tm k sinh trng.
6. Chn on :
Vn chn on thc hnh m ay mn c trnh by bng 15 - A. Hi cn thn tin s
dng thuc gm Aspirin, khng phi - Steroids, nu nghi ng m ay vt l c th lm test th
nghim thch hp. M ay cholinergic c chn on tt nht l bi tp th lc ra m hi v
tim trong da acetylcholin hoc mecholyl n s to nn sn ph nh. M ay do nh sng lm
test UVB, UVA v nh sng kh kin. M ay do lnh bng test p cc hay ng cha cc ,
n c . Nu m ay khng bin mt sau 24 gi l vim mao mch m ay v nn lm sinh
thit da. Hi chng m ay- ph mch do tng bch cu i toan mu c st cao, bch cu cao
(phn ln l bch cu i toan ) tng cn do gi n c.
Ph mch di truyn c tin s gia nh r v c c tnh ph mch mt v cc chi do hu
qu ca chn th ng hoc au bng v thy gim mc cht c ch C4 v
C 1 esterease v cht c ch lon chc nng .
7. Sinh bnh hc.
- Tn th ng m ay cp trung gian IgE do cc cht hot tnh sinh hc t t bo Mast v t
bo i kim c gii phng do khng nguyn gy nn, cc t bo mn cm khng th IgE
type I tng mn cm loi qu mn.
- 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.
- Trong m ay mn tnh histamin c tit ra t t bo Mast da l cht trung gian ch yu.
Cc cht trung gian khc gm eicosanoids v neuropeptides cng c th c vai tr mt phn
trong s to thnh tn thng nh ng o trc tip cc cht ny khng thy c thng 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 thng ca con ng arachidonic.
M ay to ra do cht trung gian khng phi cytokine m trng l ng phn t ln hn 1 triu
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
vo cc di ni lin IgE ca th th hp dn cao lin k. Nh vy t khng th khng IgE
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.
7. Tin trin v tin lng .
Mt na s bnh nhn b m ay tn th ng ko di mt nm, c 20 % tn th ng ko di 20
nm.
Tin lng phn ln l tt tr ph mch di truyn c th t vong nu khng c iu tr.
8. X tr iu tr .
- D phng cc cn ni m ay bng vic loi b cn nguyn thuc v ho cht , aspirin, thc
n, c bit trong m ay mn tnh ti pht nhng t kt qu.
- Khng histamin: cc cht chn H1 nh : hydroxyzin, terfenadine v nu tht bi dng cht
chn H1 v H2 ( cimetidine ) v thuc lm n nh vng t bo Mast (Ketotifen). Doxepin mt 3
vng ( Tricyclic) , mt thuc chng trm cm vi tc dng khng histamin H1 r c gi tr khi b
m ay nghim trng c kh chu v trm cm.
Prednisolon ch nh cho hi chng m ay-ph mch tng bch cu i toan mu.
Danozol tr liu di ngy cho ph mch di truyn huyt t ng t i ton b hoc cht c ch
esterase C1 trong cn cp.

Bng 15A :c im cc loi m ay mn tnh.
Kiu m ay la tui
ca bnh
nhn
c im lm sng ch yu ph mch
kt hp
Test chn on

M ay mn tnh
t pht

20-50
t hoc nhiu lan to sn
hoc sn m ay, sn ph
hng hoc ti nht, thng
hnh vng c nga.


C

Dermographism
Chng da v ni

20- 50
Nga, sn m ay thnh
vt, ng , xung quanh
mu sng, v tr co
gi c st.

Khng
Vch nh vo da
gy nn sn m
ay ngay lp tc,
c nga

M ay vt l
khc: lnh

10- 40
Nga, s ng hoc mu ti
v tr tip xc lnh hoc n
c.

C
10 pht p cc
gy nn sn ph
trong vng 5 pht
sau khi b cc .

M ay do p xut
t p

20- 50
S ng nga hoc au
nhiu v tr p sut (
bn chn, lng bn tay
hoc hng )

Khng
S dng p
vung gc vi da
tao nn sng
dai dng sau thi
gian tim n 1-4
gi.

M ay do nh
Sng nga v tr chiu
UV hoc nh sng kh kin
Chiu nh sng
nhn to 2,5 KW(
sng mt tri 20- 50 C 290- 690 nm) 30-
120 giy gy nn
sn ph trong
vng 30 pht.

M ay cholinergic

10- 50
Nga, < 5 mm. Sn ph
hng hoc ti, n dng
thn mnh, c v cc chi

C
Bi tp th lc
hoc tm nc
nng lm xut hin
ban


63. BAN M AY

- V tr: u mt, thn hnh, tay chn, ri rc nhiu ni.
- 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.
C khi nhiu sn lin kt vi nhau thnh mng vn vo nh bn :
Xut hin t ngt,; bin i nhanh chng trong vng mt vi gii- mt vi ngy, khng li vt
tch g trn da.
Nu mc vng da lng lo nh mi mt, da bu th lan to nhanh.
Triu chng c nng:
Nga d di, dm dt:
C khi km au bng, a lng, kh th ( do ban, c ng h hp).
Tin trin tng t vi ngy, c khi ti pht dai dng hng thng.
- Cn nguyn :
+ Thng do d ng, gii phng Histamin, Serotomin. Th ia d ng IgE tng.
+ Cy c, cn trng lng sc vt, phn hoa.
+ Ho cht
+ Thuc men: Sulfamid, aspirin, penixilin.
+ Thc n- tm cua c, c (hi sn).
+ Do lnh: Nc lnh, gi lnh, ma lnh.
+ Khng r nguyn nhn.
- iu tr:
- Ti ch : Bi h nc, du km oxide km
+ Bt Ialc menthol 1%.
+ M Corticoid: Flucinar.
- Ton thn:
+ Khng sinh Histamin tng hp
+ Chlopheniramin 2-4 vin / ngy.
+ Vitamin C.
+ Clomacanxi 0,50 1 ng tnh mch chm.
+ C th cho dng mt t Corticoid nu khng c chng ch nh:
. Nng tim truyn
. Va, nh dng loi ung ( clerton hoc Prednisolon)
. Cimetidin 200mg 3-4 vin /ngy.

64. BCH BIN
( vitiligo)
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 :
+ V tr tn thng : gp bt k vng da no trn c th, nhng hay thy vng bn nim
mc: mi, mi mt, sau l mt, c, ngi v u mt tay hoc chn.
+ Tn thng c bn l cc dt trng, kch thc khong vi mm sau to dn ra ( c th t t
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
hin vng da lnh khc.
Bnh nhn khng c triu chng ch quan g c bit (khng mt cm gic au, nng, lnh).
+ Mt vi th lm sng thng gp:
- Th khu tr ( Localized type) tn thng l mt hoc nhiu dt trng nhng v tr c lp.
- Th t on ( Segmental) tn thng l cc dt trng to thnh mt di thng xut hin dc
theo dy thn kinh cm gic.
- Th lan to (Generalized type) tn thng phn b rng ri lin kt vi nhau to thnh hnh
vn vo v thng i xng hai bn c th.
- Th u chi hoc mt ( Acral or Acro- facial type) tn thng khu tr u chi nh mu ngn
tay, ngn chn, c th kt hp vi tn thng quanh ming v mt.
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 ).
5. Chn on v chn on phn bit.
+ Chn on quyt nh :
- Da vo hnh nh lm sng tn thng l cc dt trng, nu c lng tc vng da tn
thng cng mt sc t ( y l du hiu qu khng nh chn on).
- Triu chng ch quan : khng b ri lon (c th khi phi nng tn thng hi hng ln, rt v
nga nh).
+ Chn on phn bit :
- Bch tng.
- Phong bt nh.
- Lang ben.
- Di chng sau mt s bnh ngoi da nh zona, vy nn...
6. iu tr : l mt bnh kh iu tr, kt qu tht thng, thng p dng mt trong cc bin
php sau y:
+ 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 dung dch ph c ch bi v ung cho bnh nhn.
+ 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.


65. BNH BOWEN

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.
Giai on sau t nhin cc m tn thng tr ln trt, lot, si rt ging ung th t bo gai.
3.Chn on quyt nh v chn on phn bit
+ Chn on quyt nh : da vo lm sng v m bnh hc ( cc t bo gai c nhn hnh qu
du, c khng bo gi l t bo Bowen hoc t bo lon sng Darier).
+ Chn on phn bit : vi bnh vy nn, lupt , ht cm da du, giang mai III, lao da dng
ht cm, liken ht cm...
4. iu tr : giai on sm t lnh, t in su c kt qu tt. Giai on mun ct b tn
thng bng ngoi khoa , quang tuyn liu php.

66. BNH DUHRING BROCQ
TS Nguyn Khc Vin
Bnh Duhring - Brocq (DH) l mt bnh da mn tnh, c mi la tui, c xp vo nhm
bnh c c ch t min vi 4 triu chng lm sng in hnh, nhn chung iu tr c kt qu tt
nhng d phng ti pht cn nhiu kh khn.
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.
2.Cn nguyn bnh hc:
Cho n nay phn ln cc tc gi u cho rng:
2.1. Yu t di truyn.
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.
Nm 1967 Cormane , Meer (1969) pht hin thy s lng ng KT IgA nh nh b, ca
bnh nhn DH, cn vi pemphigoid bng nc th IgG l lp khng th ph bin nht
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.
2.3. Lin quan vi nhng bnh t min.
Bnh DH c m t vi mt s bnh t min nh: vim cu thn, thiu mu Bermeer, vim
tuyn gip, lupus ban h thng, vim a sn mn tnh teo.
2. 4. Vai tr ca gluten.
Gluten c cp nhiu trong cn nguyn ca bnh v c xem nh l mt khng nguyn
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.
2.5. DH v bnh i chy m (coeliac disease- CD)
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
cm gluten v khng th phn bit c vi bnh CD. Ngy nay c xc nh r , c hai
bnh DH v CDu c nhng ri lon nhy cm vi gluten, u c khuynh hng gia nh v
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:
Tn thng thng xut hin t t trn mt th trng hu nh khng c bin i g c bit,
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
xp l t hay cm li nh trong bnh ecpt. Cc bng nc ny to bng ht ng cng, trong
cha dch mu vng chanh, him c bng nc xut huyt. Bng nc tn ti 5- 7 ngy , sau
lm m v v ra li vt trt, ng vy tit,vy m, du hiu mit da Nikolsky thng m
tnh. Cc tn thng y c nhiu la tui, c ch l ban , c ch l bng nc, c ch
lot,thm ch c ch ch li mt dt sm mu. D c phng m nhng t khi c bin chng
vim hch hoc vim ng bch huyt.
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
thng, tr mt vi trng hp ngi cao tui, lu ngy c th b suy kit.
4. Cc xt nghim chn on, chn on phn bit bnh DH:
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 nhng t bo gai Malpighi c hnh nh qui d do b phn ly bi mt cc cu ni lin kt.
4.4. Test min dch hunh quang trc tip.
y l test c gi tr nht trong chn on bnh DH. T l dng tnh 85- 90% trng hp. Test
cho ta thy c lng ng IgA nh nh b.
4.5. M bnh hc.
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:
5.1. Chn on quyt nh
+ 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.
Bnh tin trin nhiu t, ton trng t bin i.
+ 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.
5.2. Chn on phn bit:
+ Pemphigus thng thng: y tn thng mang tnh cht n dng l bng nc lp
thng b v test KI m tnh...
+ Pemphigoid bng nc: bnh thng gp ngi cao tui, bng nc cng to kh v, nu
v th chng lnh, test min dch hunh quang trc tip pht hin lng ng khng
th IgG v b th mng y...
+ Ban a dng: tn thng b nhim t bo nh trong DH.
+ Chc: bng nc trn nn da vim , bng nc nhanh chng v li vy tit mu vng
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.
+ Ti ch: ch yu dng cc dung dch st khun Milian, tm metyl, xanh metylen bi vo
cc tn thng ( nu tn thng cn phng nc nn dng kim v khun chc thm dch trc
khi bi). Khi tn thng kh c th bi m cloroxit, flucina.
+ Ton thn:
- Corticoid 30- 40 mg/ ngy , sau h liu dn trong 4- 8 tun, ch dng cho cc trng hp
nng.
- Erythromyxin 1- 1,5 gam/ ngy cho tng t 7 ngy x vi 3 t.
- DDS mi ngy 50- 300 mg dng ko di 1- 2 thng.
- Sulfapiridin mi ngy 1-3 gam, 1-2 thng lin tc.
+ 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.
+ D phng : ch n cn hn ch n thc phm c nhiu gluten nh go, ng.


67. BNH CHM
1. Tnh hnh .
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).
1.3. L bnh da nga in hnh, mn tnh hay ti pht, iu tr cn kh khn.
2. Nguyn nhn .
Nguyn nhn phc tp nhiu khi kh hoc khng pht hin c. C th do :
2.1. Nguyn nhn ngoi gii .
Cc yu t vt l,ho hc, thc vt, sinh vt hc ng chm vo da gy cm ng thnh vim
da, eczema ( cc cht ny gi l di nguyn ). V d : nh sng, thuc bi, tim ung, cc ho
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.
2.2. Nguyn nhn ni gii.
- 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 ".
Theo Halpern, Coombs phn ng eczema c xp vo kiu " mn cm t bo tr hon" trong
c vai tr ca cc t bo lymph mang k c khng nguyn.
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. Tn thng c bn : tn th ng c bn trong bnh eczema l m mng da v mn
nc, mn nc l tn thng in hnh ca bnh eczema, eczema pht trin qua 4 giai on :
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.
3.2.2. Giai on mn nc ( cn gi l giai on chy nc ): mn nc ngy cng nhiu v
xut hin trn khp b mt m tn th ng, mn nc eczema c cc c tnh sau :
- Mn nc nh bng u tm, u kim 1-2 mm.
- Nng, t v.
- San st bn nhau kn khp b mt th ng tn .
- n t d i ln ht lp ny n lp khc .
m tn th ng b mt chi cht cc mn nc. Mn nc nng, t v v do nga
gi nn m tn th ng b trt, chy dch nn cn gi l giai on chy nc, giai on ny
ko di nhiu ngy hoc vi tun, cc mn nc v i li im cht nh nh chm kim ( cn
gi l ging eczema ca Devergie) nhiu im cht lin kt thnh m mng trt , r dch ,
ng thi d nhim khun th pht c m, vy tit..
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,
nn da hi nhim cm, sm mu hn.
3.4. Giai on liken ho ,hn c tru:
Eczema tin trin lu ngy da cng ngy cng sm mu, tng nhim cm, b mt x x th rp ,
s nn cng cm, cc hn da ni r, gia cc hn da c cc sn dt nh trong bnh lichen,
qu trnh ny gi l lichen ho.Nga tn ti dai dng.
- Giai on da, mn nc , chy nc cn gi l eczema giai on cp tnh.
- Giai on ng vy da, nn da non, kh hn gi l eczema bn cp.
- Giai on lichen ho , hn c tru c gi l eczema mn tnh.
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
eczema l bnh da ng a in hnh.
Tin trin : mn tnh hay ti pht, nhiu t vng bnh, xen k cc giai on tm .
4. Cc th lm sng :
4.1. Eczema tip xc: ( contact eczema, contact dermatitis).
- V tr : xut hin u tin vng tip xc thng l vng h, c khi in hnh vt tip xc ( v d
hnh quai dp, hnh dy eo ng h...)
- Tn thng c bn : da xung huyt, c khi xung huyt mnh, hi n, trn b mt c mn
nc, c khi c bng nc, cp tnh trt t, chy dch, ph n. C th c hnh thi mn tnh,
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.
- Lm th ng da (Skin test) vi cht tip xc ( d ng nguyn ) thng dng tnh, thng lm
test p da, test con tem ( Patch test) nh ng khng lm khi bnh ang vng hay ang iu tr
corticoids.
- Mt s d ng nguyn (Allergens) ngoi gii gay eczema tip xc nh : Nikel, potassium
dichromate, fomaldehyte, xi mng, cao su, neomycin, Streptomycin...
- 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 :
- Pht hin d ng nguyn tip xc v trnh tip xc vi d ng nguyn.
- M corticoids ti ch.
- Corticoids ung khi bnh lan rng hay tn thng mt, sinh dc, ung vo bui sng.
4.2. Eczema th a , vim da c a ( Atopic dermatitis) (AD).
Vim da c a l biu hin ngoi da ca c a Atopy ( Atopic state, Atopic diathesis), 70 % s
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.
Sinh bnh hc v min dch hc ca vim da Atopy (AD)
- C tnh cht gia nh r rt, nu c hai cha m b bnh d ng 79 % con ci b AD, 73 tr em b
AD c tin s gia nh b AD.
- Nghin c v gen hc gn y pht hin bnh nhn AD thy :
+ Nhim sc th ( NST) 11913 chui b ca th th c i tnh cao vi IgE.
+ NST 5931 - 33 l gen ca cc cytokins IL4. IL5, 6MCSF.
+ NST 14911 - 1 l gen ca Chymase ca d ng bo (Mastocyte).
+ NST 6q gen ca HLA - DR.
+ NST 16 p 11- 2-11.1 gen ca th th IL4.
- Vai tr ca khng th Reagin trong bnh sinh ca AD c ngh n .
IgE tng cao 80 % s bnh nhn AD v cng cao nu AD cng nng , mc IgE bnh nhn
AD cao hn hen xuyn v vim mi d ng. Tuy nhin 20 % s bnh nhn AD vn c mc
IgE bnh th ng. Gii thch iu ny bng c ch sau:
Mt mt trong bnh AD, Histamin tc ng ln th th H2 ca bch cu, lm cho chc nng ca
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.
- IgE tng cao khng phi l yu t c bn trong sinh bnh hc ca AD.
- Theo Thomas Biefer ( CHLB c ) t bo Langerhans bnh nhn AD bc l ln b mt mt
th th rt i tnh vi IgE, v t bo Langerhans mang th th ny s c kh nng c nh IgE
v ni nhp khng nguyn, sau khi ni nhp khng nguyn c s hot ho sn xut cytokines
v chimiokines s khi pht mt phn ng eczema. bnh nhn AD ch cn mt t d nguyn
bay trong khng kh cng khi pht phn ng eczema . C ch ny gp 30- 40 %
bnh nhn AD.
- Trong bnh AD min dch trung gian t bo b suy gim gim st tnh phn ng trong test da
chm nh Tuberculine , Candidine...
Chuyn dng lymph b gim st nht l trong t bnh AD v ng ty gim st s l ng
lympho T l u hnh c bit T c ch mang th th IgE - Fc iu gii thch s sn xut tng
qu mc IgE trong bnh AD.
- Tnh ho ng ng bnh nhn AD b gim st d b nhim trng khi b sang chn, xy x c
hay b nhim trng t cu vng, 90% s bnh nhn AD c phn ng Coagulase d ng tnh vi
t cu vng, c th ni t cu vng l vi khun chim u th trn da bnh nhn AD v s c
mt th ng xuyn ca t cu trn da bnh nhn AD dn n khi ng s gii phng
histamin, gy nga v vim da trong AD.
- Bnh nhn AD c mc Acetylcholine cao trong da, iu gii thch mt phn nh h ng
ca yu t xc ng trong bnh AD.
- C s tng cao hot tnh ca Nucleotid- Phosphodiesterase lm thu phn nhanh chng cht
Nucleotid vng, hu qu l cAMP b gim st nn tc dng c ch sn xut histamin b km tc
dng, trong khi cGMP tng c ng, dn n histamin c sn xut qu mc bnh nhn
AD.
- 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.

L mt bnh kinh din hay ti pht, cc thng tn lm sng ch yu l :
+ Vim da : dt km sn mn nc.
+ Hn c tru.
+ Kh da, xy xc, nhim trng th pht.
Bnh hay gp tui u th t 2 thng n 2 tui, tr em, thanh thiu nin v c ngi ln.
D i 7 tui chim 80- 90%, khong 10 % bnh ko di n tui trng thnh.
Cc biu hin lm sng theo la tui :
4. 2.1. Eczema th a tui s sinh v nh nhi , u th.
(infantile Atopic dermatitis) ( infancy) gp tr t 2 tun n 2 tui. Thng gp tr b bm 2-
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.
C th km i lng, vim tai gia.
4. 2.2. Thi k tr em ( child type atopic dermatitis): tr em ( childhood) hoc thanh thiu nin (
Adolescent ) 2-3 tui n 12- 20 tui. L cc m mng lichen ho ( hn c tru ) dng a lc
u cc mt dui, u gi, ci tay, sau lan n cc np gp, ngoi ra c th sn nga, da
kh, hn c tru.
C khi km c thu tinh th, vim kt mc.
4.2.3. Thi k trng thnh ( Adult type atopic dermatitis): ng i ln (Adult) ch yu l hn c
tru, v tr c bit l cc np k ln v bn tay, n gii c th c vim nm v, vim mi.
Tin trin mn tnh, c khi chuyn thnh hen hoc st ma c kh.
4.2.4. iu tr eczema th a cn ch mt s im sau :
- Trnh cc cht gy kch ng da.
- Gi n c cho da dng cream, m lm m da ( Lacticare...) trong cc t bnh n nh.
- Tm n c hi m nhng khng nng, hn ch x phng.
- Bi m glucocorticoids.
- Khng sinh chng t cu vng khi c bi nhim nn dng erythromycine.
- Khng histamin tng hp.
- Corticoids ng ton thn ( ung) nn hn ch dng, ch dng cho giai on vng bnh
v dng tng t ngn.
- UVA , UVB, PUVA c hiu qu.
4.3. Eczema vi khun .
- Do d ng vi c t ca vi khun t cu, lin cu hoc c t ca nm Trichophyton,
epidermophyton.
- Thng xut hin trn cc vt xy xt da nhim khun, vt cn trng t, vt bng, l r, vt
m...
- V tr th ng cng chan mt bn hoc hai bn c khi quanh vt m, quanh l d, hay quanh
tai sau vim tai gia chy m.
- m tn th ng cht , chy dch, c m dch, vy tit, gii hn t ng i r.
- Quanh m tn th ng c th c mt s mn m, nht " kiu v tinh ".
- C trng hp ngoi m tn thng chnh mt, thn mnh, cc chi c cc m nh, b
mt ln mn sn , mn nc v nga gi l " ban d ng th pht xa" .
4.4. Eczema th ng tin ( Nummular eczema):
C c im l c cc m tn th ng hnh trn, oval nh ng xu (coinlike), ban u l m
tit dch, c mn n c, sn, hi n, sau c vy tit, vy da, lichen ho gii hn r , thng
khu tr thn mnh, mt dui ca chi, trc x ng chy, mu bn tay.
Th ng gp n ng tui trung nin, nht l ma thu ng.
C kin cho rng eczema th ng tin l mt th c bit ca eczema vi khun, l ban
d ng vi nhim khun khu tr bn trong c th. Hin nay eczema th ng tin l mt phn
th ca eczema th a ( Atopic eczema) nhng IgE bnh thng, tuy nhin vn ny cn
tranh lun.
M bnh hc c tng gai, xp bo.
iu tr corticoids, c khi tim cortiocids d i tn th ng c th bi Coaltar.
Khng sinh ton thn.
PUVA kh hiu qu .
4.5. Eczema da du , vim da da du ( Seborrheic dermatitis) l bnh da mn tnh th ng gp
c c tnh l da v vy , vy m vng tuyn b hot ng mnh nh mt, u v cc np
gp. Th ng gp phn ln ngi 20 - 50 tui, c th gp tr em ( nhng thng u ), tui
u th, nin thiu. Nam th ng b nhiu hn . C th a di truyn " th a da du ".
V tr th ng gp nht l u, mt thng b lng my, quanh mt, gia mi, np mi m.
sau tai, c khi thn mnh nht l da vng c , lin b, cc np nch , bn di v, sinh dc.
Tn thng l m mng , trn c vy, vy m c khi c sn trn b mt, gii hn t ng i
r, kh, nhng vi th c hin tng xp bo.
M bnh hc da c sng, tng gai, xp bo, chn b vim khng c hiu.
Cn chn on phn bit vi vy nn, chc, nm da u, nm mt, nm thn, lupus .
iu tr : m corticoids bi c hiu lc nhng cn ch bi mt c th gy teo da, gin mch.
Chiu UV
- u c th dng loi Shampoos c lu hunh v coaltar hoc dung dch cortioids.
Shampoo ketoconazole 2% hoc dng cream.
- Np k dng dung dch castellani.
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...)
- Trnh tip xc vi d ng nguyn nu pht hin c .
- Trnh co gi ch xt, trnh x phng.
- Nu c nhim khun r ( st, bch cu tng cao, tn thng s ng ty au, ni hch, c m
vy tit) cho dng khng sinh ung 1 t 7 - 10 ngy (Tetracyclin,erythromycin)
- Cho thuc gii cm, chng nga, chng d ng: khng histamin tng hp .
Eczema ang vng lan rng, c ban d ng th pht c th ch nh corticoids ung mt t
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....)
- Vi eczema mn tnh c th dng Gondron, coaltar, m corticoids hoc m corticoid+
a.salicylic nh m diprosalic.



68. BNH GIANG MAI

1- Tn bnh: Giang mai. Syphilis, Lues.
Giang mai l mt bnh nhim khun, ly truyn ch yu qua ng tnh dc nhng c th ly
qua ng mu, ng m sang con v ng tip xc trc tip vi cc th ng tn giang mai
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.
Nu khng c iu tr bnh c th xm nhp vo ti c cc ph tng c bit l da, tim mch,
thn kinh trung ng gy nhiu bin chng rt nng, c nhiu hnh thi lm sng khc nhau
nn chn on cng rt kh khn.
Bnh nh hng ti sc kho bnh nhn thm ch gy t vong hoc tn ph sut i nu
khng c iu tr kp thi. N nh hng su sc sc kho v s pht trin ni ging ca
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.
S thc bnh giang mai c t i thng c v trong ti liu ca Trung Quc, n , Hy Lp
ng i ta m t nhng th ng tn x ng ngui ging ht cn bnh giang mai.
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
vng Trung M nh Mehico...
- Bnh Pinta ( ting B o Nha Maldel Pinta c ngha l v mu, v bnh ny li cc vt
mu xanh). Nguyn nhn gy bnh do T.carateum. Bnh ny gp Nam M nh Braxin,
Achentina...
- Bnh giang mai gy nn do T.Pallidum . Bnh ny gp e tt c cc n c trn th gii.
2. Mm bnh:
Bnh giang mai gy nn do xon khun nht (Treponema pallidum) do Schaudinn
v Hoffmann pht hin ra nm 1905. y l 1 loi xon khun hnh l xo c 6-10 vng xon,
ng knh ngang khng qu 0,5, di 6-15. Xon khun c th c 3 loi di ng:
- Di ng theo trc dc kiu vn inh c.
- 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
ng h, n cht nhanh chng ni kh, ni m t n sng dai dng hn. trong n c v
lnh -20C n vn di ng c rt lu.
45C n b bt ng v c th sng c 30 pht.
X phng c th git c xon khun sau vi pht.
Xon khun vo c th qua ch da v nim mc b xy xt th ng l do tip xc trc tip do
giao hp, ng sinh dc,ng hu mn hay ng ming. T xon khun i vo hch v
1 vi gi sau n i vo mu v lan truyn khp c th.
3- Ngun bnh v ng ly:
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.
T 1956-1964 Min Bc gii phng, i sng n nh, cc nhm c nguy c cao c
kim tra. pht hin trong nhng nm u l 1000-1500 ca/nm. T l so vi dn s l
0,1/1000.
S lng gim dn, cho n 1963-1964 mi nm ch pht hin khong 20 ca (t l so vi dn
s lc l 0,01/1000). Bnh giang mai cng nh cc bnh LTQTD khc gim 10 ln so vi
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
khi t n c c thng nht, s ngi b mc bnh giang mai ln ti 160.000 ca, t l l
5/1000 (so vi tng s dn lc l 45 triu).
S gi mi dm tng, thnh ph H Ch Minh khong 30.000 ng i (64% trong s ny c th
nghim huyt thanh + ).
T l giang mai bm sinh: 1,25%.
T l sn ph b giang mai: 4,5%.
T 1975 n 1990, mi nm ngnh da liu iu tr cho khong 10-20.000 bnh nhn giang mai.
S liu ny cn c th nhiu hn v bnh nhn t cha hoc cha t khng n cc c s y t
ca nh n c c s liu thng k chnh xc.
Theo iu tra ca Bi Kim n 1977. T l mc bnh giang mai trn gi mi dm khu vc H
Ni l 18,8% trn cc i tng c hnh vi nguy c cao (nhn vin massage c t l t ng ng
l 1,8%). T l phn ng huyt thanh giang mai d ng tnh l 1%, qua iu tra trn 1600 mu
mu ca cc i tng n khm ti phng khm chuyn khoa da liu.
Ngun bnh: l ngi mc bnh giang mai k c giang mai kn, giang mai.
Giai on 3: Ngoi ra khng c ngun no khc nh t ng vt hoc cn trng.
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:
- Ly truyn qua ng tnh dc.
- Ly truyn qua ng mu(tim truyn mu hoc tim chch ma tu m bm tim khng v
khun).
- Truyn t m sang con (qua nhau thai t thng th 4 tr i).
4 - Triu chng lm sng:
Theo c in bnh giang mai tin trin lm 3 thi k : giang mai 1, giang mai 2, giang mai 3.
Gia cc thi k c giai on khng c triu chng lm sng gi l giang mai kn .
Theo cch phn loi mi , bnh hiang mai c 2 loi :
- Giang mai mc phi ( Syphilis acquise)
- Giang mai bm sinh ( Syphilis congnitale).
Giang mai mc phi :
Giang mai mi v ly
Giang mai thi k 1
Giang mai thi k 2:
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.
Giang mai mun khng ly
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.
Giang mai bm sinh:
Thai nhi b ly t m khi cn nm trong t cung nn khi ra mc bnh, d i nhiu hnh thi
khc nhau.
- Giang mai bm sinh sm xut hin trong 2 nm u.
- Giang mai bm sinh mun xut hin khi b trn 3 tui.
- Di chng ca giang mai bm sinh:cc th ng tn giang mai thai nhi thnh so v khi b
ra i c sn cc du hiu nh trn d, mi tt hnh yn nga, x ng chy hnh l i kim,
tam chng Hutchinson (rng Hutchinson, ic nht thi, lc quy t).
Lm sng giang mai thi k 1:
c im giang mai 1 l thi k xon khun xm nhp ti ch v qua h thng mch mu
lan ton thn. Tn th ng khu tr ti ch, nng iu tr khi hon ton khng li di chng t
nguy him cho bn thn ngi bnh nu iu tr kp thi. Nh ng rt nguy him cho x hi v ly
rt mnh (nhiu xon khun ti cc tn thng, bnh nhn khng c cm gic ch quan vn
quan h vi nhiu bn tnh c).
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.
n b th ng xut hin c t cung, thnh m o, mi ln, mi b, m vt. Cn c th c
mt s v tr khc nh hnh nhn, hng, l i hoc mi, trn trn, v c khi ngn tay nht
l i vi n h sinh cho bnh nhn giang mai.
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.
- Khng nga, khng au.
- Nn rn nh mnh ba.
Ngy nay ngi ta gp nhiu loi chancre khng in hnh nh m t.
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.
Mt s trng hp khng in hnh:
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).
n b lot mi ln gy ph n nhiu mt bn m h. Khu tr c t cung hay gp
nhng thng b b st v khng gy au n g. hu mn khi biu hin bng vt nt thm
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.
-Khng lin kt li vi nhau.
Tr ng hp lot b bi nhim, hch cng sng nng au nhng khng v m.
4.5. Giang mai thi k 2:
c im ca giang mai 2: l thi k nhim trng mu. Xon khun xm nhp vo tt c cc c
quan ph tng. Tn thu ng a dng nh ng ch a ph hu t chc nn c th hi phc hon
ton nu c iu tr kp thi. Thi k ny i vi bn thn bnh nhn ch a thc s nguy him
nhng i vi cng ng x hi th rt nguy him v ly lan rt mnh, tt c cc tn thng
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.
Tn th ng giang mai thi k 2 c nhng c im sau:
- C nhiu dng th ng tn, c im chung l khng nga, khng au.
- Cc th ng tn sm th ng lan to ton thn v i xng.
Cc thng tn giang mai 2 mun c khuynh h ng khu tr hn v khng i xng.
- Thng tn rt a dng th ng nng hn trn mt da nh dt (hng ban) sn, sn vy, sn
m, mn m.
- Vim hch nh lan to vi cc tnh cht nh giang mai 1, rn khng au v di ng.
- C 1 s triu chng ton thn: st nhc u v m, khn ting au x ng khp.
- Khng c triu chng c nng km theo. Tuy nhin cc th ng tn nang lng, mn m c
th hi nga. Cc th ng tn t, chy m hay tit dch c th nga rt.
- Cc th ng tn giang mai 2 ti pht th ng thnh hnh vng cung, hnh nhn v khng i
xng.
Cc loi thng tn ca giang mai thi k 2:
- o ban l cc dt mu hng, n knh mt, th ng thy vng bng, mng s n, b vai, cc
np gp tay chn. o ban xut hin da u gy rng tc.
Sau 1 thi gian khng iu tr g o ban cng mt i li mt t vt c sc t nh. ng i da
mu c th gp nhng dt trng loang l trn hay bu dc quanh c, vai c gi l vng v
n.
- Vim hch lan to: Cc hch nh, rn xut hin nhiu ni nh c, d i cm sau tai, nch, bn,
ci tay, ln d i ngn tay, khng dnh vo nhau.
- Cc mng nim mc khu tr vo cc nim mc nh quanh mp mi, quanh hu mn, m h.
C th trt lot, sn si hoc nt r, c vy tit, cha nhiu xon khun v rt ly.
- Sn ni cao trn mt da rn chc, mu ng hnh bn cu chung quanh c vin vy.
Sn rt a dng: sn c vy, sn trt, sn c m, sn lot, a dng c v v tr v cch sp xp:
sn hnh cung, sn hnh nhn, sn nang lng, sn dng trng c.
nhng vng nng v m ca c th nh k mng, hu mn, m h, nch, cc sn th ng c
chn b ra b mt phng v t c khi xp thnh vng chung quanh hu mn, m h, cha rt
nhiu xon khun v rt ly gi l Comdylomalata.
lng bn tay, bn chn do lp sng dy sn thng c b mt phng, bong vy da theo h
ng ly tm nn li mt vin vy chung quanh sn gi l vin vy Biett.
nhng t giang mai 2 ti pht mun, cc sn thng xp thnh 1 chm trung tm l 1 sn
ln, chung quanh c nhiu sn nh gi l corymbiose syphilide ( chm sn giang mai).
- 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.
Nu khng c iu tr cc th ng tn ny cng t mt i khng phi l khi m bnh n vo
trongv tip tc ph hoi c th. l giang mai kn (giang mai n).
Giang mai kn(giang mai n):
Thi k ny c th chia lm 2 giai on: khong 2-6 thng sau khi xut hin cc th ng tn ca
giang mai 2 ri t bin ht v b c vo giai on kn sm. Thi k ny khng c triu chng lm
sng nh ng vn ly cho ngi khc.
Khong 25% bnh nhn khng c iu tr li thy xut hin cc thng tn ca thi k 1
hoc 2 so lot c vo cui nm th 2 hoc cc tn th ng ph i chung quanh hu mn
nh condylomalata.
Cc thng tn ny khng c iu tr cng bin mt v sang thi k giang mai kn mun.
thi k ny bnh khng ly lan na, bnh nhn tng khi tuy nhin vn ly lan cho thai nhi
thnh giang mai bm sinh.
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.
Giang mai thi k 3:
c im ca thi k ny l tn th ng khu tr mang tnh cht ph hy t chc gy nhng di
chng khng hi phc, thm ch t vong cho bnh nhn. i vi x hi thi k ny t nguy him
v kh nng ly lan trong cng ng b hn ch. Nh ng nu l thai ph c kh nng sinh ra con
b giang mai bm sinh.
Thi k bt u vo nm th 3 ca bnh. Ta c th phn giang mai thi k 3 thnh 3 th bnh:
Giang mai c v gm giang mai :
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.
- Cc gm thng tin trin qua 4 giai on:
+ Giai on cng: 1 khi rn, trn, ranh gii r di da, b mt da vn bnh thng.
+ Giai on mm: mm t nng n su, dnh vo da lm da ln, khng di ng c.
+ Giai on lot: v m snh, dnh nh gm li 1 lot ng thnh, y c m ln mu. B
trn u hoc thnh cung.
+ Giai on thnh so: m cn, gm khi li 1 so rm r.
V tr th ng gp l mt, da u, mng, i, cng chn, vng trn ngc.
nim mc hay gp ming, mi, vm ming, l i, sinh dc v hu hng.
sinh dc gm c th xut hin trn so c nn c gi l chancre Nedute khngc hch
km theo, khng tm thy xon khun.
l i c th gp vim gm x lm l i to ln, tin trin mn tnh v c th bin chng c tnh.
Giang mai tim mch:
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 nht l vim ng mch ch lc u khng c triu chng g r rt. in tm bnh
thng. Khi ng mch gin rng th pht hin bng chiu X quang.
H ng mch ch nghe r ting thi tm chng. Huyt p ti a cao, ti thiu thp.
Phng ng mch ch khong 40% bnh nhn. C th b v v thnh mch yu dn.
Giang mai thn kinh:
Giang mai n su vo tu sng vo no gy vim mng no huyt qun (Meningo-
Vascular Syphilis. Xut hin 10-20 nm sau khi b lot).
Giang mai m thn kinh(Parenchymatous Nevrosyphilis) bao gm bnh Taber dorsa:
- au chi, d dy, khp.
- Tng phn x u gi.
- Tr ng lc c gim
- Ri lon cm gic su (khng ng c khi nhm mt)
- Ri lon tit niu
- Ri lon dinh dng,u gi to do tit dch.
- Phn ng huyt thanh VDRL (+).
Bi lit ton thn, cc ri lon tm thn. Xy ra khong 10-25 nm sau khi b bnh v chim
khong 4% s bnh nhn khng c iu tr.
4.6.4.Giang mai v thai nghn: (Giang mai bm sinh)
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 thai nhi b nhim mt cch t th sy thai thng 5, 6 hoc cht l u.
Nu nhim nh hn thai nhi c th thng nh ng cht l u hoc ra cht ngay.
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.
y l du hiu ca giang mai bm sinh sm, xut hin trong 2 nm u.
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).
Cc triu chng thng gp l:
- 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.
- To u gi c nc (hydrarthros) 2 u gi klhng au xut hin lc 16-20 tui.
- ic c 2 tai bt u t 10 tui, thng km theo vim mng mt k.
- Th ng tn x ng: thng vm ming, mi tt, trn d, xng chy l i kim.
5- Cc k thut xt nghim tm vi khun:
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.
5.2. Cc phn ng huyt thanh chn on giang mai:
- K thut pht hin nhanh.
Phn ng Citochol bng git mu hin nay khng lm.
Phn ng RPR ( Rapid) Rapid Plasma Reagin
Khng nguyn Cardiolipin tinh ch c gn than hot. Kt qu nhanh v c hiu cao
- Cc phn ng huyt thanh c in bao gm:
+ Phn ng kt hp b th nh BW c in, BWKolm.
+ Phn ng ln bng nh VDRL, Kahn, Citochol.
Tt c cc phn ng ny u dng khng nguyn khng phi l xon khun m dng khng
nguyn lipit ly t ph tng ng i, tim b, b pht hin khng nguyn reagin c trong huyt
thanh bnh nhn.
- Cc phn ng c hiu gm:
+ Phn ng bt ng xon khun TPI (Treponemal Pallidum immobili sation test).
+ 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.
+ Phn ng ngng kt hng cu c gn khng nguyn khng khun TPHA (Treponemal
pallidum hemagglutination test).
Cc phn ng khng nguyn l xon khun ny u d ng tnh vi mt s
bnh khc nh Pinta, gh cc (Pian).

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.
T khi c penicilline n nay hu nh tt c cc n c trn th gii u s dng penicilline v
nhng li th ca thuc ny i vi xon khun. V da vo s hiu bit ca cc yu t sau:
- C cu ca xon khun giang mai.
- S tng hp lp v ca xon khun trong qu trnh trng thnh v phn chia.
-C ch tc dng ca penicilline i vi c cu v qu trnh trng thnh v phn chia ca xon
khun.
- Chu k sinh sn ca xon khun.
- S nhy cm ca xon khun.
- Hot ng dc l ng hc ca penicilline trong c th bnh nhn.
- Penicilline c tc dng i vi xon khun bng cch c ch men transpeptidaza trong qu
trnh sinh sn.
- 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.
Nng c tc dng l 0,07-0,2 UI trong 1 ml huyt thanh v gi u n t 15-30 ngy v
xon khun sinh sn 33 gi 1 ln,s bt gp d c 10-22 ln sinh sn.
- Tt c cc loi Penicilline G u c tc dng.
- gi nng thng xuyn ko di, ngi ta hay dng cc loi penicillin chm tiu
nh Benzathine penicilline ho tan trong nc (Bicilline, Extencilline, Pendura, Pennadura)
hoc loi ho tan trong du nh BOM (Benzathine penicilline in araehide oil, alumine
monosteard). Khi tim 2,4 triu Benzathine penicilline c th gi c nng dit khun
0,03v/1ml huyt thanh trong vng 3-4 tun.
C th dng penicilline procaine in arachide oil +2%monodarate dAlumine (PAM) nhng ch l u
li trong mu 3-4 ngy. Nu dng fenacilline A ca CHDC c (Penicilline procaine + 25%
Penicilline sodique th nng P cao hn trong mu nh ng ch ko di c 12 gi v vy phi
tim ngy 2 ln mi ln 500.000 v.
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
( Tham kho bi nguyn tc phc iu tr bnh LTQTD)
Phng bnh giang mai
1. Phng c nhn: m penicillin, m calomel ra x phng vn khng m bo.
- Bao cao su: c th ly qua ch xy xt khc khng c bao cao su bo v.
2. Phng chng trong cng ng:
- Hp tc nhiu ngnh gio dc nam n thanh nin sng lnh mnh - Bo v thun phong
m tc ca dn tc.
- Phng nga thi ho tru lc.
-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).
- Gio dc y t v bnh LTQTD.
- Xy dng mng l i y t t trung ng n phng x ch trng cc thnh ph, th, hi
cng.
-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
).
+ Vi khun lu bt mu gram (-) , nm trong t bo bch cu a nhn, ng tng i mt , khi
lu cp tnh thng c hnh nh r, khi lu mn thng phi nui cy chn on xc nh (
nui cy trong mi trng thch mu c CO2 ),dng hnh nh i th v phn lp trn mi
trng ng xc nh vi khun lu.
Sc khng vi khun lu km, ra mi trng ngoi c th v cc thuc st trng thng
thng u dit c.
+ C ch bnh sinh : sau khi quan h vi bn tnh c bnh, vi khun lu c sc bm dnh vo
mng t bo biu m tr ca ng tit niu sinh dc ngi lnh, nn vic nhim bnh xy ra
rt nhanh ngay sau khi quan h tnh dc.
+ Tnh hnh khng khng sinh ca vi khun lu: cho n nay cc khng sinh sau y cn c tc
dng ( xp theo gim dn ).
Ceftriaxone , Spectinomycine, Erythromycin, Ciprofloxacin.
2. Triu chng lm sng .
2.1. nam gii.
+ 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
- Mc du c iu tr ng mt s trng hp bnh vn c th chuyn thnh bn cp vi
cc tn thng sau:
.Vim cc tuyn khu tr cnh giy hm rnh qui u.
. Vim cc ng v cc tuyn khu tr cnh ming so.
. Vim cc tuyn Littre.
. Vim tuyn Cowper.
+ Bin chng xa hn :
- Vim ng dn tinh v mo tinh hon.
- Vim ti tinh v ng phng tinh.
- Vim di nim mc niu o gy nhiu ti m xung quanh niu o, t khi v ra ngoi.
2.2. n gii .
+ bnh: thng t 2 tun tr ln.
+ 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.
- a s cc trng hp bnh bt u bng vim niu o kn o. Bnh nhn i kh, c cm
gic nng hay rt khi i tiu, l niu o bnh thng, n vo niu o c m chy ra ( khm
sau khi i tiu t nht 3 gi ).
- Vim c t cung: biu hin bng ra kh h, l c t cung c th , trt ph, l tuyn .
- Vim phn ph (vi trng): vim lan t m o, c t cung ln. Him khi theo ng mu.
2.3. Bin chng ton thn v cc c quan khc ( gp c nam v n ).
+ Vim hu mn - trc trng do lu do giao hp ng hu mn. Hu mn - trc trng au v
tit dch m.
+ Vim hng do lu : quan h ng gii.
+ Vim khp do lu ( xy ra ng thi vi lu cp ng sinh dc ).
Biu hin da vng sinh dc : c nhng ti m, mn m khu tr gn b phn sinh dc.
Phn ng ton thn c th c dt , ban m ay hoc hng ban a dng do phn ng qu
cm ng ca c th vi song cu lu.
+ Vim quanh gan hoc hi chng Fitr- Hugh v Curtis.
+ Bin chng tim : vim ni tm mc do lu cu khun .
+ Lu mt : vim kt mc c m tr s sinh do lu ( vi khun c truyn sang tr s sinh
trong khi sinh ). C th c bin chng lot gic mc, thng gic mc.
3. Chn on khc :
Chn on phn bit :
+ Vi cc vim niu o khng phi do vi khun lu .
- Do nm Candida.
- Do k sinh trng Trichomonat.
- Do t cu, lin cu.
Cn xc nh bng lm sng v xt nghim tm cn nguyn.
+ Lu pht hin cc bnh LTQTD khc nh giang mai, nhim HIV/AIDS, xt nghim kim
tra loi tr.
4. Chn on .
4. 1. Chn on lm sng da vo .
+ Tin s : hi bnh, hon cnh mc bnh, thi gian mc bnh.
+ Thm khm lm sng:
- Nam gii : hi chng vim niu o cp, mn v tit dch niu o.
- N gii : hi chng au bng di v ra kh h.
+ 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.
- Phng php nui cy, phn lp :
Mi trng thch hp nht l mi trng chn lc thayer- martin (TM) hoc thch scola, nhit
35- 36C, CO2 3%- 10%. Xc nh s c mt cc khun lc nghi ng lu t 24 gi n 48
gi.
5. iu tr v d phng.
5.1.Nguyn tc chung.
+ iu tr theo phc qui nh trn c s da vo tnh nhy cm vi khng sinh ca cc chng
vi khun a phng .
+ iu tr c v chng v bn tnh ca bnh nhn.
+ Bnh nhn cn phi ngh ngi, trnh i xe p, i nga, chy nhy gy sang chn b phn
sinh dc - tit niu.
+ Kt hp iu tr cc nhim khun sau lu (C.trachomatis, lin cu, tp khun...).
+ nh k khm lm sng v xt nghim li.
5.2. Phc iu tr lu khng bin chng.
Spectinomycine 2 gram: tim bp liu duy nht
Hoc Ceftriaxone 250 mg: tim bp liu duy nht.
Sau dng Doxycyclin 100 mg x 2 vin / ngy x 7 ngy .
5.3. iu tr lu bin chng.
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.
5.4. Phng bnh.
+ Cha c vacxin phng bnh c hiu.
+ S dng bao cao su khi quan h tnh dc hn ch ly bnh lu
+ Gio dc, thng tin v cc bnh STD, tnh dc an ton.
+ Khi c cc biu hin nghi ng b vim niu o phi i khm bnh ngay.


70. BNH LYME

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
on mn tnh teo", hay l bnh" Pick- Herxheimer".
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.
2. Cn nguyn bnh sinh.


Mi la rui u c th mc bnh lyme. Thi im mc bnh cao nht l t thng 6 - 10 , nhng
cng c th b bnh quanh nm.
+ 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
v c tim bnh nhn Lyme.
3.Triu chng lm sng:
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
ban pht trin ly tm v c th di chuyn a im. C th l mt ban ng u nhng thng l
mt ban hnh vnh v c th t mt sau vi tun hoc vi thng. C th l ban xut huyt
hoc khng di chuyn v km theo triu chng ton thn kiu cm. Dch no tu thng khng
c biu hin ca vim.
+ 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
thng ch yu mt dui ca cc u chi vi tn thng n, mu - xanh lc u s tin
dn thnh teo- nhn da. C th xut hin nt dng x cnh khp v c th xut hin qu trnh
x.
Vim no mn tnh ca Lyme v vim no- tu c th c nhng rt him.
4. Xt nghim ,chn on v chn on phn bit.
+ 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
xt nghim huyt thanh ph thuc vo giai on bnh.
+ Chn on : cn c vo hnh nh lm sng v xt nghim.
+ Chn on phn bit.
- Bnh ban a dng.
- Cc bnh l ni khoa khc : thn kinh, tinh mch, khp...
5. Tin trin v tin lng.
6. iu tr:
Phc Sterre ( 1989):
6.1. Thi k sm (thi k 1, 2 khng c tn thng nng).
+ Ngi ln:
- Amoxilline 500 mg x 4 vin/ ngy(chia lm 4 ln trong ngy) x 10- 30 ngy.
- Tetracyclin 250 mg x 4 vin/ ngy (chia lm 4 ln trong ngy) x 10- 30 ngy.
- Doxycyclin 100 mg x 2 vin/ ngy (chia lm 2 ln trong ngy)x 10- 30 ngy.
+ 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. 2. Khi bnh c biu hin h thng thn kinh, tim, khp...
- Ceftriaxone tnh mch x 2 gam x 1 ln/ ngy x 14 ngy.
- Penicilline G tnh mch 3 triu n v x 6 ln/ ngy x 14 ngy.
- Penicilin G tnh mch 3 triu n v x 6 ln/ ngy x 14 ngy.
6.3. ACA(vim da vin on mn tnh teo) iu tr nh thi k sm trong 1 thng.
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

(Erythme fixatum pigmentosum rcidivans- fixed drug eruption)
Th.S Nguyn T

1. nh ngha.
Ban nhim sc c nh ti pht (BNSC) l mt phn ng da do thuc (d ng thuc), th
ng l do thuc ung, c c im l tn thng da hnh trn, bu dc, n, c khi ni bng
n c, trt, nhim sc giai on thoi lui, th ng ti pht sau nhng ln dng thuc, c nh
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.
2. Cn nguyn v c ch bnh sinh.
+ Nguyn nhn thng gp nht ca BNSC l do cc nhm thuc : cm st, khng sinh,
sulfamid, an thn v gim au.
+ C ch bnh sinh ca BNSC thuc p ng min dch d ng tp III v IV v c xem
nh l do mn cm , ti pht khi bnh nhn dng li th thuc dng hoc c cng thc ha
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...
Khi bnh ti pht tn th ng li xut hin nhng v tr b ln trc, ngoi ra cn c th
thm v tr mi.
C tr ng hp c th tn th ng nim mc ming, vim mng tip hp, hoc t ng t herpes
simplex, vim niu o.
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.
S l ng m tn th ng th ng t, mt vi m, t khi qu 10 m, song cng him ca rt
nhiu tn th ng hay tn th ng thnh m ln 10-20 cm ng knh, c khi t ng t hi
chng Lyell.
Khi tn th ng trt ming v sinh dc gy cm gic au.
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).
3.3. Triu chng c nng:
Nga, rt bng, c khi cm gic ny c tr c v tr s mc tn thng.
3. 4. Triu chng ton thn:
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 sn, th my ay, th n, th mn n c, phng n c (hay gp nht), th xut huyt d i
da, th lot, th gi teo.
3.6. Tin trin v tin l ng:
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.
4.1. Chn on xc nh:
+ S lin quan ti vic dng thuc.
+ V tr s l ng tn th ng.
+ Tnh cht tn th ng.
+ Tnh cht ti pht: ti pht ng vo v tr b ln tr c, nhim sc tn ti sau vim.
+ Tt ni b,tt p da( patch test) vng da b tn th ng vi cht nghi ng p ng 30% s
ca hoc cho dng th cht nghi ng (t dng,nn trnh)
4.2. Chn on phn bit:
+ Ban a dng.
+ Xut huyt d i da.
+ Trt sinh dc phn bit vi herpes.
+ Hi chng Stevens-Johnson.
+ Trt ming phn bit vi aphthosis, herpes.
5. iu tr v d phng.
+ Nhn dng v ngng ngay thuc nghi vn:
+ Ti ch bi thuc du da nh du xyt km, hoc kem corticoid
+ Ton thn dng khng histamine tng hp, corticoid, vitamin C, clorua canxi tim tnh mch
chm.
+ Nhim sc sau vim ko di vi thng hoc nhiu nm v nn iu tr bng hydroquinone.
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.

72. VIM NIU O DO CHLAMYDIA
TRACHOMATIS

1- Tn bnh : c 2 loi nhm bnh gy nn do Chlamydia trachomatis
(C. trachomatis) ly truyn qua ng tnh dc .
- Nhim Chlamydia niu o ( nam , n) ,m o, t cung , mo tinh hon, bung trng.
- Bnh ht soi ( Lymphogranuloma venereum LGV) hay cn gi l bnh Nicolas - Favre.
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 %.
- Tr s sinh ngay t ngy u c th nhim t ng sinh dc ca m. C t 20 - 50 % s
tr s sinh b nhim C. trachomatis nu m b mang bnh. Trong s c t 15- 20 % c biu
hin mt v t 10- 20 % c biu hin ng h hp .
4- ng truyn bnh .
- Qua giao hp vi ng i nhim Chlamydia.
- Con trong giai on s sinh b mc bnh hoc h hp do ly truyn trc tip t cc dch m
o sinh dc ca m khi sinh .
5- Triu chng lm sng.
5. 1. nam gii : c th biu hin bng cc hnh thi sau :
- Vim niu o khng do lu : nhiu cng trnh nghin cu xc minh C.Trachomatis l nguyn
nhn quan trng ca bnh ny v:
+ T l phn lp c C. Trachomatis niu o khong 30 - 60 % trng hp vim niu o
khng lu .
+ Vim niu o sau lu pht trin hu ht cc tr ng hp lu c iu tr bng Pnicilline
hoc Spectinomyxin ng thi c km theo c vim nhim do C. Trachomatis.
+ Vim niu o sau lu th ng xut hin nhiu hn ng i b nhim C.Tachomatis so vi
nhng ngi b lu nhng khng b nhim C. Trachomatis.
- Vim mo tinh hon : l mt di chng thng gp trong vim niu o do C. Trachomatis v :
+ Thng thy c s kt hp vim niu o khng lu vi vim mo tinh hon.
+ Hiu gi ca khng th Chlamydia trong cc tr ng hp vim mo tinh hon cp tnh khng
do lu tng .
+ Nghin cu trn nhng trng hp chng ( c xc nh do C.Trachomatis) thng gp
vim mo tinh hon .
+ C th phn lp trc tip c C.Trachomatis trong dch ht t mo tinh hon b vim .
- 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
ngh rng nhim khun C.Trachomatis c th gy nn hi chng Reiter nhng c nhn c sn
c tnh di truyn vi bnh .
5.2. n gii : c th c cc hnh thi lm sng nh sau :
- 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
sng r rt nhng vn phn lp c C.Trachomatis t trong c t cung .
- Vim phn ph : s lin quan gia C.Trachomatis v vim phn ph cp tnh rt r rt.
Thu in trong 20 ng i b vim phn ph cp tnh th c 6 ng i
( 30 %) tm c chlamydia vi trng. Trong 53 trng hp vim c t cung th 19 ngi tm
c chlamydia c t cung(36%). Chn on bng huyt thanh th c khong 30% dng
tnh do nhim chlamydia trong s bnh nhn n khm vim phn ph.
- Hi chng i kh, i nhiu ln n gii. C.Trachomatis cng c xc nh l mt cn
nguyn c th gy hi chng ny.
- Bin chng n gii .
+ Vim quanh gan : nm 1978 ngi ta chng minh c C. Trachomatis c th l cn
nguyn gy vim quanh gan m tr c kia ch cho rng bnh l bin chng ca vim phn
ph do lu.
+ 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 .
- Vim kt mc th vi : thng xut hin 7- 14 ngy sau khi . Th ng t gii hn v lnh
nhng cng c th bnh kinh din v km theo gim th lc.
- Hi chng vim phi do C. Trachomatisd. Ng i ta xc nhn c s lin quan gia mt hi
chng vim phi v s phn lp c C.Trachoncatis trong dch tit ca ng mi kh qun v
kh qun ph nang v tr s sinh b bnh. Loi vim phi ny khng km theo st. Vim mang
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 .
6.1. Chn on lm sng .
- Hi bnh, tin s bnh .
- Thm khm lm sng.
Tr bnh ht soi c th chn on da vo lm sng cn cc vim nhim ng sinh dc, niu
o mn tnh khng phi do lu rt kh chn on nu khng c cc xt nghim km theo.
6.2. Chn on xt nghim .
- Ly bnh phm nhum xem t bo cho kt qu dng tnh thp 15 - 30%.
- Phn lp trn t bo cho t l dng tnh cao 95 - 100 %.
- 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%).
- Chn on bng k thut pht hin axits nucleic PCR.
7- iu tr .
7.1. iu tr nhim C.Trachomatis niu o , c t cung hoc trc trng.
- Doxycylin 100 mg , ung mi ngy 2 ln, trong 7 ngy .
- Hoc Tetracylin 500 mg, ung mi ngy 4 ln, trong 7 ngy ( khng dng cho ph n mang
thai ).
- Hoc Erythromycin 500 mg ung 4 ln trong ngy, trong 7 ngy.
7.2. iu tr bnh ht soi .
Doxycyclin 100 mg ung mi ngy 2 ln, trong 14 ngy .
Hoc Tetracyclin 500 mg , ung mi ngy 4 ln , trong 14 ngy .
Hoc Erythromycin 500 mg, ung mi ngy 4 ln, trong 14 ngy .
Trong tr ng hp hch hoc p xe c m, c th ht bng kim , trnh chch hoc m rng
hch tho m v s lm so rt lu lnh.
8 - Phng bnh .
- Ch a c vacxin d phng.
- S dng bao cao su.
- Gio dc truyn thng c vn v tnh dc.

73. BNH MN RP (ECPET)

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.
Bnh gy nn do Herpes- simplex virus typ I v II.
3. Lm sng.
Tr c khi ni tn th ng th ng c cm gic kh chu, nga , rt dm dt ti ch. Bt u
bng mt vt , n, sau nhanh chng xut hin cc mn nc thnh cm nh " b hoa" t
3- 10 ci, trn hoc hnh cu, u nhau, nh 2-4 ly ng knh. Dch ban u trong sau thnh
c. C nhng ecpet khng l phng n c to nh trong bnh Duhring. Sau vi ngy, mn n
c v, kh ti ch ng vy tit vng hoc hi nu, gn cht, khi bong li mt vt , sau
tr li bnh th ng khng thnh so cc hch lympho ln cn c th sng v au. T khi bt
u n khi ln tt c khong 8- 15 ngy.
Th ng ch c mt m nh ng cng c khi c nhiu m ri rc mt vng sinh dc. Bnh
ni tng t, c khi thnh chu k. Th ng l khng st, khng au nh ng mt s tr ng hp
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.
- Xt nghim chn on t bo Tzanck thy c t bo a nhn khng l.
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.
Cc thuc kch thch min dch : Immurong/ Muren , T.F.X...
Ti ch : Acyclovir cream 1% bi 5 ln / ngy.
Dung dch Millian / castellani.
M khng sinh nu c bi nhim.


74. BNH TIU THNG B PHNG
NC BM SINH

- Kobner (1886) pht hin.
- Bnh c phng n c th ng xut hin t b
- C tinh cht gia nh.
- Di truyn hoc tri hoc ln.
- C nhiu cch phn loi ; th ng chia thnh :
+ Tiu th ng b phng n c n gin.
+ Tiu th ng b phng nc lon hnh .
1. Tiu th ng b phng nc n gin
(Pemphigut di truyn do sang chn )
1.1. i c ng .
- Bnh di truyn theo tri, n v u.thng pht sinh t lc hoc trong cc thng u .
- C khi pht mun hn ( tui thiu nin hoc thanh nin ).
- c tr ng bi s phng da mt cch t ng i d biu hin bng phng nc khi da b c
st hoc sang chn . Tn th ng khng li so.
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.
- Yu t thun lic khc : nng, m , Tranpirat tm nng , ung nng.
- Phng va hoc to, cng, nc trong trong him khi c mu.
- Xut hin khng au .
- Mt sau vi ngy, khng li so.
- Phng him gp nim mc ming ( 2 %) v rt him nim mc sinh dc (giao hp ?).
- Du hiu Nikolsky : tht th ng . Th ng m tnh.
- C da, ko di mt s ng i bnh c th gy phng.
- Ton trng : bnh th ng - khng c d dng g khc .
- Cng c gp ra nhiu m hi ch yu l lng bn tay, bn chn. ( Khng c lin quan cn
nguyn g ). C nhn thy c th c thi gian ng mu ngn li, hparine gim i song song
vi mt s ri lon h thng axit hyaluronic - hyaluronidaza.
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.
Tuy nhin cng c khi thy phng n c d i th ng b , c tc gi nh Lever th cho l phng
d i thng b nh ng v biu m phc hi nhanh nn phng thnh ra nng, nht l cc
phng c. Mt khc c tn th ng si chun gin, tuy khng c phn ng vim ca trung b.
1. 4. Tin trin .
- Thay i tht th ng.
- C khi t ngt ( theo ma : ng, theo tui, nht l hot ng sinh dc - dy th , cha ).
- Th ng vi tui, cng ln cng .
- Tin l ng lnh- c ca dai dng sut i, mc gim i.
1.5. iu tr .
- Khng kt qu.
- Bin php hn ch xut hin phng.
- Th ng rt kh iu tr .
- C th dng t i mu sau khi tim Sulfarsnol v moranyl i khi cng lm mt s ca.
- C ca dng ni tit sinh dc c ( nu c thiu nng sinh dc ).
- C ca vi corticoid.
- Hin nay c tc gi th dng Hparine tim bp hoc l tnh mch.
- C tc gi dng H.T . Bogomoletz hoc tim ni b v tim bp H.T ng i b bng ang d ng
sc .
- Ti ch : MnO 4K.
2.Tiu th ng b phng nc lon hnh .
( Pemphigut lin tip c u nang th ng b ).
2.1. i c ng .
- Wickam Legg pht hin 1883.
- Phng n c xut hin t nhin bn cnh phng n c do sang chn .
- Tn ti so teo sau phng nc.
- C u nang thng b xut hin.
- C tn th ng mng v mt s lon hnh khc.
- Di truyn theo tri hoc ln.
2. 2. Lm sng .
- Th ng xut hin vo nhng nm u sau khi .
- Thnh t gm phng t nhin, km theo phng do sang chn th ng rt nh ( p )
- Phng cng hoc nho , i khi c mu.
- Cc t ni phng c th km theo nga, rt bng.
- Phng kh hoc mt i nhanh hoc chm.
- Sau khi phng mt li mt vt hi teo hoc mt so t ng i r, i khi co dm hoc li.
- So sau phng khng phi lc no cng c i vi tt c cc phng nu c , th ng l ch
hay va chm nhiu ( ci, gi ).
- Ly ngn ci ln da s th ng gy ra mt s bong th ng b ngay tc khc v d
dng. l mt du hiu Nikolsky gi do bong tch trung b -th ng b.
- Ci v gi c mt v rt c bit ging nh trong hi chng Ehlers- Danlos (nho da, nho
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
do khng nhng v phng nc v bong tch do sang chn m c v tn thng t nhin ca t
chc chun gin.
- 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 ).
- C khi thy i ra porphyrine ( ca nng - lin quan vi porphyrine da cng c phng n c ? )
2.3. Th lm sng khc nhau .
- Th lon hnh nh ( mt s t phng li so , xut hin t nhin cc tn th ng kiu
Duhring lon hnh ring r kiu tng sn ( dy mng ) ). Th ny th ng di truyn theo tri.
- Th vt trng - dng sn ( albo - papuloi'de) ng thi vi phng cn c vt trng ng hoc
hng hi g cao hoc bng, c ci nh, ring r, hnh chm hoc khng u, c ci thnh gii
hoc mng vin rch hoc a . B mt cc tn thng trn trn, thng c chm l cc l
chn lng b gin v lm xung , nm vo chc, chun gin. Hay thy thn v vai- c ca xut
hin mun hn phng nhiu - tn th ng ny tn ti lu di c l do qu sn si ca t chc
lin kt vi th ng tn thay i ca cc si chun gin.
- Th lot - xi : mt s lot xi xut hin quanh l t nhin v nim mc - li so quan
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 ).
2.4.Hin nay kt hp lm sng v di truyn hc, Touraine xp thnh 3 th :
- Tiu thng b phng nc n gin : di truyng tri n chi c phng nc do sang chn ,
nng, khng c lon hnh g khc.
- Tiu thng b phng nc qu sn : di truyn tri n v th ng u xut hin t lc n
dy th . Phng a s do sang chn, him do t nhin, c ci nng khng li so, c ci su
c li so i khi li. Hay c vt teo v u nang k nh ng s lng t lon hnh km theo
loi qu sn ( da c v dy sng, dy trng sng , dy mng, thm mu da ) rng khng tn
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 ).

Tiu th ng b phng nc lon sn .
Di truyn ln th ng n xut hin t lc hoc trong nm u.
Phng t nhin v do sang chn , th ng nho v c mu, th ng su li so trng - xm
mu. Nim mc th ng b - hay c vt teo v u nang k. Du hiu Nikolsky th ng (+).
Lon bnh th ng dng thiu sn ( da mng, tm ti vin on, mng khng c hoc th s,
teo u cc ngn, ri lon v rng, t lng). Ri lon th lc, tm thn hay c, sc khng rt
km (Touraine xp c th xi, dt v nng vo nhm ny ).
Tuy nhin cng c nhng ca ngoi l .
3. T chc bnh l :
Phng n c d i th ng b vi nhng u nang nh, ging nh nang k (milium ) phn trn
ca trung b , vi xu h ng mt si chun.
Tuy nhin cng c ca phng trong thng b ( lp gai ) hnh nh th nng, phng trung b .
Tn thng t chc chun c ca b c ca khng.
4. Cn nguyn :
Ch a r , ngoi yu t di truyn. S thiu gn b gia thng - trung b c l do s ri lon
chuyn ho cc muco- polysaccharides ca vng ni tip v ca trung b, c bit do s mt
cn bng axit hyaluronic - hyalurodinaza, c ch ny cng nu trong cc bnh phng nc
khc .
5. Chn on .
Chn on phn bit vi bnh phng n c khng di truyn th ng xut hin mun hn.
Chn on phn bit vi d ng do thuc c phng nc.
6. iu tr .
Ging nh tiu thng b phng n c n gin.

75. TNG QUAN BNH LY TRUYN
QUA NG TNH DC

1. Tnh hnh bnh ly truyn qua ng tnh dc (LTQTD) Vit Nam.
+ 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
AIDS v 6065 bnh nhn AIDS t vong ).
+ D bo n 2005 bnh LTQTD tip tc gia tng, ring nhim HIV c th ln ti 197.581
ngi , 81.256 bnh nhn AIDS v 46.202 bnh nhn AIDS t vong.
+ Bnh ny c tt c cc thnh phn trong x hi, mi la tui ( t s sinh n ngi cao
tui) mi a phng, gii tnh ( n > nam ) vi t l 4/1 -3/1.
+ Cc yu t lm lan trn bnh LTQTD ti Vit Nam.
- Bn cht ca bnh l bnh ly truyn, bnh chu tc ng ca nhiu yu t x hi : kinh
t,vn ha, i dn, li sng ca gii tr.
- Vit Nam ang nm trong vng trung tm, c t l mc bnh cao ca khu vc v trn th gii.
- Cn nhiu bt cp gia cc chnh sch v can thip.
+ 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 chng nm: candida albicans
- Cc ng vt nguyn sinh : trng roi, amip
- Cc k sinh trng; gh , rn mu
2.Cc biu hin lm sng : rt phong ph v a dng.
2.1. b phn tit niu : i a s cc trng hp.
+ Vim niu o : do song cu khun lu, chlamydia, ureaplassma, urealyticum.
+ Vim mo tinh hon : do song cu khun lu, chlamydia.
+ Vim m o : do trng roi, candida albicans.
+ Vim c t cung : do song cu khun lu, chlamydia, virut, ecpet 1,2.
+ Lot sinh dc : do xon khun nht, trc khun ducrcy, virut ecpet alpha 1 v 2, chlamydia.
2.2 . Ngoi b phn sinh dc.
+ da: vim k do candida, gh, vim kt mc vim vng mc.
+ khp : c th vim cp do lu cu chlamydia trachomatis.
+ d dy v rut:
- Vim trc trng do chlamydia trachomatis, do lu cu.
- Vim gan do virut, vim gan B, virut ecpet 5, xon khun nht.
+ h h hp : vim hng, vim phi: do lu cu, chlamydia.
+ 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.
3. Cc nguy hi ca bnh LTQTD.
3.1.V sc kho ( bin chng ca bnh LTQTD).
+ Cht hp niu o gy i kh, b i.
+ V sinh do vim tc vi trng ( n), ng dn tinh vim tinh hon, mo tinh hon ( nam).
+ Vim h chu, cha ngoi d con, thai cht lu.
+ Tr s sinh: nhim khun mt ( lu mt), nhim khun ton th ( giang mai bm sinh), hu
sinh v dng.
3.2. V kinh t x hi.
+ Chi ph ln cho ngn sch: phng tin chn on, thuc men iu tr, cc bin chng, cc di
chng bnh nhn v cc th h tip theo ca h, kinh ph phng chng ...
+ Mt bn phn tch gn y cho thy mt s nc ang pht trin, cc bnh LTQTD
(khng k n AISD) lm mt khong 5% tng s nm sng kho mnh ( vng gn Sahara,
Chu Phi). Cn ring AIDS v nhim HIV, t l ln n 10%.
+ nhiu vng th Chu Phi, 4 bnh ( giang mai, chlamydia, lu v h cam) c xp vo
1 trong 20 bnh ng hng u v kha cnh lm mt s ngy sng kho mnh tnh theo u
ngi, ch ng sau cc bnh si, nhim HIV, st rt, vim d dy v rut n ng trc cc
bnh suy dinh dng, lao v un vn rn s sinh.
3.3. Tc hi qua li gia bnh LTQTD v i dch HIV/AIDS.
Bnh LTQTD to iu kin cho vic lan truyn HIV/AIDS.
+ Cc thng tch l lot do bnh LTQTD gy ra s l ca ng thun li cho nhim HIV/AIDS.
Ngc li trng thi suy gim min dch do nhim HIV/AIDS gay nn s to iu kin thun li
ngi bnh mc cc bnh LTQTD. l 2 bnh ng hnh v tng h nhau.
+ 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.
Nh vy cc bnh LTQTD l bn ng hnh , li l ng lo lm trm trng thm i dch
HIV/AIDS.
4. Cc kh khn trong qun l cc bnh LTQTD.
+ a s bnh nhn khng n iu tr cc c s chuyn khoa do nh nc qun l,
l mt hin trng thc t khp cc tnh/ thnh ph Vit Nam v :
- 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.
+ Trang thit b thiu mt s c s khm bnh nh nc, nn mc chnh xc hn ch, kt
qu iu tr khng cao.
5. Mc tiu chng trnh phng chng cc bnh LTQTD.
5.1. Ct t nhanh chng ngun ly lan.
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.
- Bn cht bnh AIDS hin nay cha c thuc iu tr c hiu qu.
- 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.
- Do thiu hiu bit ca nhn vin y t v ca nhn dn.
+ Hu qu ca vic k th.
- K th i x bnh nhn b bnh LTQTD v nhim HIV/AIDS l xm phm nhn quyn i
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.
- K th dn n bnh nhn du bnh, bnh nhn c cc hnh ng khng tt lm ngun ly
nhim bnh tng ln.
- Hu qu s tc dng chung n an ton x hi nh hng n s pht trin ca nn kinh t.
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
tuyn trong mnh li chuyn khoa, a khoa v CSSKBD trong c nc.

76. BNH NM ACTINOMYCOSIS

PGS Nguyn Ngc Thy
1. Cn nguyn :
Bnh c Nocard v Lucet pht hin nm 1888. Cn nguyn gy bnh l mt s loi
Actinomyces nh A. wolfisrali v A.ctinomyces l vi sinh vt nm gia vi khun v nm, hay to
ra cc si nm gi, ng knh rt nh (di 1mm), c khi to rc cc si dng tia nn c tn l
" nm tia" hay x khun, bt mu gam (+). Actinomyces thng sng him kh, nhy cm vi
mt s khng sinh, thng c mt thc vt, t, nc. Trn c th ngi thng xut hin
da,ming, gy bnh khi c iu kin thun li.
2. Triu chng lm sng :
Bnh da, nim mc : khi nim mc hay da c vi chn xy st Actinomyces d ly nhim v
pht trin gy bnh. Mm bnh c th qua thc n, ng cc gy bnh nim mc ming, li,
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.
Bnh vng c, mt,ngc, bng : tn thng da cc vng ny thng th pht sau cc
vim t chc di da c hay hm. Ban u xut hin mt hay nhiu cc di da, thng
cng chc, khng au, gn vi nn su, sau dnh vi mt da trn, thng c mu hng, sau
dn dn thnh gm mm, nhn gia v d m. Cc cc c th cm li thnh mt mng, mu
ta, c ch mm c ch cng chc, xut hin nhng l d ngc ngch chy dch nhiu, c
m v mu. Trong m thng c cc ht nh, ln nhn mu vng c. Bnh thng tin trin
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.
Actinomyces phi : c khong 10% bnh nhn b nm pji do ht phi mm bnh. Nm
spht trin vng rn phi, t y bnh c th lan ra mng phi ri ra da ngc. Pht bnh
bnh nhn thng b st, kh th, suy h hp. Tn thng pht trin lm da ngc b sng n,
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.
Ngoi ra nm cn c th gy bnh thn, gan, bnh ph khoa, h thn kinh.
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,
khng c vch ngn, bt mu tm gram (+).
Nui cy : bnh phm c th nui cy trn mi trng BHI, mi trng Bouillon, mi trng
nhit 37
0
C trong iu kin ym kh, nm c th pht trin sau 8- 10 ngy.
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.
77. Y HC C TRUYN IU TR BNH
NGOI DA
PGS Nguyn ngc Thy
1. Phng chm v nguyn tc.
Phng chm kt hp 2 nn y hc hin i vi y hc c truyn l mt trong nhng phng
chm c bn ca nn y hc nc ta, mang ba tnh cht khoa hc, dn tc v i chng.
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
nng cao sc kho cho nhn dn.
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.
Bnh ngoi da c nghin cu iu tr bng cy thuc c thun li hn so vi cc bnh khc
v d nh gi tc dng kt qu iu tr, d bo m an ton v c ngi bnh d dng ng
tnh cng tc.
Cc nguyn tc p dng y hc c truyn trong iu tr bnh ngoi da.
+ An ton trong iu tr: thuc dng phi an ton, t c hi vi cc c quan ni tng, khng gy
tn thng da, khng d ng,khng gy tai bin.
+ 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
cu ton, khng i hi phi bit r cng thc ho hc c ch tc dng. Song cn phn u
nng cao dn tnh khoa hc nghin cu cng thc, chit xut ,tinh ch, bo ch.v.v...
+ ng dng phi c trng tm, trng im tng thi k, t thp ln cao, t gin n n phc
tp, t triu chng n nguyn nhn, tin ti thay th mt phn thuc ty y, c kt lun , tng
kt dt im khi nghin cu cc bi thuc c truyn.
i chng : cc phng php iu tr phi ph bin i tr, i chng, cy con thuc d tm
kim a phng no cng c, d ch bin, s dng n gin , r tin nhng hiu qu.
Mt s bi thuc.
1. iu tr bnh chc lot.
1.1. Thuc ra: hi t 1-3 th l sau y, ri un sc c ra k ni b chc lot trc khi p,
bi hoc rc thuc.
L o,l i,l sim, l vi, l ch ti, l kh sm, l ct ln, l b cu v.
1.2. Thuc p: l u vn ta 10 gam, l nh li 10 gam, rau sam 10 gam, ba th gi nt vi
mt t mui, p ln ch chc khong 1 gi sau b b i lau kh ri bi thuc.
1.3. Thuc bi : chanh qu nguyn t thnh than, tn nh ho vi du vng hoc du lc
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.
1.5. Thuc p: l vi voi 20 gam, l m qu 20 gam gi nh mn ri p vo ch chc hoc
lot ngy 1- 2 ln.
2. iu tr eczema (chm).
2.1. Thuc ra: nh nu phn iu tr chc lot.
2.2. Thuc p : sm i hnh 2 c, l bc thau 1 nm , l b cu v 1 nm, gi nt ri p ln
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
gam, cc th thi nh un sc ly nc ung hng ngy.
3. iu tr t a.
3.1. Thuc bi ngoi:trng g ly lng em t chy thnh du , ly du bi ngy 2-3 ln.
3.2. l bch hoa x 1 nm gi nt, luc chn, p v bng li trc khi i ng, sng dy b thuc
ra, ngy bng mt ln.
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.
+ Nc tm :l kh sm, l ba chc, l thu du ta, l xuyn tm lin, vi ba th l trn un sc
c ri tm ra hng ngy.
+ Thuc bi :
- L tru khng 7 l, dng 1 tha c ph, em gi nt trn u, bc gc xt vo ch b gh.
- Ht mu ch 100 gam gi mn, du lc hoc du vng 50 gam, hai th nu k ngui 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.
+ Cao vng m lng ( m pomt) ngy bi 1-2 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
dch 15% vo tn thng, ko di 2-3 thng.
7. iu tr ht cm.
+ Ly l ta t st ln tn thng ngy 1 ln x 20- 30 ngy.
+ 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.
L kh chua 20 gam gi vt nc ct ung, b gi vo gc st vo ch da ni .
8. iu tr nm da.
+ Cn r cy bch hc ( uy linh tin, kin c).
R cy bch hc thi nh, gi nt 20- 50 gam.
Cn etylic 70
0
va 100 ml.
Ngm trong 1-2 tun, sau lc qua bng, ly dch bi ngy 2 ln vo tn thng nm hc lo,
lang ben.
+ Cn l cy cht cht ( cy li b).
- L cht cht thi nh 30 gam.
- Cn etylic 70
0
va 100 ml.
Ngm trong 2 tun, lc ly dch bi ngy hai ln vo tn thng nm da.
+ L cy cht cht 100 gam.
C ring 100 gam.
Chanh 1 qu.
L cy cht cht v c ring gi nt, vt nc chanh vo, un nng ri bi vo vt tn
thng nm.
+ Cn ht mung tru:
Ht mung tru ha nh 30 gam.
Cn etylic 70
0
va 100 ml.
Ngm trong 2 tun , lc ly dch bi nm hc lo, lang ben.
+ L mung tru 10 gam.
Mui n 1 tha c ph.
Gi nt, bc vo gc st vo tn thng nm da hng ngy.
+ Ht mung tru 100 gam.
Kh chua 40 gam.
L tru khng 10 l.
Gi nh, bc vo gc st vo tn thng nm da hng ngy.
+ Dung dch ring, dm thanh.
Ring gi nh 30 gam.
Dm thanh va 100 ml.
Ngm 1 tun, sau bi cha lang ben.

78. PHNG TRNH BNH STD V
NHIM HVI/AIDS

1. Nhc li mt s nt v bnh ly truyn qua ng tnh dc.
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 li di chng nng n nu iu tr mun nh giang mai, lu.
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.
2. Nhng hiu bit rt c bn v nhim HIV/ AIDS:
2. 1. HIV l virus gy nn AIDS ( HIV = Human immunodeficiency virus).
2. 2. AIDS l giai on mun ca nhim HIV(acquired immunodeficiency syndrome).
2. 3. L mt bnh dch ton cu ai cng c th b .
2. 4. Cha c thuc cha khi, kt thc bnh bng ci cht.
2. 5. Ch a c vc xin phng bnh.
2. 6. C th phng bnh c nu hiu bit v HIV/AIDS v lun lun c thc d phng.
2. 7.S v din bin ca nhim HIV/ AIDS


Cc dch th ca ng i nhim HIV c cha HIV l :
+ Tinh dch
+ Dch tit m o
+ Mu .
+ Sa m
2.8. Vn kh trng HIV
+ 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
Cc bin php trn u c th tit trng c.
Mt vi vn ch a c tr li mt cch tho ng: ngoi khng kh (v d mt git mu
ca ng i v nhim HIV) ri ung t hoc ri ln qun o th th ng bao nhiu lu sau virus b
tiu dit.
3. Cc yu t nguy c ly bnh LTQTD v nhim HIV/ AIDS:
3. 1. Quan h tnh dc khng an ton.
+ Th no l hnh vi tnh dc khng an ton.
- C trn 1 bn tnh ( cng nhiu cng nguy c cao).
- Giao hp qua hu mn m khng dng condom l cc k c nguy c cao
- Khng dng Condom
+ Trong quan h tnh dc ngi ph n c nguy c ly nhim HIV/ AIDS cao hn nam gii.
V : - Ph n c rt ngiu nguy c ly nhim ngay t ln giao hp u tin.
- Khi mc STD th ng khng c triu chng, kh chn on khi c STD th cng d
nhim HIV.
- Ph n th ng bt li khi quan h tnh dc ( do t th ) hoc do cng bc .
3. 2. Ung r u, chch ma tu c cc nguy c ly bnh l:
+ Ung r u dn n mt t ch quan h tnh dc khng dng condom
+ Dng chung bm tim, kim tim khi chch ma tu.
+ Dng chung kim xm mnh m khng tit trng.
3. 3. Nhng ng i bnh phi truyn mu hoc sn phm ca mu nh : b bnh chy mu (
hemophilia), suy tu, bnh bch cu, m ln.
Hoc nhng ng i nhn tng : ghp tim, ghp thn ...
3. 4. Mt s ngh nghip tip xc trc tip vi nhiu ng i:
+ Nhn vin massage ( massage mt, ton thn, chn), nhn vin tm qut.
+ Th ct tc co ru cho khch m khch b nhim HIV (+)
+ Nhn vin y t : khm bnh, tim thuc, thay bng, lm tiu th thut chy mu, m, xt
nghim, nh rng ...
+ Nhn vin lm thm m : xm mnh, xm mi, mt ...
3. 5. Mt s giao tip khc: bt tay, hn c th b nhim HIV nu c 2 ng i cng c vt x c
da.
4. c im ca lc l ng v trang v vn ly bnh LTQTD v nhim HIV/AIDS.
+ Nhim v ca qun i lm cho qun nhn lun lun xa nh , xa v.
+ Nhu cu gii to cng thng, bun t trong doanh tri.
+ Ung r u, chch ma tu gii bun.
+ Mt s ln qun nhn tr c nhu cu hot ng tnh dc rt cao.
+ C t t ng ch quan,khng ng:(tt c l do s mnh, quan h tnh dc c th b bnh nh
ng ch a chc ri vo ta ).
+ Cn c qun s, cc doanh tri qun i l ni thu ht gi mi dm n kim tin .
+ Chin tranh v s bin ng x hi lm tng s ng i tm n tnh dc gii to cng thng
.
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,
truyn hnh, bo t ng v c bit gio dc ng ng
( tc l ng i n ni cho ng i kia bit trong cng mt n v).
+ 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 .
5. 2. Thc hin an ton trong quan h tnh dc :
Th no l tnh dc an ton.
+ Khng quan h tnh dc ( tit ch, king ) ba bi.
+ Sng chung thu mt v mt chng.
+ Hn ch s l ng bn tnh, chung thu vi bn tnh.
+ Khng dng cc hnh ng li ko nh m , hn .
+ 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.
+ Khng lp thm cc dng c vo d ng vt nh : cy bi , eo mt gi, ui nga...
+ 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.
5.3. X dng bao cao su ng quy cch c nam v n.
5.4. Khng ung r u say, khng dng ma tu , khng xm mnh.
+ Khng dng chung kim tim, bm tim.
-+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 ).
5.6. i vi nhn vin y t :
+ Gi an ton i bn tay khi tip xc vi cc vt nhn, sc.
+ Ra sch tay bng x phng, n c sau khi xong vic.
+ Dng gng tay, qun o bo v, eo knh khi tip xc vi mu v cc sn phm t mu.
+ Kh trng rc thi y t ( hu kim tim sau khi tim ).
+ Kh trng tt cc dng c y t .
+ Khi tip xc vi bnh nhn, s vo tn th ng da phi i gng tay.
5.7. i vi nhn vin massege, th ct tc, nhn vin lm thm m nn ngh vic khi i bn
tay khng c lnh ln.
6- Mt s ch khc :
+ Khng nn bt tay khi tay bn khng lnh ln.
+ Khng nn hn nu c vt xy x c, mn mi , ming, da mt. Khi hn khng nn gy ra
vt x c chy mu.
+ Khi ct tc hiu : mi ng i dng mt l i dao co ring, vt b sau khi dng.


79. PHC IU TR THEO HI
CHNG CC BNH LTQTD

1. u im ca phng php iu tr theo hi chng.
+ iu tr rng ri v nhanh chng hn, 95% t hiu qu tt.
+ Bnh nhn c iu tr cng mt lc tt c cc tc nhn gy bnh m gy nn hi
chng m bnh nhn c.
+ Phng bnh thng qua gio dc y t trong cng ng nhanh chng hn.
2. Nhc im ca ph ng php iu tr theo hi chng.
+ Chn on c hi chng thc ra cng khng phi l n gin cho cc thy thuc c s
+ iu tr theo hi chng l khng khoa hc.
+ Khng dng cho cc c s c iu kin xt nghim.
+ S dng nhiu thuc.
+ Lm cho vi khun tng kh nng khng thuc.
3. Phc c th:
3. 1. Hi chng tit dch niu o

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.
3.2. Lot sinh dc

Phc iu tr giang mai v h cam:
+ Erythromycin 500mg ung 3ln/ngy x 7 ngy+Benzathinepenicillin G 2,4 triu v , tim bp
(liu duy nht).
+ Ceftriaxone 250 mg tim bp liu duy nht+Benzathinepenicillin 2,4 G triu v, tim bp (liu
duy nht).
3.3. Hi chng tit dch m o
(Khm c dng c v lm xt nghim)

Phc iu tr bnh lu:
+ Ciprofloxacin 500 mg (ung liu duy nht) + Doxycylin 100 mg
ung 2 ln/ ngy x 7 ngy
+ Spectinomycine 2g tim bp ,liu duy nht + Doxycyclin 100 mg
ung 2 ln / ngy x 7 ngy.
+ Ceftriaxone 250 mg tim bp liu duy nht + Doxycyclin 100 mg
ung 2 ln / ngy x 7 ngy
3.4. Hi chng tit dch m o
( Khng c xt nghim).


* Nguy c(+): Bn tnh c triu chng,hoc c bt k 2 yu t no trong 4 yu t sau y:
1-Tui:<30 tui (<21 tui?)
2-Ch a lp gia nh.
3-C trn mt bn tnh.
4-C bn tnh mi trong 3 thng gn y.
*Vim c t cung: iu tr lu v chlamydia.
*Vim m o: iu tr trichomonas v candida.


80. THUC BI CORTICOID IU TR
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.

T nm 1952 thuc bi corticoid c cha Hydrocortison c tung ra bn th trng, sau l
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
Chlorocid-H v Flucinar c nhp t nc ngoi. Cho n thi im ny th th trng thuc
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
cu s dng rt cao v k nng cnh tranh ang din ra rt si ng.

II. Phn loi thuc bi corticoid dng ngoi da
Phn loi v corticoid dng ngoi da theo mc tc ng va phi, kh mnh, mnh, rt
mnh. S phn loi ny ch yu da trn th nghim lm co mch trn da. S i i ca phn
loi ny vi tc ng lm sng khng phi lun lun cht ch. Tuy nhin s phn loi ny cng
l im mc c ch v mi bnh da phi c iu tr bi mt corticoid thch hp. Ty theo kt
qu ngi ta c th phi thay thuc ang s dng bng thuc mnh hn hoc yu hn.

Cc corticoid dng ngoi da l mt phng tin iu tr triu chng m kt qu i khi nhanh v
r rng. C th xy ra ti pht thm ch kch pht ca tn thng khi ngng iu tr c bit
trong nhng trng hp ngng thuc t ngt.

Tm quan trng ca s thm qua da ca mt corticoid v cc at1c dng ca n ty thuc vo
din tch da c iu tr, vo tnh trng ca tn thng b, vo bn cht ca t dc, vo kh
nng tc ng ca corticoid v vo thi gian iu tr.

1. Loi tc dng va:
- Hydrocortisone 1%, 2,5% (Hytone).
- Dexamethasone 0,1% (Decadron).
- Clobetasone butyrate 0,05% (Eumovate, Eumosone).

2. Loi tc dng mnh:
- Amcinonide 0,1% (Cyclocort).
- Betamethasone dipropionate 0,05%, 0,25% (Diprosone).
- Desoximethasone 0,05%, 0,25% (Topicort).
- Diflorasone diacetate 0,05% (Florone, Psorcon).
- Fluocinomide 0,05% (Lidex).
- Halcinonide 0,025%, 0,1% (Halog).

3. Loi tc dng kh mnh:
- Betamethasone valerate 0,01%, 0,1% (Betnovate, Fucicort).
- Desonide 0,05% (Tridesilone, Tridsonid, Locapred).
- Flumethasone privalate 0,03% (Locacorten).
- Flucinolone acetonide 0,01%, 0,025%, 0,2% (Synalar, Flucinar, Flucort).
- Flurandenolide 0,025%, 0,05% (Cordran).
- Hydrocortisone butyrate 0,1% (Locoid).
- Hydrocortisone valerate 0,2% (Wesrcord).
- Mometasone fuorate (Elocon, Elomet).
- Triamcinolone acetonide 0,025%, 0,1%, 0,5% (Aristocort, Kenalog).

4. Loi tc dng rt mnh:
- Betamethasone dipropiomate 0,05% trong propylene glycol (Diprolene).
- Clobetasol propionate (Tenovate, Dermovate).
Phi hp thuc:
- Corticoid + acid salicylic
Diprosalic, Loriden A (A: acid salicylic)
- Corticoid + khng chun
Betnovate C (N); Sicortene plus; Tenovate G; Cortibion C (F); Cidermex
- Corticoid + khng nm + khng chun
Gentrisone, Triderme

III. C ch tc ng
C ch tc ng chnh xc ca tnh cht chng vim vn cha c xc nh r, tuy nhin tc
dng quan trng l gy co mch v gim chc nng hot ng ca lympho bo v bch cu
khc, ngoi ra cn c tc ng lm gim s gin phn ca t bo thng b cha c hiu r.

Hiu qu tc ng ca thuc ty theo s thay i cu trc ha hc t dc.

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.
S p ng ca corticoid ty theo bnh:
Hiu qu nht Hiu qu trung bnh t hiu qu
- Vy nn ( np k) - Vy nn dng nh - Vy nn (bn tay,
bn chn, mng)
- Chm th tng (tr
em)
- Chm th tng
(ngi ln)
- Vy nn lng bn
tay, bn chn
- Chm tit b - Chm dng ng
tin
- Chmg dng t a
(cp v mn tnh)
- Vim k - Vim da kch thch
nguyn pht
- Luput
- M ay - Pemphigus
- vy nn - Lichen phng
- Lichen n gin mn
tnh
- U ht vng
- 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
9. Da lng bn tay v lng bn chn
10. Mng tay chn

V. Chng ch nh
- D ng vi thnh phn ca thuc.
- Bnh lot da.
- Da ang b nhim trng, nhim nm, nhim k sinh trng, nhim virus.

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:
Tim mch: tng huyt p
H thn kinh trung ng: thay i hnh vi, lon tm thn (psychosis), gi bu no
(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.
H mu: gim lympho bo, gim monocyte.
H min dch: b bnh c hi.
H c xng: long xng, hoi t v trng u xng di hoc xung cnh tay, bnh c.
Th gic: tng nhn p, cm.
Thn: dch v mui, gim kali mu.

VII. Mt s iu lu khi dng thuc corticoid
1. Phi phn tch tn thng c bn, giai on bnh, mc ch yu cu ca iu tr trn c s
quyt nh dng thuc g, dng no thch hp.

2. Bm st din bin ca bnh thay i cch dng thch hp.

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.

5. Khng nn ngh rng tng hm lng, t l thuc l tng cng tc dng, cn lu n
nhng tc dng ph v hin tng bng pht mnh ln ca bnh sau khi ngng bi thuc.

6. Khng nn bi thuc trn nhng tn thng da ang b nhim trng, nhim nm, nhim virus,
gin mch, lot da.

7. i vi nhng thng tn ang chy dch, ng nhiu vy, nhiu mi th cn ngm p gt
cho gim cht dch, gim vy.

8. Khng nn bi thuc trn mt din rng ln, nht l tr em.

9. Cn nn phi hp vi loi thuc ton thn khc, khng phi al2 corticoid v cn tm ra
nguyn nhn gy bnh phng trnh nhm hn ch s ti pht ca bnh.

10. Hn ch ti a vic dng thuc cho ph n c thai v tr em di 12 tui.



HT