人人小组 - [皮肤病区] 特异性皮炎的香波治疗及其他局部治疗
[皮肤病区] 特异性皮炎的香波治疗及其他局部治疗
SHAMPOO AND OTHER TOPICAL THERAPY IN ATOPIC DERMATITIS
特异性皮炎的香波治疗及其他局部治疗
&Richard EW Halliwell
SHAMPOOS香波
Introduction引言Shampoos are helpful in treating both the primary defect and also the secondary complications of CAD. Indeed they represent a very important ancillary aid to the treatment. The most appropriate shampoos will change with the stage of the disease and the extent and nature of the secondary complications.香波在治疗CAD原发缺损和继发性并发症治疗方面都是有用的。事实上，他们是非常重要的辅助手段。最合适的香波能够改变疾病的阶段和程度，也能改变继发性并发症的性质。&The properties and nature of the active ingredients required include:
Anti-inflammatory and anti-pruritic effects
Antibacterial
Anti-yeast
Anti-seborrhoeic effects (anti-scaling)
Restoration of& barrier function活性成分的性质和功能包括：
抗炎和抗瘙痒
抗马拉色菌
抗皮脂溢（抗皮屑）
屏障功能的恢复
Anti-inflammatory/antipruritic effects
抗炎/抗瘙痒
(i)&&&&&&&&&&&&&&&& Non-steroidal非甾体
Colloidal oatmeal: 胶态燕麦片Products consist of fine particles of proteins, fats and carbohydrates. Their mode of action is largely unknown, but they are believed to have emollient, astringent, anti-inflammatory, analgesic and soothing effects. The effect may last for 1-2 days only, and is appreciable, though not dramatic.由蛋白质、脂肪和碳水化合物的细小颗粒组成的产品。他们的作用形式还非常不清楚，但是普遍认为他们有滋润、收敛、抗炎、止痛和缓解的作用。作用可能持续1-2天，尽管这种作用并不明显，但是是可以察觉到的。
Antihistamines:抗组胺These have some effects, although they are likely to be short-lived.这些药品是有作用的，尽管它们的作用时间可能很短。
Pramoxine:丙吗卡因This is marketed in the USA, and many find it useful.这种产品在美国有市售，并且许多人发现了他的用处。
Monosaccharides:
单糖In addition to interfering with bacterial adherence, these products have also been shown to have immunomodulating effects. They do this because attachment at the lectin receptor of the host cell in turn triggers the release of inflammatory cytokines. It is well-documented that this can be abrogated, to a significant extent, by competition from topically applied monosaccharides
这些产品除了能够干扰细菌的黏附，同时也表现出了免疫调节的作用。因为它们能依此的与畜主细胞的凝集素受体结合，触发炎性因子的释放。已经有研究证明，通过局部相应单糖的竞争作用，能过有效的清除这些炎性因子。
(ii)&&&&&&&&&&&&&& Steroidal甾体
1% hydrocortisone:1%的氢化可的松
&This is well tolerated, and does not suppress the pituitary/adrenal axis这能被动物很好的耐受，且不会抑制垂体/肾上腺轴
0.01% fluocinolone: 0.01%的氟轻松This likewise has been shown not to suppress the pituitary/adrenal axis. 这同样也不会抑制垂体/肾上腺轴
Antibacterial:抗细菌&&&&&& Such properties may be required where there is bacterial overgrowth, or in cases of overt pyoderma. The following are amongst those employed:细菌过度增生或脓皮症时，可以使用。下列成分包括这些功能：
Benzoyl peroxide:过氧化苯甲酰：&&&&&& This is generally used at concentrations of 2-3%. Irritation reactions occur occasionally. It is metabolized by the epidermis to benzoic acid, which lowers the pH of the skin. Note that a significant period of contact is necessary for this to occur. This agent also has degreasing properties, and a follicular flushing effect. Mild keratolytic action is also attributed to this agent.通常使用的浓度是2-3%。这种成分偶然会引起刺激反应。它被表皮代谢成苯甲酸，后者能够降低皮肤的PH值。注意为了能够发挥作用，有效的接触时间是非常必要的。该成分也有脱脂的活性，具有毛囊冲洗的作用。它还有轻微的角质溶解活性。
Ethyl lactate:& 乳酸乙酯This is hydrolyzed by the epidermis to ethanol and lactic acid, after a contact period of 10-25 minutes. It thus has a similar effect of lowering the skin pH as does benzoyl peroxide. The production of free fatty acids is also reduced. This agent is particularly well-tolerated by the most sensitive of skins.乳酸乙酯与表皮接触10-25分钟后，被表皮水解成乙醇和乳酸。因此，它与过氧化苯甲酰有相似的作用，都能降低皮肤的PH值。同时，也会减少游离脂肪酸的产生。这种成分能够被皮肤的敏感性很好的耐受。
Chlorhexidine: 洗必泰This very safe agent has taken over from hexachlorophene, which had a tendency to neurotoxicity. It is generally used at around 2%. Although it has been shown to have antibacterial activity at 0.5%, at the higher level it also has activity against Malassezia.这种安全成分来自于双三氯酚，后者有神经毒性倾向。通常用2%的浓度。0.5%的该成分就有抗菌活性，在较高浓度时还具有抗马拉色菌的活性。
Piroctone olamine: 吡罗克酮乙醇胺This is antibacterial both to gram-positive and gram-negative organisms. It also has significant activity against Malassezia spp.这是对革兰氏阳性和革兰氏阴性细菌均有抗菌活性的药物。该成分对马拉色菌也有明显的活性。
Monosaccharides: 单糖Although not strictly antibacterial, these products have anti-adhesive effects, interfering with the ability of the bacteria to attach to the cellular receptor. This is a rapidly emerging area of interest - not only in dermatology. Rhamnose, galactose and fucose are two incorporated into veterinary shampoos.尽管没有严格的抗菌性，但是该产品有抗黏附的作用，阻碍细菌与细胞受体的接触。这种成分迅速起作用，不仅仅在皮肤病区域。鼠李糖、半乳糖和岩藻糖可以两种掺和到兽医香波中。
Anti-yeast effects抗马拉色菌作用Proliferation of Malassezia is commonly encountered in CAD. The extent to which this proliferation contributes to the pathogenesis of the disease under question is not always clear, in that effective therapy can eliminate the yeasts, but does not always result in a clinical sure. Products that have been shown to have efficacy include:马拉色菌的增殖在CAD时比较常见。造成发病的增殖程度还不是很清楚，以至于即使有效的清除了马拉色菌，但是并不一定总是得到较好的临床结果。有效的产品包括：
Chlorhexidine:& This agent is effective at 2-4%, but not at 0.5-1%. The fact that it also has antibacterial activity makes it particularly suitable for use in animals in which there is overgrowth of both.洗必泰：这种成分的有效浓度是2-4%，在0.5-1%无效。事实上它也有抗菌活性，尤其适合使用在两种都过度增殖的动物。
Miconazole:& 咪康唑This is effective at 2%.有效浓度2%
Selenium sulphide: 二硫化硒This is effective at 1%. It may be drying, but is quite useful as an initial treatment in very greasy skins. 有效浓度1%。本品可能会干化，但是在油性皮肤首次治疗时非常有用。
Piroctone olamine: 吡罗克酮乙醇胺This has been shown to have good anti-yeast effect following a single application.单独使用就有很好的抗马拉色菌活性。
Ketoconazole: 酮康唑Although not marketed for veterinary use, ketoconazole shampoos would be expected to be very effective. 尽管没有市售的兽用产品，酮康唑香波必定会很有效。
Anti-seborrhoeic effects
抗皮脂溢作用
Keratolytic products: 溶角质产品These assist in the breakdown of the intercellular adhesiveness of the cells of the stratum corneum, thus facilitating desquamation. Keratolytic products include:这些产品有助于分解角质层细胞间的粘连，因此易于脱屑。溶角质产品包括：
Sulfur硫磺
Salicylic acid (which has synergistic activity with sulfur)水杨酸（与硫磺有协同效应）
Ammonium lactate乳酸铵
Benzoyl peroxide过氧化苯甲酰
Selenium sulphate硫酸硒&
Keratoplastic products: 角质促成剂These reduce the rate of cell division in the basal layer of the epidermis, thus helping to normalize the process of keratinisation and desquamation. Gents with this effect include:这些产品能够降低上皮基底层的细胞分裂速度，因此有助于角质化和脱屑进程正常化。有这些功效的成分包括：
Sulfur 硫磺
Salicylic acid水杨酸
Benzoyl peroxide,过氧化苯甲酰
Ethyl lactate 乳酸乙酯
Ammonium lactate &乳酸铵&
Restoring barrier function修复屏障功能An abnormality of the epidermal ceramides, which are responsible for cementing the superficial epidermal cells together, is one of the fundamental defects in CAD. Shampoos aimed at rectifying this problem include those containing:表皮神经酰胺（负责把表层上皮细胞粘合在一起）异常是CAD患者最根本的缺陷之一。解决这类问题的香波包括：
Ceramides themselves, and神经酰胺本身
Phytosphingosines, which are precursors of ceramides.植物鞘氨醇（神经酰胺的前体）&
Mechanisms for prolonging the activity of shampoos延长香波活性的机制This has obvious advantages, in that any active ingredient is ordinarily removed when the shampoo is rinsed off. Two approaches are in current use:这种机制有点很明显，为的是当香波被冲洗后，任何活性成分都能大部分的停留在皮肤。目前使用的有两种路径：
Liposomes脂质体Here, the microvesicles have an inner aqueous layer, into which ingredients may be incorporated. The outer lipid layer attaches to the skin and haircoat, breaks down gradually releasing ingredient and imparting an emollient action.这些微泡有一个内在的水层，有效成分可以掺入其中。外面为脂质层，与皮肤和被毛接触并崩解后，渐渐的释放其中的有效成分，并发挥其滋润的功效。
Spherulites球粒Multiple layer microvesicles are made with the addition of chitosanide, derived from crustacea shells. Chitosanide enhances the adhesion of the Spherulites, and has hydrating properties. Active ingredient can be incorporated both in the microvesicles, for slow release as each layer breaks down, and in the suspending fluid for immediate effect.添加chitosanide（从甲壳中提取而来）制成的多层微泡。Chitosanide能够增加球粒的附着力，并具有吸水的活性。有效成分被掺和在微泡（降低其释放速度）和悬吊的液体（产生瞬即效应）当中。&
Practical considerations
实践中的考虑
Which shampoo to choose?选择哪种香波？The strategy is determined once a full assessment of the case has been made, and when the relative roles of specific and symptomatic therapy have been determined. It is perfectly permissible to use more than one shampoo if all of the required properties are not available in one. Be prepared to reassess and change shampoos - the best for one case is not necessarily the best for the next case.当病例被完整的评估，特异性治疗和对症治疗的相对重要性被确定后，我们就需要确定相应对策。如果一种香波不具有所有的功效，允许使用一种以上香波。随时准备重新评估和变更香波&对一个病例有效的香波未必对另一个病例也有效。&
How often to shampoo?洗澡的频率如何？This can be as often as daily in the early stages of therapy of a severe condition. More often it would be on alternate days or twice weekly to commence with, then declining to weekly administration.对于严重病例，早期可以一天一次。开始阶段频繁些，隔日一次或一周两次，然后减为一天一次。
What temperature of the water should be used?应该用什么温度的水？This is difficult. Cool shampoos are more soothing if there is an inflamed skin, whereas shampoos at body temperature will give better lathering qualities.这很困难。如果皮肤有炎症，洗凉水澡更舒适，而在体温水平的水中洗澡可能会有痛感。
Should the eyes and ears be protected?应该保护眼睛和耳朵吗？Studies have shown that putting Vaseline, or any other ointment in the eyes will actually concentrate any shampoo inadvertently spilled into the eye, and worsen the problem. It is useful to place cotton wool in the ears, so long as care is taken to remove afterwards.有研究认为在眼睛上抹上凡士林或其他任何软膏都会把香波吸收到眼睛里，从而是问题更糟糕。在耳朵里放药棉是可以的，只是事后一定要记得把它取出来。
Contact time?接触时间？Antibacterial shampoos MUST have a 15 minute contact time in order for them to work.抗菌药香波必须接触15分钟才能起作用。
Drying?干燥？Towel drying is generally fine. Hair dryers also can be used, so long as overheating is avoided. 毛巾擦干就很好了。毛发干燥机也可以使用，但是要避免过热。&
TOPICAL CORTICOSTEROIDS局部用类固醇Recent studies have shown that topical use of corticosteroids, rather than in shampoos, has a role in the treatment of CAD. This is especially because there are often focal areas of more intense inflammation. Agents employed include:近来的研究认为在CAD的治疗过程中，使用局部类固醇优于使用类固醇香波。这是因为局部焦点区域有更加严重的炎症。包括：
Hydrocortisone aceponate (Cortevance&, Virbac). This is metabolized in the epidermis and not absorbed. It is thus particularly suitable to topical use.醋丙氢可的松(Cortevance&, Virbac)。在表皮代谢，且不被吸收。因此，更适合局部使用。
Triamcinalone acetonide (Genesis&, Virbac). This is a spray formulation. 丙酮缩去炎松(Genesis&, Virbac)。这是一款喷剂。&
SKIN LIPD COMPLEXA& number of products are available that include ceramides aimed at restoring the abnormal barrier function in CAD. Of these, the Allerderm& Spot-On (Virbac), has been shown in electron microscopic studies to assist barrier repair.许多包含神经酰胺的产品并使用，以帮助恢复CAD时的皮肤异常屏障功能。在这些产品当中，Allerderm& Spot-On (Virbac)通过电镜研究已经证明有助于恢复皮肤屏障。
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?什么叫非特异性皮炎?
　　或许是非特异性免疫引起的疾病。可能属于过敏反应或自身免疫病 。　　资料;　　非特异性免疫　　简介　　非特异性免疫又称天然免疫或固有免疫。它和特异性免疫一样都是人类在漫长进化过程中获得的一种遗传特性，但是非特异性免疫是人一生下来就具有，而特异性免疫需要经历一个过程才能获得。比如猪瘟在猪群中传播很快，但和人类无缘。这是因为人类天生就不会得这种病；还有炎症反应也是人一生下来就有的能力。　　固有免疫对各种入侵的病原微生物能快速反应，同时在非特异性免疫的启动和效应过程也起着重要作用。　　固有免疫系统包括：组织屏障（皮肤和黏膜系统、血脑屏障、胎盘屏障等）；固有免疫细胞（吞噬细胞、杀伤细胞、树突状细胞等）；固有免疫分子（补体、细胞因子、酶类物质等）。　　特点　　①作用范围广。机体对入侵抗原物质的清除没有特异的选择性。②反应快。抗原物质一旦接触机体，立即遭到机体的排斥和清除。③有相对的稳定性。既不受入侵抗原物质的影响，也不因入侵抗原物质的强弱或次数而有所增减。但是，当机体受到共同抗原或佐剂的作用时，也可增强免疫的能力。④有遗传性。生物体出生后即具有非特异性免疫能力，并能遗传给后代。因此，非特异性免疫又称先天免疫或物种免疫。⑤是特异性免疫发展的基础。从种系发育来看 ，无脊椎动物的免疫都是非特异性的，脊椎动物除非特异性免疫外，还发展了特异性免疫，两者紧密结合，不能截然分开。从个体发育来看，当抗原物质入侵机体以后，首先发挥作用的是非特异性免疫，而后产生特异性免疫。因此，非特异性免疫是一切免疫防护能力的基础。　　发挥保护功能的几道屏障 首先是外围屏障。皮肤粘膜是机体第一道防线，包括：皮肤粘膜的机械阻挡作用和附属物（如纤毛）的清除作用；皮肤粘膜分泌物（如汗腺分泌的乳酸、胃粘膜分泌的胃酸等）的杀菌作用；体表和与外界相通的腔道中寄居的正常微生物丛对入侵微生物的拮抗作用等。其次是内部屏障。抗原物质一旦突破第一道防线进入机体后，即遭到机体内部屏障的清除，包括：淋巴和单核吞噬细胞系统屏障；正常体液中的一些非特异性杀菌物质；血脑屏障和胎盘屏障等。　　①淋巴和单核吞噬细胞系统是机体的第二道防线。微生物进入机体组织以后，多数沿组织细胞间隙的淋巴液经淋巴管到达淋巴结，但淋巴结内的巨噬细胞会消灭它们，阻止它们在机体内扩散，这就是淋巴屏障作用。如果微生物数量大，毒力强，就有可能冲破淋巴屏障，进入血液循环，扩散到组织器官中去。这时，它们会受到单核吞噬细胞系统屏障的阻挡。这是一类大的吞噬细胞。机体内还有一类较小的吞噬细胞，其中主要的是中性粒细胞和嗜酸性粒细胞。它们不属于单核吞噬细胞系统，但与单核吞噬细胞系统一样，分布于全身，对入侵的微生物和大分子物质有吞噬、消化和消除的作用。　　②在正常体液中的一些非特异性杀菌物质，如补体、调理素、溶菌酶、干扰素、乙型溶素、吞噬细胞杀菌素等，也与淋巴和单核吞噬细胞系统屏障一样，是机体的第二道防线，有助于消灭入侵的微生物。　　③血脑屏障主要是由软脑膜、脉络膜和脑毛细管组成，可以阻止微生物等侵入脑脊髓和脑膜内，从而保护中枢神经系统不受损害。血脑屏障随个体发育而逐渐成熟，婴幼儿容易发生脑脊髓膜炎和脑炎，就是血脑屏障发育不完善的缘故。胎盘屏障是由母体子宫内膜的基蜕膜和胎儿绒毛膜滋养层细胞共同组成的。这个屏障既不妨碍母子间的物质交换，又能防止母体内的病原微生物入侵胎儿，从而保护胎儿的正常发育。
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关于特异性皮炎（四弯风）的治疗与饮食
医院、龙华医院、新华医院、华山医院，西医说这是特异性皮炎、中医称四弯风，几乎每个月都在为他看病，所服用和涂得中西医药物无数。孩子已经尽量克制抓挠，但是在睡眠中下意识还是会去抓瘙痒的部分。想问，这个病能治好吗？在饮食上要注意哪些问题？
儿童特异性皮炎的护理工作特别重要，要注意以下几个方面： 1、喝母乳，母乳是新生儿较好的食物，有过敏性疾病家族史的婴儿，若完全以母乳哺育，则其发生小儿特异性皮炎及食物过敏的几率大为降低。
　　2、减少环境过敏原，灰尘和尘螨是常见的过敏原，也是小儿特异性皮炎恶化的因子。因此家中较好不要用地毯，家具改用皮质、木制质地的，保持环境清洁，以减少灰尘。起居室内湿度不要太高。让宝宝远离绒毛玩具、家中宠物、二手烟，同时清洁剂、洗衣粉、洗洁精、消毒水等化学物质，也不可直接接触幼儿皮肤。
　　3、掌握洗澡要领，补充皮肤的水分是小儿特异性皮炎的根本治疗法，每天至少补充保湿性产品2-3次，洗澡时让宝宝以微温的水（水温约33℃-40℃，越热的水冲刷油份的力量越强），越快洗完越好。避免使用刺激性的化学药剂和消毒性产品，洗澡后立刻涂抹保湿性强的乳液或乳霜，才能锁住水分，使水分不至于流失。绵羊油或绵羊乳液则要避免（因为羊毛脂本身可能引起过敏）。冬天较少流汗的话，可以选择鼠蹊、腋下、手脚等部位清洗即可，另外还要涂抹保湿性高的护肤品。尽可能减少肥皂的使用，不可用毛巾、刷子或海绵搓洗皮肤。
　　4、宝宝衣物应为全棉材
儿童特异性皮炎的护理工作特别重要，要注意以下几个方面： 1、喝母乳，母乳是新生儿较好的食物，有过敏性疾病家族史的婴儿，若完全以母乳哺育，则其发生小儿特异性皮炎及食物过敏的几率大为降低。
　　2、减少环境过敏原，灰尘和尘螨是常见的过敏原，也是小儿特异性皮炎恶化的因子。因此家中较好不要用地毯，家具改用皮质、木制质地的，保持环境清洁，以减少灰尘。起居室内湿度不要太高。让宝宝远离绒毛玩具、家中宠物、二手烟，同时清洁剂、洗衣粉、洗洁精、消毒水等化学物质，也不可直接接触幼儿皮肤。
　　3、掌握洗澡要领，补充皮肤的水分是小儿特异性皮炎的根本治疗法，每天至少补充保湿性产品2-3次，洗澡时让宝宝以微温的水（水温约33℃-40℃，越热的水冲刷油份的力量越强），越快洗完越好。避免使用刺激性的化学药剂和消毒性产品，洗澡后立刻涂抹保湿性强的乳液或乳霜，才能锁住水分，使水分不至于流失。绵羊油或绵羊乳液则要避免（因为羊毛脂本身可能引起过敏）。冬天较少流汗的话，可以选择鼠蹊、腋下、手脚等部位清洗即可，另外还要涂抹保湿性高的护肤品。尽可能减少肥皂的使用，不可用毛巾、刷子或海绵搓洗皮肤。
　　4、宝宝衣物应为全棉材质，衣物的选择较好是宽松、柔软的棉质的衣物，甚至连寝具、家具装饰等都要尽量避免对皮肤刺激的因素，皮肤也不要直接接触羊毛、尼龙、牛仔布等人造或粗糙纤维。
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