马拉色菌相关皮肤病

马拉色菌相关皮肤病 北京大学附属第一医院 王爱平 马拉色菌(Malassezia)为一种嗜脂性酵母菌，是人类及温血动物皮肤上的正常菌群之一。作为一 种条件致病菌，在某些易感因素作用下，马拉色菌常侵袭皮肤角质层引起浅部真菌感染，如花斑糠 疹、马拉色菌毛囊炎、脂溢性皮炎、特应性皮炎、银屑病、甲真菌病及新生儿脓疱病等疾病等。通 过此的学习，使学员充分掌握花斑糠疹、马拉色菌毛囊炎、脂溢性皮炎和皮肤念珠菌病的诊治 方法。 一、花斑糠疹 (一)定义 花斑糠疹是由马拉色菌侵犯皮肤角质层引起的一种慢性、无症状的浅部真菌病，常见于热带、亚热带地区，男性明显多于女性，多数患者在20,45岁，它不是一种传染性疾病，但有遗传倾向，12.9,18.8%的患者有阳性家族史，符合多因素遗传。 (二)发病机制 花斑糠疹的发病往往是多种因素综合作用的结果。内源性因素主要包括遗传易感性、皮脂腺分泌过剩、多汗及先天性或后天性免疫抑制等，外源性因素主要有环境湿度及空气中二氧化碳水平等。在这些因素作用下，马拉色菌由孢子相转变成菌丝相，侵入皮肤角质层，引起疾病。 (三)临床表现 花斑糠疹多在躯干脂溢部位好发，热带地区常累及面部，婴儿常以额面部皮损首发。皮损特征为色素沉着和/或色素减退斑，上覆少许细糠状鳞屑，形态可点状、钱币状或融合成片(图1,3)。约1/3患者有中度痒感，一般患者并无症状，常因皮肤颜色的改变而前来就诊，Wood’s灯下可见黄色荧光。真菌镜检显示，成群厚壁圆形或卵圆形芽生孢子和弯曲似S形的菌丝(图4)。 coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, (四)治疗 1.局部治疗 局部治疗是首选的治疗方法，可外用各种抗真菌药物，每日1,2次，连用2,4周既可。如果花斑癣非常广泛，可选用一些特殊制剂，如2%酮康唑洗剂、二硫化硒洗剂、吡硫翁锌等，每晚1次，连用2周。 2.系统治疗 对于皮损面积大、严重而单独局部治疗无效者，可以考虑口服治疗，可选用伊曲康唑200,400 mg/d ，连续口服1,2周，建议同时联合局部治疗，效果更好。 3.预防复发 可采用2%的酮康唑洗剂每周清洗皮肤一次。也可口服伊曲康唑，每月服1次，服400mg既可。另外，也可口服氟康唑或酮康唑，使用方法均为每月服1次，服400mg。这些方法都可起到预防复发的作用。 马拉色菌是人体皮肤表面正常菌群之一，菌群密度增加时容易导 致发病，所以应该注意预防复发，请问预防复发可有哪些方法, (五)预防 预防花斑糠疹，应注意通风，避免居住或工作环境高温、潮湿，勤洗澡、勤换内衣等。 二、马拉色菌毛囊炎 (一)概念 马拉色菌毛囊炎是由马拉色菌引起的慢性毛囊性感染，多见于青年，好发于人体上半部皮脂腺丰富部位，表现为外观形态一致的暗红色圆顶丘疹或脓疱，不融合，自觉瘙痒。毛囊阻塞导致马拉色菌大量生长也许在该病的发病中起着重要的作用。 (二)易感因素 马拉色菌毛囊炎的易感因素有:局部应用抗菌药物;系统或局部应用糖皮质激素;糖尿病;心脏移植患者;免疫低下患者;孕妇等。 (三)临床表现 1.一型:常见于青年，背、上胸部散在瘙痒性毛囊性丘疹或脓疱的毛囊炎。常发生于日晒后、用抗生素或免疫抑制剂后。 2.二型:见于某些脂溢性皮炎患者，胸、背部多发性小毛囊性丘疹(图5、图6)。 3.三型:见于艾滋病患者，多发性脓疱，分布于躯干和面部，常合并严重脂溢性皮炎。 (四)辅助检查 1.直接镜检:一般看不到菌丝，可看到很多孢子，而且孢子往往有出芽现象(图7)。 2.组织病理检查:在毛囊内可见到真菌孢子，少见菌丝，具有诊断价值(图8)。 coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, (五)鉴别诊断 以下是马拉色菌毛囊炎和痤疮的鉴别方法。 疾病 马拉色菌毛囊炎 痤疮 发病年龄 青春期后 青春期 基本损害 毛囊性丘疹、脓疱，瘙粉刺、丘疹、脓疱、 痒显著 结节、囊肿 发病部位 上背、肩、胸、前臂 面部、上胸、背部 治疗 抗生素治疗无效或加抗生素治疗有效 重，抗真菌治疗有效 致病菌 马拉色菌 痤疮丙酸杆菌 (六)治疗 1.局部治疗 马拉色菌毛囊炎的治疗原则同花斑糠疹是一样的，轻者以外用抗真菌药为主，如可外用酮康唑洗剂等。 2.系统治疗 对皮损数目较多、较严重者，可口服伊曲康唑200,400 mg/d，连续服用4,6周，同时联合局部治疗。 3.预防复发: 可口服伊曲康唑，每月1次，服200~400mg即可，也可用酮康唑洗剂清洗。另外，对于这类疾病还应 避免含糖多、辛辣及油多的饮食。 4.相关文献 Razek等采用不同方法治疗马拉色菌毛囊炎，共分为4组，疗程均为4周。 第一组:口服酮康唑200mg/d，同时用2%酮康唑香波清洗，1次/d，100%治愈; 第二组:口服酮康唑200mg/d，75%治愈; 第三组:外用1%硝酸益康唑霜，10%治愈; 第四组:外用2%咪康唑霜，10%治愈。 可见，联合治疗是最佳选择，可达到较为满意的治愈率。 三、脂溢性皮炎 coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, (一)概念 脂溢性皮炎是一种发生在皮脂溢出基础上的慢性皮肤炎症，临床上以头面部及上背部黄红色斑片伴油腻性鳞屑及结痂为特征，并伴有明显的炎症反应。头皮屑属于轻型脂溢性皮炎，不伴有头皮的炎症反应，二者是同一疾病的不同阶段。 脂溢性皮炎临床主要以头面部及上背部黄红色斑片伴油腻性鳞 屑及结痂为特征，与头皮屑是完全不同的两种疾病，这种说法对吗, (二)发病机制 脂溢性皮炎的发病是遗传、皮脂分泌增多、感染、免疫缺陷、精神及环境等众多因素综合作用的结果。皮肤表面皮脂增多及化学成分的改变，使存在于皮肤的正常菌群大量异常增殖，侵犯皮肤从而引起疾病。马拉色菌在其中的发病机理至今尚不清楚，可能与马拉色菌介导的免疫反应密切相关;可能由马拉色菌产生的毒素及酯酶活性造成。 (三)临床表现 脂溢性皮炎好发于头皮、面、耳、胸及背的上部。皮损表现为脱屑性红斑。对于HIV感染患者，脂溢性皮炎是CD4抑制的早期表现，常突然发病，且病损广泛。 (四)治疗 1.局部治疗:可外用咪唑类、低效糖皮质激素、钙调磷酸酶抑制剂等，头皮屑较多时可采用2%酮康唑香波，每周2次，连续使用2,4周。 2.系统治疗:局部治疗无效者、严重性脂溢性皮炎可口服酮康唑200mg/d，连续口服1,2周，或伊曲康唑200mg/d口服 1周。 四、皮肤念珠菌病 (一)定义 念珠菌病是由念珠菌属所引起的感染，一般来说，白念珠菌是皮肤念珠菌病最主要的病原菌。 (二)临床类型 皮肤念珠菌病的临床类型包括:擦烂红斑、甲沟炎及甲床炎、须疮、丘疹型皮肤念珠菌病、婴儿泛发性念珠菌病、念珠菌性肉芽肿、慢性粘膜皮肤念珠菌病等。 coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, (三)临床表现 1.间擦疹 间擦疹主要发生于皮肤间擦部位，如指间、乳房下、腋下、腹股沟、颈部等处。表现为界限清楚的红斑，表面糜烂，其外围有散在的米粒大的丘疹，上覆细圈脱屑损害中央可有水疱、脓疱。婴儿、肥胖多汗者、糖尿病多见。 2.尿布皮炎 尿布皮炎指的是使用尿布的新生儿臀部和肛周出现的红斑损害，白念珠菌在其中产生的作用仍不清楚。 3.真菌镜检存在酵母细胞和假菌丝。 (四)治疗 1.局部治疗 皮肤念珠菌病的局部治疗原则与体股癣是一样的。对于尿布皮炎伴发念珠菌感染的婴儿可局部使用含糖皮质激素和(或)抗细菌抗生素的抗真菌制剂。 2.系统治疗 对皮损波及毛囊、甲沟、甲板、新生儿或并发系统感染者，可口服伊曲康唑100,400mg/d ，或儿童每日口服伊曲康唑3,5mg/kg，也可口服氟康唑，每日6,12mg/kg。 (五)预防 预防皮肤念珠菌病，应首先去除易感因素，如避免使用大量抗生素、免疫抑制剂等。应保持皮肤清洁、干燥，勤更衣、勤换床单。 作为一种条件性致病菌，在某些易感因素的作用下，马拉色菌常侵袭皮 肤角质层引起浅部真菌感染，但随着抗生素及免疫抑制剂的大量应用，其与 菌血症和脓毒病等深部真菌感染也有着密切联系。 coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave,