䙖兂 1-1 Macule Patch (color) Papule Plaque Nodule Wheal ex. Urticarial Dermatographism Blister Vesicle Bulla Pustule(㚱 pus 䘬㯜㲉) Erosion(basal layer) Ulcer(dermis) Crust Scale(僓) Fissure Scar Atrophy Lichenification(剼䘔⊾) Excoriation (䙖兂䘊: pruritis) Erythema(埨䭉㒜) Purpura(䲭埨䎫㺚㺷)

䙖兂䥹䓐喍 1. Oral Antihistamine H1

∗ἄ䓐烉䜉ˣṌデ䕯䉨ˣᶵ㔜 2. Sedating (ex. Hydroxyzine/ Diphenhydramine) 3. Topical Steroid

性䓐共ˣ㚫昘ˣ䙖兂䙢㐢嗽 ∗ἄ䓐烉striae, skin atrophy, purpura 僶ᶲ儢

4. Tar 5. Topical calcineurin inhibitor (ex. Tacrolimus, pimercrolimus)

ᶵ㚫崟䙖兂厶炻 cytokine transcription 䅺䀤デ

庫慵䘬喍 1. Systemic glucocorticoid 2. Cyclosporin (T cell 䕓) 3. Antimetabolite 4. UV light

<0.5cm >0.5cm

papule vs. nodule(真皮、皮下)

膨疹蕁麻疹

會有疤

結痂

壓diascopy 會退色

<0.5cm >0.5cm

small deep narrow ulcer

extravasation of boold

transient swelling due to dermal fluid

steroid acne, contact or irritant dermatitis

交感症狀：口乾、視力模糊、尿意滯留

止癢抗發炎

Doxepin 是抗憂鬱藥，也可以當抗組織胺 不建議用外用的抗組織胺~~~

non steroid, 臉、眼瞼可以用

急性

抑制cytokine轉錄

與itraconazole合用 食慾增加

動物實驗可能會致癌 避免太小的小朋友使用

㽽䕡 Eczema Dermatitis Inflammatory skin reaction 䎦 spongiosis, acanthosis, z Contact dermatitis Allergic type IV, Langerhans cells TH1 cell Irritant nonimmune, no memory T0cell or antigen specific Ig involved Ex. 愠ˣ渤烊 晙佭垚 z Atopic dermatitis

ㄊˣ䘤ˣˣTH2(IgE)ˣ㕷忶㓷ˣἝ䘤忶㓷滣䀶ˣ㯋ˣ晐⸜漉䶑妋 Hygiene hypothesis: TH1 ㅱḮ TH2 䳘傆䘤 Fliaggrin(堐䙖晄噳䘥)љĐĞƌĂŵŝĚĞљ 噳䘥㹞妋愞ј ᾅ㯜љ AD: TH2, IgE (IL-4, IL-13) ㄊ AD: TH1 Fliaggrian 堐䎦慷㷃⋲炻㚫枧 stratum corneum TSLP 㚫婀ἧ Dendritic cell 婀䘤 TH2 response 䕯䉨炰炰炰 1. Pruritus 2. chronic/ relapsing, 3. 㚳烉共ˣ柕䙖偊Ỡ“(extensor)烊 ⸜䲨庫烉偊“(flexor) 4. 㕷忶㓷 㱣䗪 1. 䦣昌婀䘤䳈 2. 性妠忶㓷 3. ᾅ㽽 4. 㬊䘊烉antihistamine sedating 喍䈑(Hydroxyzine & Diphenhydramine)

z Seborrheic dermatitis : ㄊ䕡毿䙖兂䕭 (chronic papulosquamous) 夳ˣ䙖傪㹊ˣ柕䙖ˣ共ˣ幨⸡ˣHIV (85%)ˣ⅔ら⊾ 䙖剥却;WŝƚLJƌŽƐƉŽƌƵŵͿї溜却喍(Ketoconazole) v.s. psoriasis (Ḧ䘔Ϳ ї^ĞďŽƉƐŽƌŝĂƐŝƐ erythema, 毿䉨⊾僓(scaling)

z Hand Eczema 㼌兂ḛˣ䓐栆愯

細胞間水腫

棘細胞增厚itching redness

Allergic type IV, 呈現給

patch test Irritant nonimmune,

ㄊˣ䘤 TH2(

負責角質化的基因產物

母系遺傳

併發：易有眼睛的問題、感染、手部皮膚炎、脫屑性皮膚炎(exfoliative)

v.s. psoriasis ( Ϳ(Ḧ䘔Ϳ ^ĞďŽƉƐŽƌŝĂƐŝƐ

Malassezia furfur

治療：tar, 仁山利舒、 zinc pyrithione, selenium sulfide, salicylic acid topical steroid

Fliaggrin(

溜却喍

TH2 response

z Pompholyx 㯿㯿䙘䕡 ㇳ儛央䎦䲭㔹㯜㲉 young man

z Asteatotic eczema 仢傪= ⅔䘊 ⅟ˣḦˣ侩Ṣˣḛ㵚ˣ儧兪ㇳ

z Statis dermatitis(Gravitational eczema) 櫙埨 朄傰㳩ᶵ列ˣ刚䳈㰱䧵ˣ㼘䖵ˣ堐㶢朄傰

z Lichen simplex chronicus 㜙㕡Ṣˣemotional stressˣNeurodermatitis ⤛烉儎ˣ柠側悐 䓟烉昘ㄊ㽽䕡 三䎫桐~

z Prurigo nodularis ね䵺ˣNeurodermatitisˣ怈䪗偊橼ˣỠ“

z Nummular Eczema 拊⸋䉨㽽䕡

z Autosensitization dermatitis Secondary( primary 嗽㚫慳 cytokine) 䁢䧙

z Exfoliative dermatitis 崭忶 90%䲭䕡+慵僓 Erythroderma Ἦ㚱䘬䙖兂䕭侴Ἦ Ḧ䘔ˣ㽽䕡

䙖兂 1-3 Dermatophyte 溜却烉Ὕ䉗䓚ˣ柕䙖ˣ奺⊾䘬䙖兂 ᶱᾳⰔ烉䙖㮃炰 Microsporum(剥却)ˣEpidermophyton(堐䙖䘔却)ˣTrichophyton(㮃䘔却) Most common: T. rubrum M. canis E.floccosum ὅῷ⤥烉Anthropophilic, zoophilic, geophilic ὅ斄䭨↮䓇傆⫸烉Ectothrix, Endothrix Active border! 䡢姢: Wood lamp, KOH(㹞妋噳䘥岒ˣ傪岒ˣ䙖炻䔁ᶳ⸦ᶩ岒ˣ態噳䘥) skin biopsy, Culture Dermatophytosis:

原因可能：dsyhydrosis, atopic dermatosis, allergic contact dermatitis fungal infection (id reaction)

中年人、靜脈回流、重力相關

Xerosis 乾燥症

小心細菌感染

這兩個病的治療：Sedative antihistamine, cryotherapy(液態氮冷凍), thalidomide ???

四肢、搔癢造成

=erythroderma

原因： or CTCL Sezary syndrome

併發：電解質不平衡、體溫恆定不良、心跳加快、高輸出心衰竭、低白蛋白、周邊水腫

皮癬菌

紅色毛癬菌 犬芽孢菌 絮狀表皮癬菌

比較不會在臉~~

!!!KOH 看fungus的！

z Tinea capitis M. canis; T. tonsurans (㕟檖㮃䘔却) 3-14 yrs!!!! 朆曺㗍㛇 夳 asymptomatic carrier ὅ㚱䃉䘤䀶↮栆烉 Noninflammatory: M. audouinii, M. ferrugineum

Inflammatory: M.canis, M. gypseum Black dot: T. violaceum, T. tonsurans

䛇却喍㱣䗪 systemic antifungal, oral glucocorticoid, ketoconazole (䓐㒎䘬㰺㓰)

z Tinea cruris (偉偉䘔) 2nd T.ruburm, T.mentagrophytes, E.floccosum 冒橼⁛㝻 嘇䘤滈已悐ˣpubic area, 偉 (!!!!!!!ᶵ㚫Ὕ䉗䓇㬾!!!!!!!!!!!) v.s. 䎈却デ㝻

z Tinea pedis & Tinea manus Tinea pedis (楁㷗儛) 1st

1. Interdigital type 2. Chronic hyperkeratotic type:

T. rubrum, ᶨ䇯ᶨ䇯ˣᶵ䘊ˣ䘤䀶ᶵ慵ˣ㱣䗪ㅱᶵ⤥ˣTwo feet- one hand syndromeˣ儛側ㇵ㚱㖶栗 active border

3. Vesiculobullous type烉T. mentagrophytesˣ嵛ˣ怲䶋 4. Acute ulcerative type烉bac coinfect: T. mentagrophytes + Gram(-)

ᶲℑ䧖䕓慳㓦姙 ĐLJƚŽůŝŶĞї䑘їṾ嗽㯜㲉їsĞƐŝĐƵůĂƌŝĚƌĞĂĐƚŝŽŶ Tinea manus 1. Hyperkaeratotic : 䲳ˣ䭨 2. Cresentic 3. Onychomycosis烉䓚ḇ塓デ㝻 䀘䓚

z Tinea unguium : Dermatophyte デ㝻䓚

v.s. Onychomycosis: ảỽ溜却デ㝻䓚 䓟ˣ厠ˣ⸜䲨ˣ怲≽傰䕦䕭 dŝŶĞĂƉĞĚŝƐїKŶLJĐŚŽŵLJĐŽƐŝƐїZĞŝŶĨĞĐƚŝŽŶŽĨĨĞĞƚ

1. Distal烉㚨夳 2. Proximal烉䕓≇傥⓷柴 3. White superficial烉㚨㖻㱣䗪 4. Candidal烉⎰Ἕ䓚㹅䀶ˣ䲭儓ˣNail cuticle ᶵ夳ˣ䓚ℑ“嬲湫

z Tinea Corporis

全世界TW USA

ectothrix anthropophilic

zoo geo

endothrix anthropophilic

要穿越髮根

, selenium sulfide

3-14 yrs!!!! 小孩！

(Tinea pedic來的)

(!!!!!!! !!!!!!!!!!!) !ᶵ㚫Ὕ䉗䓇㬾! v.s. 䎈却デ㝻

Interdigital type Chronic hyperkeratotic type:

Vesiculobullous type烉TAcute ulcerative type 可發展成cellulitis

手背，active border

anthropophilic: T. rubrum, T.violaceum, T. tonsurnas

onychomycosis: fungal 感染

paronychia: bac 感染

X ㇳ X 儛 X 滈已悐䘬㹹䙖兂 㚳: M.canis T.rubrum, T. mentagrophytes, M.canis Annular leision: 䁢䙖䘔却㚫䘤䀶ㅱ庫Ỷ䘬崘 冒橼⁛㝻

㱣䗪烉 1. antifungal agent Topical or Systemic

Terbinafine: 㭢溜却炻 Dermatophytes, Aspergillus, Scopulariopsis 庫㚱㓰 Intraconazole: 溜却炻potent inhibitor of cytochrome P450 3A4 旵埨傪喍ˣ⬱䛈喍

contraindicate Fluconazole烉Candida 䓐 ---Azole: 湍奺傪愯 悥㚱 GIˣ偅㭺

2. 㚱 bac 天䓇䳈 Candida albicans 侫 KOH 炰 Dimorphic yeast 洅䗉 most common AIDS 奺䀶 䢐䕡烉堃㗇䉨䲭溆炻㚫䓇㬾 (v.s. Tinea cruris) 䙖䙖剥却 Malassezia spp. 侫 KOH 炰 IJį㯿㔹(Tinea vesicolor)烉嬲刚䲈䕡ˣMelanocyte塓䟜ˣTyrosinase ijį傪㺷䙖兂䀶炷Seborrheic dermatitis炸 Ĵį㮃䀶炷Pityrosporum炸 㱣䗪烉Antifungal agent Azole ***** Terbinafine Griseofulvin㰺㓰

䙖兂 2 z Psoriasis Ḧ䘔 戨䕭 ᶵ䫱㕤䈃䙖䘔(Lichen simplex chronicus ㄊ䲼剼䘔) 䘤䕭檀Ⲙ烉20-30(Third) 50-60(sixth) 崲㖑䘤䕭崲 䈡烉怲䓴㶭㤂ˣSilvery scales(ᶳ㕡⊣䲭刚)ˣ䧙ˣAuspitz signˣKobner’s phenomenonˣ nail pitsˣonychodystrophy DD onychomycosis(䀘䓚) Psoriatic arthritis

Ring worm

Active border

M.canis

感染確診： 1. KOH2. Skin biopsy H&E 紫紅色

PAS 紅 Silver methenamine黑

3. Culture

口服antifungal: Griseofulyin

若有onychomycosis: Terbinafine, itraconazole, fluconazole

配合局部corticosteroid (才不會癢得要命)

和anti-H1 會有心律不整

allylamine類

azole類

azole 類

療程久、副作用多、不用來治灰指甲

Terbinafine: Intraconazole:

Fluconazole上面三種藥都是這個機轉

常合併甲溝炎、紅腫熱痛、nail cuticle不見

㚫䓇㬾 (

德國香腸

義大利麵和肉丸

1. thrush

=acute pseudomembranous candidiasis

2. angular cheilitis

3. candidial intertrigo 大片癢紅斑，有satellite vesicopustules

4. diaper dermatitis,

5. interstitial candidal infection

6. vaginal and vulvovaginal candidiasis

7.balantitis/balanoposthitis 龜頭炎、龜頭包皮炎

Malassezia 熱帶、年輕人

皮脂處常見菌叢、復發率高

Parasitic mycelial form感染力高Yeast 會過濾光線

Terbinafine Griseofulvin n㰺㓰

好發於DM病人

Intraconazole對candida 和Malassezia治療效果較好

Psoriatic arthritis

loss of control of normal epidermal turnover

越往北罹患比例越高

外力撥開會有小出血點

Kobner's phenomenon:

Psoriasis, LP (開刀傷口可能會出現病灶)

wart, molluscum contagionsum

PIP, DIP (: single) v.s. 栆桐㽽炻 MP joint v.s. ankylosis spohdylitis炻HLA B27 gene 䔘 ϭPsoriasis Vulgaris Ḧ䘔 柕䙖ˣ儘/啎㢶ˣ偊Ỡ“ ijį暐㺜䉨(Guttate)ˣϯErythroedemaˣϰPustularˣϱInverse(偊䘬“) Triggering factors!!!!!!!!!!!!!!!!! TIDES T: trauma: Kobner’s phenomenon I: infections: streptococcus, HIV D: drugs: Antimalarial, ACEI Beta-blockers, biologics Corticosteroids Drug for depression: lithium E: environment (cold weather) 暨天春ㇵᶵ㚫农䕭旧!! Stress Pathogenesis 奢㗗冒橼䕓ї>LJŵƉŚŽĐLJƚĞƐŝŶĨŝůƚƌĂƚŝŽŶ UnindĞŶƚŝĨŝĞĚĂŶƚŝŐĞŶнD,їW嵹lymph node ἧ T cell 㳣⊾ї Th1 cytokines ї/&E-gamma/L2 TNF-alpha (喍䈑target) їŬĞƌĂƚŝŶŽĐLJƚĞᶵ㬋䓇ˣ㵳䎫嬲 IL-12 IL-23ḇ㗗㱣䗪慵溆 ї忶㓷䕦䕭㷃 ex. Atopic eczema 䁢: Th1 Th2 ї䳘却デ㝻㷃 䁢烉Defensin 䫱↮㱴≈ Associated systemic disease!!!!!!!!!!!!!!!!!!!! 冒橼䕓ṌḺ忋䳸旧~ Atherosclerosis, MI, DM, hypertension, autoimmune 㱣䗪 ᶵ傥㱣䗺炻傥 dŽƉŝĐĂůĂŐĞŶƚƐ ĐŽƌƚŝĐŽƐƚĞƌŽŝĚƐsŝƚϯĂŶĂůŽŐZĞƚŝŶŽŝĚĐŽĂůƚĂƌ Photo therapy Systemic agents: corticosteroid (⫽䓐炻䁢retinoid, methotrexate 㚱䔠偶),

calcineurin inhibitors ex. Cyclosporine ZĞƚŝŶŽŝĚ(A愠) 天㱣 pustular psoriasis

口訣：extra big head

ϭPsoriasis Vulgaris s s

(Guttate) ϯErythroedema ϰ Pustular ϱ Inverse( )ijį暐㺜䉨( )ˣϯ aˣϰ rˣϱ (偊䘬“)常在URI後發生(infection 後)

使用太強的類固醇突然停藥

atopic dermatitis是TH2 喔！阻止keratinocyte凋零 促淋巴球增生

ICAM-1 增加

IL-12 IL-23ḇ

TIDES

影響：

抑制keratinocyte的增生

和Vit D 作用類似+ 減少發炎

止癢

UVB 280-320 刺激皮膚產生Vit D

PUVA 320-400

!!暨天春ㇵᶵ㚫农䕭旧!

Immunobiologic target TNF-alpha Inverse psoriasis䓐Ỷ∹慷栆愯

z Parapsoriasis LPP >5cm 歕欂䰱ˣ楁厠䳁ˣatrophy, telangiectasia(埨䭉㒜䕯), hyper or hypopigmentation ᶵ夷ˣᶵ䧙 㖻嬲ㆸ mycosis fungoides Cutaneous T-cell lymphoma ẍ天䧵㤝㱣䗪 SPP <5cm 列ˣㄊˣ堐Ⰼ䘤䀶 ἳ烉Digitate dermatosis(⁷ㇳˣ幓橼ℑ“)

z Pityriasis lichenoides (PL)

PLC (chronica) 䗺⎰ᶵ㚫䔁䕌炻Ἦㄊㄊ PLEVA (et varioliformis acuta) 䗺⎰㚫㚱栆Ụ㯜䖀䕌炻Ἦ炻⎰Ἕ柕䖃ˣℐ幓䃉≃䘤䅺

䫱 䓐ˣ㚵栆愯ˣ䓇䳈ˣ䗪 (antimetabolites ex. Methotrexate)

z Lichen planus(LP) ⸛剼䘔䕡

4P Purple, Polyglonal(奺), pruritic(䘊), papules (↠崟Ἦ) HLA 䚠斄 Wickham striae ᶨ凔攟ㇳ僽ˣ儛㚚悐ỵ炻僼䓇㬾 Inverse LP 攟僳ᶳˣ儡偉㹅ˣḛᶳ悐㹅inframmammary area Nail! 䓚ᶲ䘥䶂ˣtentingˣloss of nail plates ㅱ娚ḇ㗗冒橼䕓ℓ??? 傥崟䘬喍ACEI, antimalarial, beta-blocker ᶨ凔1~2⸜㚫⤥炻ᶨ䚜悥ᶵ⤥傥㗗SCC!!!!!

䙖兂 3-1 Autoimmune Bullous Dermatoses 冒橼䕓㯜㲉䕦䕭 天㓣㑲desmosome ɦacantholysis (䳘傆妋暊)ɦ㯜㲉 Desmoglein 㥳ㆸdesmosome

Dsg1 Dsg3 stratified squamous epi.

ĐĂŶƚŚŽůLJƐŝƐZĞƐƵůƚŽĨůŽƐƐŽĨĂƉƉƌŽƉƌŝĂƚĞŬĞƌĂƚŝŶŽĐLJƚĞ-keratinocyte adherence Pemphigus 䕙䗉

z Pemphigus vulgaris

Etranercept, infliximab, adalimmumab

很罕見

Cutaneous T-cell lymphoma 屁股、屈側

chronic plaque parapsoriasis

苔癬樣糠疹

會有膿皰、出血性壞死

1~3年

數星期

varioliform scars

LP spares the face

Lichen planus(LP)

Wickham striae

減少可能引起LP的藥物、刺激

用類固醇治療(外用，注射到leision，systemic)

or PUVA

PLEVA (et varioliformis acuta) 䗺PLC (chronica)

可能有Kodner's phenomenon

陸續上市後發現有副作用

由living organism 製造

target precise immune response

Ustekinamab 會block IL-12, IL-23

ɦacantholysis

Pemphigus vulgaris pemphigus 中最嚴重的

較淺，都在BM上方 vulgaris : Dsg3 → mucous 深層破裂

Dsg 1&3 → mucous 和skin都整層

䙖兂悥㚫䟜 IgG 慵 䕭 䀋 Positive Nikolsky sign Direct: 㬋䘬䙖兂炻㚫䎦㕘㯜㲉 Indirect: 㯜㲉ᶲ䘤炻㕩怲㚫䎦㕘㯜㲉 䡢姢烉 skin biopsy IgG㰱㽙炻suprabasal epidermal cleft 㬋ᶲ㕡

IIF䔞㧁㰢⭂㗗 喍 Antigen: Desmogleins(1&3) or Non-Dsg pemphigus antigens Skin Dsg1 㔜Ⰼ悥㚱 塪㶢 Mucous membrane Dsg3 㔜Ⰼ悥㚱 塪㶙 ẍ㓣㑲 1 or 3 䙖兂湷兄ᶵᶨ㧋 㱣䗪 慷㚵栆愯!!!! Immunosuppressant ZŝƚƵdžŝŵĂď;ĂŶƚŝ-CD20 monoclonal Ab)

z Pemphigus vegetans ῤ

z Pemphigus foliaceus 句叱 Environment ẍtrigger 朆堐㶢炻㚱㗪῁䚳ᶵἮ⁷㯜㲉炻㚱㗪῁䚳崟Ἦ⁷㽽䕡ˣ䲭䙖䕯ľņŹŧŰŭŪŢŵŪŷŦġťŦųŮŢŵŪŵŪŴġˤ ᶵ㖻㚱䟜(䁢㓣㑲Dsg1 )

z Pemphigus erythematosus 枸ᶵ拗 ẍ“ANA(+) Antinuclear antibody Localized PF 怲䓴㶭㤂 㱣䗪 ∹慷庫Ỷ䘬栆愯 Immunosuppressants: Tetracycline, niacinamide, hydroxychloroquine;^>ƚŽŽͿ Dapsone!!! 侩喍㕘䓐炻㚱嬲䲭埨䎫ˣ屏埨䘬∗ἄ䓐炻㛔Ἦ䓐leprosy 䚠斄䕦䕭 慵䕯倴䃉≃ 傠儢䗌(thymoma) 冒橼䕓䕦䕭~~ 喍䈑䘤 : D-penicillamine, caƉtropril

z Paraneoplastic pemphigus 䖃䘬湷兄Ὕ国 㧋䕭䀞 㚱僼䀶;Stomatitis!!! ͿŝŶƚƌĂĞƉŝĚĞƌŵĂůĂĐĂŶƚŚŽůLJƐŝƐ

ŝŶƚĞƌĨĂĐĞĚĞƌŵĂƚŝƚŝƐŬĞƌĂƚŝŶŽĐLJƚĞŶĞĐƌŽƐŝƐLymphoproliferative neoplasm 1st:Non-Hodgkin’s lymphoma 2nd: Chronic LymphŰcytic Leukemia 3rd: Castleman’s disease

Pemphigus vegetans

Pemphigus foliaceus

Pemphigus erythematosus

Paraneoplastic pemphigus

可以通過胎盤，所以孕婦有的話baby可能會有暫時性的表現

中東、地中海、猶太人較常見

Skin Dsg1 Mucous membrane Dsg3

復原過程出現嚴重結痂，表皮增厚

檢查 1. Nikolsky sign2. skin biopsy DIF(IgG) or IIF監控： 1.小心感染 2. IIF評估病毒活性 3. may die from therapy

IIF 是側血清中的相關抗體

促使B cell溶解

vulgaris: Dsg 3 → mucous深層

Dsg1&3 → skin, mucous都整層

foliaceus: Dsg 1 → skin 淺層

不太有mucous問題

less severe, 50-60yrs, 臉部、上半身

black fly

DIF 出現位置較vulgaris更表淺

主要attack Dsg1㑲Dsg1

=senear-usher syndrome

Erythematosus也是主要攻擊Dsg 1

臉部、上半身

含有-S-H鍵，使Dsg 抗原性增加

䚠斄䕦䕭

(thymoma) ~~慵䕯倴䃉≃ 傠儢䗌( 冒橼䕓䕦䕭~

90%死亡率

㱣䗪

!!!! Immunosuppressant ZŝƚƵdžŝŵĂď;ĂŶƚŝ-CD20 monoclonal Ab)慷㚵栆愯!

subcorneal

DIF䚳IgG complement ΛD䦣昌儓䗌䙖䕡⋲㚫㴰

Pemphigoid 栆栆䙘䨿 z Bullous pemphigoid

䵲ᶵ㖻䟜炻䘤䓇㖻㐑㒎䘬ỵ伖ˣᶵ㚫Ὕ䉗mucosaˣ侩ṢˣNegative Nikolsky’s signˣ凡忶

㯜䃉䕽 Autoantigen: 䁢䛇䙖堐䙖䘬Ṍ䓴嗽 (subepidermal, lamina lucida) BPAG1= BP230 superficial

BPAG2=BP180 (XVII collagen) transmembrane Ag-Ab complexɦ complement cascadeɦ eosinophil, neutrophil 倂普ɦ慳㓦gelatinase, neutrophil

elastaseɦ㯜㲉 㚜㶙䘬㯜㲉⋨↮烉DIF or IIF 㱣䗪烉栆愯ġŪŮŮŶůŰŴŶűųŦŴŴŢůŵĭġűŭŢŴŮŢűũŦųŦŴŪŴĭġũŪŨũġťŰŴŦġŊŗŊŨ 枸烉ᶵ拗炻Ữ侩Ṣ侩⸜䕭 z Cicatricial pemphigoid( mucous membrane)㚫㚱scar炻天䘤䓇membrane, 㚫枧夾≃ Desqumative gingivitŪs, oral erosions, conjunctival inflammation, fibrosis 僼烉100% !!!! 䛤䜃烉70% cornea~~ Antigen: 慵!!! 天㗗BPAG2=BP180 (Ṿἳ⤪VII collagen㚫lamina densa炻㶙ɦẍ㖻

scaring ) z Pemphigoid(herpes) gestationis

Antigenḇ天㗗BP180

z Linear IgA disease 䑘䉨炻pemphigoid gestationis 䚠Ụ Antigen: LAD-1, LAD-97 㚱ṃ儓䗌䚠斄炻䘚䗯喍炻ACEi 㱣䗪烉Dapsone 炻䕓∹

z Epidermolysis bullosa acquista bullous pemphigoid㚱溆⁷ Ữ㜧 ᶵ溆烉ㇳ儛炻䔁ᶳ䰱䰱䘥䘥䘬䕽嶉 Antigen: 㶙: type VIIġŤŰŭŭŢŨŦů ᶵ㖻㱣⤥ 㚫Ờ晐冒橼䕓䕦䕭

z Dermatitis Herptiformis

complementc 診斷gold standard： immunoprecipitation

較pemphigus benign

屈側

hemidesmosome

補體聯集

lamina lucida

complement c

mucosaᶵ㚫Ὕ䉗mBullous pemphigoid

Cicatricial pemphigoid(疤痕的

牙齦脫屑

檢查：也是IgG, IgA, C3 沉澱

(C3, IgG deposition)

Pemphigoid(herpes) gestationis 懷孕或生產完(BP230)

Linear IgA disease

Epidermolysis bullosa acquista

ㇳ儛 bullous pemphigoid發生在屈側skin fragility

檢查：也是IgG, IgA, C3 沉澱

後天性大砲型表皮鬆解症

Dermatitis Herptiformis

bullous pemhigoid適合topical steroid

䘥Ṣˣ䳘㯜㲉ˣ∯䘊!!!ˣ塓䔞ἄ㽽䕡㱣䗪 DIF ᶨᶨ IgA 柮䰺 Gluten sensitive ġġ湝䰱忶㓷 䓐Dapsone㱣䗪

䙖兂3-2 Internal medical disorder忈ㆸ䘬䙖兂⓷柴 DM 1. limited joint mobility, eruptive xanthomas, acanthosis nigricans 2. Scleredema diabeticorum 3. Prayer’s sign 4. Diabetic ulcer 5. necrobiosis lipodica 6. granuloma annulare䑘倱剥儓烉tinea㶟 7. diabetic dermopathy 8. acquired perforating disorder: transepithelial ᾅ㙊忂炻䓐A愠㱣䗪 9. Bullosis diabeticorum 㶙炻䨩䘤炻ᶵ㚫咻ℐ幓炻Ṿ忶䘬㯜㲉䕦䕭D.D. Thyroid 1. Thyroid dermopathy: 䃉䖃, 䧖柷刚, 彋䉨堐朊, 㺧mucin 2. 䛤䎫䨩 3. thyroid acropachy Hypo~~~ ゛゛冒慓昊ῤ䎕䳗㬣䘬㧋⫸ Malignancy 悥㗗天㱣儓䗌ㇵ㚱䓐 1. Tripe palm : gastric or lung cancer 2. Acrokeratosis apraneoplastica 柕柠悐儓䗌 3. Erythema gyratum repens ⸜廒ˣ 朆䘬 4. Necrolytic migratory erythema 檀⹎䔹 pancreatic malignancy (glucagonoma) Glucagonoma syndrome䕯䉨炰 Zinc deficiency揹 5. Hypertrichosis lanuginose acquisita

∯䘊!

䓐Dapsone

無痛、對稱性、皮膚應節節增厚；頸部、上背部

無症狀、臀部及四肢伸側、脂蛋白堆積在真皮層巨噬細胞

和血糖無關，非關節問題

risk factor: 血糖過高，視力不好，有過ulcer，有過amputation，onychomycosis

和lipid 無關，釉瓷，一圈一圈很清楚

分localized, generalized, subcutaneous, perforating

不須治療

很癢，PUVA治療

分辨hypo or hyper thyroidsim：測量血中TSH濃度

pretibial myxedema

毛髮稀疏、眼皮眼袋深、鼻子變寬、嘴唇變厚、舌頭 腫脹

癢=Bazex syndrome

男性多

白人老年男性

在身體的出孔處，painful, eroded, crusted

glutagon(升醣素)太高→刺激gluconeogenesisĺ 增加a.a.氧化→營養不足→epidermal protein deficiencyĺnecrolysis ensue

長很細的毛 lanugo hairs

bacterial infeciton 就用antibiotics Staphylococcus Coagulase + S.aureus Coagulase - S. epidermidis 院內感染

StreptococcusFolliculitis 以毛囊為中心 淺層

Furuncle 較深

Carbuncle 很多furuncle連在一起，有systemic症狀

Staphyl SSSS Staphylococcal scalded skin syndrome 新生兒、小朋友

發燒、全身變紅(diffuse erythema) ĺGeneralized desqumation skin culture negative 原因：exfloiative toxin B 切割Dsg 1 ĺstratum spinosum/granulosum受損

只要消除感染源就可以了！ 預後不錯

Strepto S. pyogenes 1. Ecthyma 病灶凹下去

2. Purpura fulminans life threatening , DIC (凝血功能不佳), 腳

兩種都會；

1. Impetigo 膿痂疹 非常淺、嬰幼兒

Bullous type: S. aureus exfoliatin 使皮膚連結變弱→金黃色蜂蜜 口訣：蜂蜜葡萄酒！

Non-bullous: Strepto 已經結痂

2. Cellulitis 蜂窩組織炎 deeper subcutaneous tissue 蜂窩組織：表皮鬆弛、脂肪比較多

Mycobacterial infection TB, leprosy

Lupus vulgaris : endogenous brownish-erythematous papules/plqaue 鼻子或耳上， diascopy: Apple jelly 治療：抗TB 藥

Leprosy : Mycobacteria lepra TT BT BB BL LL tuberculoid vs. lepromatous skin rash, neuropathy, leonine face Paucibacillary: rifampin +dapsone Multibacillary: '' + '' + clofazimine

Scabies 只寄身在人身上，皮膚皺褶處、群聚感染、侵犯角質層

確診：KOH smear, biopsy/PCR 治療； Permethrine (首選！) gamma benzene hexachloride (有中樞神經毒性)

Pediculosis 蝨

Capitis 頭蝨 很癢，對唾液敏感，

Corporis 體蝨 Pubis 陰蝨

Parasitic

病毒 Herpes Virus

1. 泡疹 HSV-1=HHV1 口腔、臉

HSV-2 =HHV2 生殖器

留在神經根、接觸傳染、潛伏期也會傳、聚集性水泡、 Tranck smear (刮水泡部位有multinucleated giant cell) \

2. 水痘、帶狀泡疹

VZV=HHV3

皮節傷害→眼睛、排泄問題 好發T3~L2 V-1 出現皮節傷害就要使用抗病毒藥物

皰疹後神經痛

潛伏期6~8wks

有nikosky sign

HPV 1. wart / verruca HPV-1,2, 4, 7, 26 2. 菜花 condyloma acuminatum HPV 6 11 3. 子宮頸癌 HPV 16 18 治療：殺乾淨 cryotherapy 冷療、最常用

藥：imiquinoid, salicyclic acid, lactatic acid

HHV4 = EBV 鼻咽癌、oral hairy leukoplakia

HHV5=CMV cytomegalovirus

TORCH C=CMV

H=HSV-2

HHV6 Roseola

HHV8 Kaposi's sarcoma

性病們！

1. Syphilis 梅毒 Spirochete= Treponema pallidum造成

Chancre硬下疳 不痛！ 3wks 潛伏期也較長 lymphadenopathy也不痛

Ļ Mucocutaneous ex. macular, papular, nodular.... the great imitator!!!!!!! **** extremely infectious 不要亂摸病人！

ex. Condylomata lata 扁平濕疣 Ļ latent syphilis Ļ a. Gumma 梅毒種、馬鞍鼻 saddle nose 無痛 b. Granulomatous nodules c. Psoriasiform granulomatous plaques d. CNS e. cardivascular 檢查：darkfield microscopy, serology, DIF .... 不能用culture的！

Non-treponemal test: 不準，用來追蹤 4~5wks titer> 1:32 ĺ + VDRL, RPR follow up 6 months 要下降至少四倍 treponemal test 準、不可追蹤 TPHA, FTA-ABS

2. Chancroid 軟性下疳

Haemophilus ducreyi 會痛！ 3~7days painful lymphadenopathy culture: school of fish！

self-limited

3. lymphogranuloma venereum LGV 披衣菌 Chlamydia trachomatis 芒果！ Genital/inguinal 不痛、ulcer、雙側 Rectal 痛！ Fistula.... 女性：Pelvic inflammatory disease 男性：副睪炎 epididymitis vs. 淋病 gonorrhea :: Chlamydia 潛伏期較長

性病治療： DoxycyclineErythromycin

4. Granuloma inguinale 腹股溝肉芽腫 Klensiella granulomatis gram(-) safety pin!!! Donovan body 不痛！！！ ulcer

5. HPV-2 Tzanck smear: multinucleated giant cell condyloma acuminatum 會痛！！！ 10~40% 有病灶

目前治療只能控制病情、無法斷根

其他：

Erythroplasia of Queyrat 衛生習慣不良、悶熱、摩擦是危險因子； 不治療可能發展成SCC Plasma cell balanitis (Zoon balanitis) 衛生習慣不好

HIV 易感染

1. 病毒： Kaposi's sarcoma(HHV8), Herpes zoster, HPV( verruca/warts, condyloma accuminata), oral hairy leukoplakia (EBV=HHV4) 2. 真菌： proximal onychomycosis, Severe seborrheic dermatitis, candidiasis 3. 細菌：結核菌、桿菌性血管瘤(Bacillary angiomatosis) candida 可刮掉 Leukoplakia 刮不掉

補充：Molluscum contagoisum傳染性軟由 好發於小孩，大人可經由性病傳染

prednisolone可以治療HIV　induced esosinophilic folliculitis

䙖兂 4 Porphyria 䳓岒䕯 Porphyrin 忶ɦ㓷デ䘬䙖兂 Urogen decarboxylase ⓷柴ɦ uroporphyrinogen III 橼ℏ䧵 㯜㲉ˣ䈁滺䰱䲭刚ˣ㮃ˣ䕌䕽

z Porphyria cutaneous tarda Genetic or acquired炻か侭㚱偅䕭ˣ惿惺炻ὧ㚱 uroporphyrin 㩊槿烉ὧ+10 㺜⅘愳愠+惺䱦 䄏 wood light ɦὧᶲⰌ䰱䲭 ὧ+ TALC(㹹䞛䰱) ɦᶳⰌ䰱䲭 㱣䗪烉旚㚔ˣőũŭŦţŰŵŰŮź㓦埨ˣ㚵 chloroquine

Pellagra 䲁䙖䕭 Vit B3 deficiency 仢 Vit B3=niacin nicotinic acid= nicotinamide Vit B3 䓙 a.a. tryptophan ⎰ㆸ侴Ἦ 姢㕟 3D: Dermatitis, diarrhea, dementiaɦɦɦɦɦɦɦɦDEATH 烉 梊梻ˣ惿惺ˣ䓐喍(ex. TB 喍烉isoniazid)ˣṾ underlying disease(ex. 偅䠔⊾ˣcarcinoid) 夳㕤屏䩖⋨ 㱣䗪烉 墄䆇梲 DM LMN DIV Lipodystorphy(傪岒䆇梲ᶵ列), Meta, Neuro, Drug, Infection, Vascular Meta 悐䘊 偃攨ˣ㚫昘悐炻⎰Ἕ溜却ˣ䎈却 DM xanthoma 埨傪䔘ɦ傪偒䘬 macrophageɦxanthoma cell 全悐ˣ偀充Ỡ“

Eruptive !!!!! Infection !!! 䎈却!!! Vascular 埨䭉䕭嬲!!!

䙖兂䘤䲭x 僃⇵刚䳈㔹x bullous diabeticorum, necrobiosis lipoidica, granuloma annulare (掉⫸㯜儓) 㯜㲉䘤䓇 dermis炻ᶵ㗗 epi(劍 epiɦacantholysisɦpemphigus) 埨䭉䕭嬲!!! AtherosclerosisɦIschemia, necrosis (ulcer, gangrene)

Neuropathy ᶳ偊䙖傪儢㷃ɦAsteatotic eczema(仢傪㹤䕡)

Porphyrin過多→產生ROS reactive oxygen speicesĺ破壞cell membrane

Porphyria cutaneous tarda

Porphyria 䳓岒䕯

Pellagra 䲁䙖䕭

影響tryptophan合成

丘疹型

Touton giant cell 花圈

為什麼容易感染呢？ 因為微循環受損、神經病變、出汗減少、Cell mediated immunity減少

PPP rare

no acantholysis

因為自主神經病變

pseud-porphyria : 可能是chronic renal failure造成的

Drug insulin 䔞Ἦ䈑 10-50% lipodystrophy 䢢傢栆(sulfonylureasˣ旵埨䱾喍䈑)

Acanthosis nigricans ら烉gastric tumor (adenocarcinoma) !!!! Tripe palm !!!! Ṿ烉偾ˣDMˣacromeglay Scleredema 䙖嬲ˣ䠔 ᶲ⏠忻デ㝻烉䨩䘤 DM 烉 ˣㄊㄊ Amyloid 愠朆㘞橼䈑岒 Congo red 㝻刚ɦApple green biregringence 喳㝄䵈ῷ Anti-parallel Žƌbeta-pleated Amyloidosis 䃉㱽㹞妋䘬举䵕䉨噳䘥橼ℏ䧵(⎬䧖⭀ˣ䳬) 䕡ˣ刚䳈㰱䧵 ƉƌŝŵĂƌLJ Cutaneous amyloidosis ϭPĂpular Lichen amyloidosis 㚨夳ˣ临䘊ˣ䰺ˣ↠ˣ ϮMacular amyloidosis rareˣ䰺ˣ⸛ˣᶳ偊 ϯNodular amyloidosis rareˣᶵ䦌ˣṖṖ䘬

ϰŶŽͲƐĂĐƌĂůĂŵLJůŽŝĚŽƐŝƐ 㩊㷔 amyloid PAS ġġġġġġġġġġġġġġġġ㷔態栆 + 䳓䲭刚 Crystal violet + 㚨䯉ὧ Congo red ῷ䵈刚! Thioflavine T bezothiazole salt beta structure 㓷デ Phorwhite BBU ^ĞĐŽŶĚĂƌLJSystemic 㚫枧昌Ḯ堐䙖ẍ䘬Ṿ⭀炻⊭䤆䴻ˣ僶冇ˣ冇 䎦 mucocutaneous symptoms烉petechiae 䖨埨ˣpurpura 䳓㔹ˣmacroglossia 冴柕嬲 Amyloidosis 䫔ᶨ㫉暋嗽䎮炻䁢beta-structure insolubility, resistance to enzyme degradation Dermal mucinosis : mucin 䛇䙖㰱䧵 Hypo: diffuse myxedema Hyper: pretibial myxedema Lichen myxedematousus 冯䓚䉨儢≇傥䃉斄炰ᶵ忶ḇ䛇䙖! Epithelial mucinosis 㰱䧵堐䙖

HIDE: Hereditary, idiopathic, drug-induced, endocrine

不易發現、過度累積→Emboli 特色：難容於水、不容易被酵素分解、green birefringence、poor antigenicity

ƉƌŝŵŵĂƌLJ taCutaneous yloidosisamy

分類嚴重要磨皮：dermabrasion

Skin amyloid的可能來源

1. 搔抓→keratinocyte受損

2. 內皮細胞 交替代謝或抗原作用

3. 巨噬細胞相關

目前對amyloid治療：

1. topical steroid, topical Dimethyl sulfoxide 2. dermabrasion 磨皮

3. 雷射

㚫^ĞĐŽŶĚĂƌLJSystemic

因為血管變脆弱 amyloid沉積

Dermal mucinosis

治療：口服mephalan&prednisolone, colchicines, DMSO, 洗腎或移植

和甲狀腺相關

euthyroid states = papular mucinosis

follicular mucinosis 分idiopathic or symptomatic

其他secondary mucinosis可能是發炎(eczema, psoiasis, tumor引起) or carcinoma

電顯下直徑：10nm

4-3 4-4 Skin tumor Benign

z Seborrheic keratosis 傪㺷奺⊾䕯 侩Ṣ㔹 㚨夳 䓇攟 !!! ᶵ㚫ˣㇳˣ儛 䚳嬄烉㚱㗪῁㚫攟⁷ Wart炻↠↠䘬 ㆸ烉solar exposure, immature keratinocytes accumulation Laser-trelat sign(䔞㔠慷䨩䃞慷≈) 炻 internal malignancy 䚠斄

z Epidermal nevus Embryonic cell 䘬 migration炻䤆䴻ˣ倴倱ˣ㵳䲣䴙㰺㚱䚠斄 䶂

z Skin tags夳 偍偾 僳ᶳˣ傾⫸ˣ滈已 ᶨ柮ᶨ柮庇庇䘬炻㚱柷刚

z Dermatofibroma 䛇䙖举䵕䗌 夳ˣᶳ偊ˣ⤛䓇ˣ㹹ˣ㚱柷刚 !!!!ℑ怲㕥Ḱ≃㗪㚫ᶳ

z Keloid 垡嵛儓 偍䕌䕽 Large collagen bundles 㚫䖃ˣ䘊

z Nevus Sebaceous 䙖傪儢㭵㔹 柕䙖ˣ傥㚱 congenital 䤆䴻㕡面䘬⓷柴 ᶱ昶㭝嬲⊾烉㕘䓇ˣ曺⸜ˣㆸ⸜ 屨䇦呁嬲⊾㚱斄 Tumor: Trichoblastoma ら炻㮃儓䗌ˣ⤛

z Epidermoid cyst 䰱䗌 共ˣ傠ˣ側 Ⰼ⸛ ⊭ỷ keratin

z Senile sebaceous hyperplasia 柮ˣᶱ⋩㬚䎦ˣ忂䪍ˣ㚔春㰺斄炰 㱡塷柕

z Syringoma 㯿䭉䗌 Duct tumor ˣᶳ䛤䝤ˣ

z Melanocytic nevi 湹刚䳈䖋

Melanocyte ᶵ䎦䙖兂~ ḇ㚫䎦夾䵚兄ˣ傰䴉兄ˣℏ俛 ẍ㶙⹎↮䁢烉junctional, compound, dermal 㕟⤥䖋烉ABCDESS

z Bleu Nevus 儛側ˣㇳ側

z Mongolian spot ㆹ奢忁㗗偶姀ℓ~~~

=stucco keratosis

表皮母斑

Embryonic cell migration䘬

䶂 lines of Blaschko's

皮贅

Dermatofibroma 䛇䙖举䵕䗌

Keloid 垡嵛儓

Nevus Sebaceous 䙖傪儢㭵㔹

: Trichoblastoma

男女比例差不，但發展成trichoblastoma女生比較多

Epidermoid cyst 䰱䗌

Senile sebaceous hyperplasia

Seborrheic keratosisstucco keratosis

Epidermal nevus 表

Skin tags

Syringoma 㯿䭉䗌

Melanocytic nevi 湹刚䳈䖋

Bleu Nevus

Halo melanocytic nevus: 潛在性白斑

Mongolian spot

Horn cyst

GI

BMpapillary dermis intradermal

Lumbar-sacral area 炻melanocyte 䔘ỵ䎦 dermis z Nevus of Ota 䓘㭵㔹

Ṇ㳚㕷佌炻ḇ㗗 melanocyte 䔘ỵ炻䎦䠔柶ˣ䳸兄ˣ朷兄ˣ溻兄 Vascular tumors

z Hemangioma Ḽ㬚ⶎ⎛ẍ冒≽徨⊾ 庫㶙 ⊭ mucous membrane Treatment indication: Ulceration, obstruction of vital structures, life threatening

z Port-wine stain 共ˣ䳪䓇ˣ゛ Sturge-Weber Syndrome !!!!! Sturge-weber syndrome 㚫㚱䤆䴻䕯䉨 夳ˣ

z Pyogenic granuloma 朆⊾內 ḇ朆倱剥儓 㹹 minor trauma 忈ㆸ 夳㕤ㇳˣ幨⸡ˣˣ儛嵦ˣ

z AVM HHT 夳䘬 familiar vascular disorder

z Angiosarcoma ら炰柕䙖ˣmargin unclear, rapid growing, metastasis to lymph node

z Kaposi Sarcoma HHV8

Premalignant conditions

Squamous cell carcinoma in situ z Actinic keratosis 㖍奺⊾

⤥䘤䘥Ṣˣ⸛炻㚫炻䔞攳⥳㽽㽽䘬ˣ㼘䖵 傥嬲ㆸらḮ炰 z Bowen’s disease

䓇攟ㄊˣ䲭刚ˣ毿䉨ˣᶵˣṵὟ旸 epidermis 冯䟟䚠斄 Arsenical keratosis炻ㇳ儛攟䘬 keratosis Multiple Bowen’s disease

z Leukoplakia 㚨夳炰 㲃ˣ朆ᶨ

Malignant

z Basal cell carcinoma Nodular, cystic, sclerosing 䳓䶂㚱斄 䇯㚱啵刚䘬 basaloid cell炻ㆸ㞝㪬䉨炻Ṿ䳬昼叿ᶨᾳ cleft 攟䘬ㄊˣ悐Ὕ䉗 High risk 天䓐烉Moh’s surgery

Nevus of Ota

Hemangioma

Port-wine stain

Pyogenic granuloma沒有細菌感染阿！

Hereditary hemorrhagic telangiectasia

在生殖器：Erythroplasia of Queyrat

V-1, V-2支配的皮膚

珍珠色澤

UVB

高風險區：眼耳鼻周圍、上唇區

局部侵犯，幾乎不會轉移

紫外線過度曝曬治療：冷凍、CO2、手術、imquimoid、5FU

Moh’s surgery烉 ᾅ䔁㚨㬋䳬炻100% check tumor炻out-patient surgery炻high cure rate

z Squamous cell carcinoma UV, 䟟, HPV ˣ㶙ˣ↮⊾ⶖ炻崲㖻廱䦣 春㙜曚崲㖻 recurrence High risk::: 共ˣ䛤俛>6mm 共悐Ṿ悐ỵ > 10mm 幨⸡偊 > 20mm ↮⊾ᶵ列ᶼ>4mm

z Paget’s disease Mammary vs. extramammary “炻㼃ḛ䗴 朆ḛ炻冯㱴、腸胃䗴䕯䚠斄 䁢 ductal carcinoma

z Cutantous T cell lymphoma 䓙 non-sun exposed 䓊䓇 MF mycosis fungoides 㚨夳 溜却䃉斄炰

䚳 pautrirer’s microabscess ( T cell 嵹 epidermis) Non-hodgkin’s lymphoma 㚨夳

z Atypical mole 䖋炰 JunctionɦcompoundɦDermal

z Melanoma ら炰 Superficial spreading 䓟烉側 ⤛烉ᶳ偊 㚫 radial growth Lentigo maligna 刚炻㚫 radial growth& vertical growth Acral lentiginous 㜙㕡Ṣ炻ㇳˣ嵛 ᶵ㖻姢㕟 Hutchinson’s sign炰 Nodular 側悐ˣᶳ偊 㚫 ulceration炻bleed 㱧叿 epidermis 䇔 嬲刚悥ᶵ⤥ angioma D.D. angioma 柷刚㚫徨

平均發病年齡52yrs (算早阿！)

ABCD( Diameter> 6cm) E SS

Risk factor: 1. 紫外線暴露

2. 皮膚特性 SPT1 or SPTII (東方人多III, IV) 3. 白人！(藍眼睛、黃紅頭髮) 4. >20cm 5.有 history

平均年齡65yrs 較老

長在指甲下方

指甲色素擴散至近端或兩側

4個stage：patch, plaque, nodule, sezary

由non-exposed 皮膚開始

Melanoma

Tumor thickness 㗗慵天↮㛇炰 Clark’s level 1 堐䙖 2 papillary dermis 3 Junction ϰ ZĞƚŝĐƵůĂƌĚĞƌŵŝƐ 5 subcutaneous fat

怑䓐 Sentinel lymph node biopsy 㶙⹎崭忶 1.0mm 儓䗌㕤 1 mm Clark level 䁢 4 reticular dermis ᶵ怑䓐 Clark level 2 or 3 㶙⹎㕤 0.75 uncertain 㶙⹎䁢 0.76~1.0mm

䙖兂 5-1 5-2 Skin appendage 䙖傪儢ˣ㯿儢ˣ㮃檖ˣ䓚 䙖傪儢烉⸦ℐ幓ˣㇳ儛㰺㚱烊T ⫿ⷞ ⇵柵ˣ滣⫸ˣᶳ Fordyce’s spots lip 湫湫䘬炻Norm 䁢攳柕䚜䙖兂堐朊 ᶨ凔攳㮃 ᾅ嬟䙖兂ˣ愠ˣ却 天 Androgen 枧 5Ƚ- reductase testosterone ɦDHT Type I 䙖傪儢 Type II 㮃ˣ䓇㬾㱴䲣䴙 z Acne vulgaris 曺㗍䖀 㕘䓇(㭵橼 hormone 枧) 70% 㚰䴻⇵曺㗍䖀ら⊾ (ᶳ) Ữ䓟䓇庫慵 ỵ伖烉共ˣ側ˣ傠ˣ偑儨 䕭烉 1. 奺⊾䘬䔘 2. 䙖傪↮㱴≈ 3. 䳘却デ㝻 4. 屨䇦呁枧 庫檀䘬 androgen sensitivity 䕭䀞↮栆烉 1. non-inflammatory 䰱 comedones 2. inflammatory erythematous papules, pustules, nodules, nodulocystic, scars 㱣䗪烉ex. Topical retinoid, azelaic acid

stage II

spots Fordyce’s

z Acne variant 喍䈑崟䘬炰 Corticosteroid ⇵傠ˣ側 pilosebaceous duct 奺⊾䈑忈ㆸ旣 monomorphic 䘤㕤共悐 Androgen, Halogen, anti-epileptic drug, antituberculous drug, acne cosmetic

㯿儢 Eccrine gland 㯿儢烉↮ⶫ炻昌Ḯ湷兄Ⰼ Miliaria 䖙䖙⫸ Crystalline (㚨㶢Ϳ ZƵďƌĂ;堐䙖冯䛇䙖攻炻㚨夳) Profunda(㶙Ⰼ) Aporcrine gland 㯿儢烉䉸冕炻ỵ㕤僳ᶳˣ䓇㬾ˣḛ㘰 婧橼㹓 㯿㵚塓䳘却↮妋 Hidradenitis suppurativa ⊾內㯿儢䀶 S.aureus, gram(-) 䳓䲭䳸䭨ɦ嬲庇ɦdrain, form sinus tractɦ hypertrophic scar 㮃檖 䠔奺岒 (䠓) Lanugo hair 偶㮃 Vellus hair 㝼㮃 Terminal hair 䳪㮃 悐↮ㆹᾹ䚳䘬柕檖 㮃檖忙㛇烉 Anagen 䓇攟㛇ˣcatagen 徨⊾㛇ˣtelogen ẹ㬊㛇 Androgenetic alopecia 晬䥧 炰 1.Terminalɦvellus 2.Shortening of anagen 3.Increase shedding of telogen hair Professor’s triangle 儎ℑ“庫ᶵ枧 ⤛烉柕枪 㱣䗪烉 䓐 Minoxidil 句‍ ℏ䓐 Propecia 㝼㱃 II 5Ƚ- reductase 天ᶨ䚜⎫炰 Alopecia areata 僓㮃䕯 櫤柕 20-30 㬚 Exclamation mark hairs !!!!!!!!!!!樂嘇柕檖 㮃厶 䘤䀶(㵳䎫㴠㼌) 䈡烉alopeica totalis, universalis, nail change 烉genetic, atopic, autoimmune, emotional 䓚 䓚㹅䀶 paronychia Nail fold 䘤䀶Ḯ炰 烉S.aureus 䓇䳈㱣䗪 ㄊ烉䎈却(溜却) 䡘㯜䘬Ṣ炻䁢 cuticle 㴰

Pigemented disease 兂刚㰢⭂ 1. Hemoglobin 2. Carotenoids 3. Melanin 㚨天 Melanocyte ᾳṢ䧖㔠慷ⶖ䔘ᶵ炻天㗗ℏ䘬 melanosome 䘬ⶖ炻ℏ㚱 melanin Melanocyte 䁢 dendritic cell炻㕩怲悥㗗 keratinocyte 湹刚䳈㕤 Melanocyte+ Keratinocyte( 䁢㚫⎫ Melanosome) 春㚅㚔䘬䙖兂炻Melanocyte ⹎䁢ᶨ凔䙖兂䘬ℑ炰 Melanosome ↮ Stage 1~4 Hypermelanosis Ephelides, Freckles 晨㔹

春㚅㚔悐ỵ炻stage 4 melanosone ≈ 㱣䗪烉旚㚔ˣ暟

Solar lentigo , Senile Lentigines 㚔㔹

春㚅㚔 Chronic actinic degenerative changes

Peutz-Jeghers syndrome Autosomal dominant 刚䳈㰱䧵ˣ僼湷兄ˣ滣⫸… 㲐シ GI polyps炻旚 malignancy

Café au Lait Macules 䈃⤞㔹

䓴䶂歖㖶㶢墸刚䎕炻朊䧵晐幓橼䫱㭼ἳ嬲 ㆸṢ䚜>1.5cm炻⸤>5mm炻ᶼ䘤(>6 ᾳ) ɦ傥䁢 Neurofibromatosis

Nevus zygomaticus 栜橐㭵㔹

夳ˣ啵䀘䳓䀘ˣℑ“栜橐㕩

Chloasma, melisma 偅㔹

䧙↮ⶫ炻柷刚⁷尔偅炻偅㰺斄Ὢˣ⤛䓇庫

Seborrheic keratosis 傪㺷奺⊾ 侩Ṣ㔹

列 tumor炻夳㕤侩Ṣ 䓴䶂↮㖶 !!Leser-trelat sign烉㔠䚖䨩䃞≈炻㚱䘊デ炻侫ㄖら儓

䗌 esp. gastric tumor ZŝĞŚů’s Melanosis

㱣䗪㓰㝄㚨ⶖ ⊾䈑岒崟

Becker’s nevus Nevus of Ota 䓘㭵㔹 V1 V2

䀘啵刚ˣ㜙㕡Ṣˣ⤛ Mongolian spot 90% 㜙㕡Ṣ㕘䓇㚱 㗪㛇㚫冒䃞㴰徨

儘啎悐ˣ全悐

曬會變黑

Postinflammatory hyperpigmentation

Fixed drug reaction 㚫㻠㻠㶉⊾炻Ữ妠忶㓷炻㚫ᶨỵ伖䘤 Hypomelanosis Vitiligo Family history

↮䁢 segemented/localized/generalized ᶵ枸㛇

溆䉨刚䳈僓䕯 侩⸜ 偊ˣᶵὝ䉗共悐 䓴䶂歖㖶 湹刚䳈䳘傆侩⊾僓 㖍㚔朆㖍㚔

Albinism 䘥⊾䕯

OCA1 ⬴ℐ䃉 tyrosinase 䙖兂柕檖䘮䘥 OCA2 怬㚱ᶨṃ tyrosinase 柕檖湫刚 兂刚⤞㱡䘥

Neves Depigmentosus 僓刚㭵㔹

䓇㗪䎦炻䳪䓇嶇叿Ἀ

Pityriasis alba 䘥刚䲈䕡

90% 䪍悥㚱 㶉㶉䘬䘥炻劍㚱Ụ䃉

Nevus Anemicus 屏埨㭵㔹

ᶨ埨䭉䚠斄炰 埨䭉ᶨ䚜厶炻 catecholamine ᶵ㓷デ

旚㚔 ABC S

䙖兂 5-3 Cosmetic 暟烉 怠㑯䅙↮妋㓰ㅱ Selective photothermolysis 1. melanin 600-1100nm 2. oxy hemoglobin 3. 㯜 䚠 selectivity Ỷ 2940nm 㲊攟崲攟ˣ䨧德崲㶙 䈡烉䨢攻ᶲ㬍 spatial coherence 怠㑯溆 㱣䗪⬴天橼堐旵㹓ˣ㱣䗪㗪天ᾅ嬟䛤䜃 ㅱ䓐烉 1. Vascular leisons ex. Port wine stain

2. らᶵ傥䓐暟炰 曺炻ᶨᾳ㚰ㇵ㚫㴰 昌㮃炻㮃䟜ˣ天㫉㱣䗪ˣlong pulse 暟 䖀䕌炻梃㡕暟(fractional) 傰堅炻㟤婒ᶵ䬿暟 㲊攟嶐 500~1200nm 暣㲊䙖炻⇑䓐堐䙖䛇䙖暣旣ᶵ 䍣愠㲐烉檀↮⫸慷態橼炻⏠㓞屗㯜↮炻Ṍ倗炻䳘却䘤愝 倱㭺㠧却烉㭺䳈䘬 Light chain ^EZ 昌炻ἧ倴倱㓦檮 5ng