Transcript allergic disorders

昆明医学院第二临床学院
皮肤性病学教研室
姜福琼
Fuqiong Jiang
Teaching & Research Group
of Dermatology & Venereology
The second Affiliated Hospital
of KMU
Case1,2,3: Nickel dermatitis from ear piercing/metallic
earrings, watch, clasp
Erythema红斑
papules丘疹
papulovesicles
丘疱疹
Case 6: Cosmetic dermatitis
Case 7: Acute dermatitis caused by hair dye 染发剂
Red and
Swelling
Erythema红斑
edema水肿
papules丘疹
papulovesicles
丘疱疹
Puffy
eyelids
What are the common
characteristics of these cases?
A. Contact history
B. The lesions appeared in the
contact area
C. Itching
What is the disease ?
A. Eczema
B. Urticaria
C. Contact dermatitis
D. Atopic dermatitis
Contact Dermatitis
Definition
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：
Contact dermatitis is an
inflammatory reaction in the skin
and mucosa resulting from
exposure to an irritant substance
or a specific allergic substance.
objective
1.List the diagnose main points of contact
dermatitis
2. Master the therapeutic principle of contact
dermatitis
3. Familiarity with the common etiological
factor of contact dermatitis
4. Comprehend some kind of specific contact
dermatitis.
Related Medical Terms
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Dermatitis 皮炎
Irritant 刺激物
Sensitizer 致敏物/Allergen过敏原
Basic lesions 基本损害
Erythema红斑
edema水肿
papules丘疹、papulovesicles丘疱疹
Blister, vesicle水疱、Bulla大疱
Exudation渗出
Erosion糜烂
Swelling肿胀
burning烧灼
itching瘙痒
Clinical manifestations
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Acute dermatitis
1.Basic lesions ：
Edema ,papules , vesicles (水
疱),bullae大疱on an erythematous (红
斑) base
Erosion(糜烂、坏死)/ulcer(溃疡）
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2.symptoms ： itching, burning and pain.
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3.Locations ： Frequent sites are head,
face, hands, feet.
(clinical features)
6S
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(Sudden onset)——S
(Site of exposure)——S
(Sharp border)——S
(Same morphology)——S
(Simple lesion)——S
(Self-limited)——S
Red and
Swelling
Erythema红斑
edema水肿
papules丘疹
papulovesicles
丘疱疹
红肿
Puffy
eyelids
眼睑水肿
Exudation渗出
Erosion
糜烂
Erythema
红斑
papules
丘疹
erythema红斑
edema肿胀
papules丘疹
papulovesicles
丘疱疹
ICD produced by nitric acid 硝酸
Erosion
糜烂
Corrosion
坏死
Animals ：
leather, fur, feather, poison hair 。
Plants：
Rhus, poison ivy , nettle, mango, ginkgo, oak, sumac,
buttercup,spurge, daisy,squash
Chemicals ：
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Metals and Metal salts:(金属及其制
品): Nickel is the leading cause of ACD in
the world( glasses frames 、ornaments),
Chromate（leather products、clothing、
cement、concrete etc.) potassium
dichromate, cyanides of calcium, copper,
mercury, silver and zinc, chlorides of
calcium and zinc.
Daily life appliance
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Household cleansing agents(日用清洁剂):
soap（皂）, detergents（去污剂） and
bleaching agents（漂白剂）
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ammonia preparations氨制剂, lye碱液,
plastics塑料, fabrics纤维, rubbers橡胶.
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Topical medicine(外用药物):benzocaine, neomycin,
miconazole,etc.苯唑卡因、磺胺（局部用药），外
用药（红汞、清凉油、橡皮膏、抗生素软膏）
Pesticide(杀虫剂): DDVP, Rogor如敌敌畏,敌百虫等.
Industrial chemical materials(化工原料):
dyes and their intermediates, oils, resins, coal tar
derivatives, crude petroleum, paraffin
Cosmetics (化妆品):
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Formaldehydes a major cause of certain
preservative chemicals widely used in shampoos,
lotions, other moisturizers甲醛 防腐剂 （洗发
水、洗剂、其他保湿剂）
paraphenylenediamine PPDA 对苯二胺（染料、
颜料、皮毛和皮革制品）
acetone丙酮
Fragrance，perfume香料（化妆品），香水
lanoline羊毛脂
Epoxy 环氧树脂（指甲油），松脂精（溶酶、颜
料稀释剂）.
Dermatitis of the ear lobes
(nickel)
Dermatitis of the wrists (nickel)
Dermatitis involving the hands
(latex gloves)
Dermatitis of the eyelids and
face caused by hair dye and
cosmetics
Rubber elastic band in
underwear
Allergic Contact Dermatitis
caused by leather or dyes used
in footwear
Irritants
Sensitizers
Irritant contact dermatitis
刺激性接触性皮炎ICD
Allergic contact dermatitis
变应性接触性皮炎 ACD
TWO TYPES
Etiology
病因
Pathogenesis
发病机制
Clinical features
临床特征
变应性接触性皮炎
Allergic Contact Dermatitis ACD
Type Ⅳ Reaction
典型的迟发型Ⅳ型变态反应
T cell-mediated late-type reaction
T 细胞介导的迟发性反应
delayed type hypersensitivity, DTH
迟发型变态反应
4-20 day
2nd antigen contact
24-48h
Allergens
sensitizers
1.Individual
difference
个体差异
2.Previous
exposure
先前接触史
3.Incubation
period
潜伏期 4-20days
Allergens/
Sensitizers
24-48hours
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Irritants刺激物: 腐蚀性Corrosive、
溶解角质层Dissolve
Acids 强酸： 盐酸、硫酸、硝酸、
氢氟酸、 草酸、苯酚（石炭酸）
Alkalis 强碱：皂、清洁剂、漂白剂、
氨制剂、 氢氧化钾
Metal Salts 金属盐类
diagnosis
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Contact history ;
Incubation period ；
Patch test 。
Patch Test（斑贴试验）
Negative (-)
阴性
Irritant reaction (IR)
刺激反应
Equivocal / uncertain
(+/-)
可疑阳性
Weak positive (+)
弱阳性
Strong positive (++)
阳性
Extreme reaction (+++)
强阳性
Team Quiz
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A 43-year-old man presents with 3 days of
intense itching and blisters on his neck, arms
and legs. He noticed the eruption 2 days after
a hike with his 3-year-old daughter. Clobetasol
ointment and oral diphenhydramine have been
ineffective in controlling his symptoms.
Past Medical History: none
Allergies: none
Medications: topical steroid, diphenhydramine
Family History: noncontributory
Social History: neonatologist, married, has a
daughter
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Review Of Systems: difficulty sleeping due to
itching
Team Quiz
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Team Quiz
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The skin exam shows erythematous plaques,
consisting of confluent papules and weeping
vesicles on his arms, legs, and neck bilaterally.
Some of them are linear. What is the most
likely diagnosis?
a.
b.
c.
d.
e.
Allergic contact dermatitis
Bullous insect bites
Cellulitis
Herpes zoster
Urticaria
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Team Quiz
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The skin exam shows erythematous papules and
extensive weeping vesicles on his arms, legs, and neck
bilaterally. Some of them are linear. What is the most
likely diagnosis?
a. Allergic contact dermatitis
b. Bullous insect bites (usually scattered, not linear or
grouped)
c. Cellulitis (presents as a spreading erythematous, nonfluctuant tender plaque, often with fever)
d. Herpes Zoster (presents as a painful eruption of grouped
vesicles in a dermatomal distribution)
e. Urticaria (presents as edematous plaques, not vesicles. In
early phase of allergic contact dermatitis, these lesions
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could be mistaken for urticaria)
Management 治疗
（一）Principles原则：
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It is important for the patient to
identify the responsible agent
and avoid it. If the individual is
exposed, washing with soap and
cool water within 5 minutes may
prevent an eruption. Protective
barrier creams are available that
are somewhat beneficial.
（二）Topical medication外用疗法：
1.Acute dermatitis ：
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No exudation & erosion ：
Lotion alba ; Calamine lotion
With blister or exudation & erosion ：
3%boric acid solution
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cold moist compress开放性冷湿敷。
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2.Subacute dermatitis：
oils, paste, topical corticosteroid
creams, emulsion
3.Chronic dermatitis：
tar, ointment, plaster
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Treatment
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（三）Oral medication内服疗法：
Anti-histamine.
Systemic steroids: 40-60mg of
prednisone in a single oral dose
daily, tapered off over a 3-week
period.
Antibiotics if necessary.
Summary
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Definition: Dermatitis resulting from exposure to a substance
Etiology & Classification: Animals, Plants, Chemicals
Irritant contact dermatitis, Allergic contact dermatitis
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Pathogenesis: ICD——corrosive
ACD——delayed type hypersensitivity
Clinical features: 6S
Management:
Principles: History finding, Avoiding contact
Topical medication: Acute Dermatitis
Sub acute Dermatitis
Chronic Dermatitis
Oral medication: Anti-histamine
Systemic steroids
Antibiotics
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Man, 39 year old
Itching for 3 hours
after dinner
What is lesion?
What is your
diagnosis?
Urticaria
Goals and Objectives
• Describe the morphology of urticaria
• Distinguish between acute and chronic
urticaria
• Develop an initial treatment plan for a
patient with acute or chronic urticaria
• Recognize the signs and symptoms of
anaphylaxis
Outline
1.What is urticaria ?
Definition（定义）
2.Who gets urticaria?
Frequency （发病情况）
3.What causes urticaria?
Etiology（病因 )
4.How does urticaria develop? Pathogenesis（发病机理
）
Outline
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5.What does urticaria display?
Clinical features（临床表现）
6.How do you make sure urticaria?
Diagnosis(诊断）
6.How is urticaria treated ?
Treatment（治疗）
urtica
Definition 定义
Urticaria, is the most frequent dermatologic disorder
with wheals(风团) that is very pruritic(瘙痒).
It appears as raised, well-circumscribed areas of erythema and
edema involving the dermis(真皮) and epidermis(表皮)
Urticaria is not a single disease but a reaction pattern that
represents cutaneous mast cell degranulation, resulting in
extravasation(外渗） of plasma into the dermis.
Frequency
发病情况
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Acute urticaria (荨麻疹）affects 15-20% of the
general population at some time during their
lifetime.
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Incidence rates for acute urticaria are similar
for men and women.
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Chronic urticaria occurs more frequently in
women (60%).
Etiology 病因
Infections
Foods
Drugs
Etiology
SLE,
rheumatoid
arthritis(类
风湿）
Environmental factors
Emotional stress
Disease
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Etiology 病因
Foods
shellfish
fish, eggs,
cheese,
chocolate,
nuts,
berries,
tomatoes
Etiology 病因
Drug
penicillins（青霉素）
sulfonamides（磺胺）
salicylates（水杨酸盐）
NSAIDs（非激素抗炎
药）
codeine（可待因）
Etiology 病因
Bacteria
细菌
Virus
Fungi
真菌
病毒
Etiology
病因
Cold
Heat
Sun
Environmental factors
Etiology 病
因 Animals
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Insect （昆虫）
Furs (毛皮）
Etiology 病
因
o Plants
o Pollens （花粉）
Etiology
病因
Emotional stress
Exercise
Pathogenesis
发病机制
Pathogenesis
Allergy
I type
II type
Non allergy
III type Some
food
Toxin
毒素
Some drugs
Pathogenesis 发病机制
Pathogenesis 发病机制
Pathogenesis 发病机制
Pathogenesis 发病机制
MC
IL-1, IL-2,
IL-3, IL-4,
IL-5, IL-6,
IL-8, IL-10,
IL-13, TNFa,
MIPs, IFNg,
GM-CSF,
TGFb,
bFGF,
VPF/VEGF,
PGD2, LTB4,
LTC4, PAF,
激活
渗出
血管扩张
组胺
Courtesy of Prof. M. Maurer.
5-羟色胺,
肝素,
硫酸软骨素,
糜蛋白酶,
纤维蛋白溶酶,
组织蛋白酶 G
募集
Pathogenesis 发病机制
？？？
速发相
迟发相
Cells
Mediators
Symptoms
Step 1
Sensitization
Itype发生机制
Step 2
Time
Early Phase
Minutes
Step 3
Late Phase
Hours
1. American Academy of Allergy, Asthma & Immunology. The Allergy Report. 2000.
Pathogenesis 发病机制
PAF
Chymase
糜蛋白酶
LTC4
Mast Cell
Late Phase发生和发展
(J Allergy Clin Immunol,2000;105:847-59)
Mediators and dytokines
Cytokines
Chemokines
Pathogenesis 发病机制
Allergen (eg, pollen, domestic mite, fungi)
Dendritic cell (antigen-presenting cell)
T cell
TH2 cell (T helper cell, type 2)
TH1 cell (T helper cell, type 1)
` B cells
IFN-g
IL-4
IL-13
Proliferation/differentiation
Activated B cells
(IgE synthesis & release)
IgE antibodies
2. Naclerio RM. N Engl J Med. 1991;325:860-869.
Clinical manifestation 临床表现
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Chronic urticaria is reported to be more
common in adults, while acute urticaria is
more common in children
Atopic dermtitis(特应性皮炎） patients
are more common suffer from urticaria.
acute urticaria 急性荨麻疹
 chronic urticaria 慢性荨麻疹
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Other Variants of Urticaria 特殊类型荨麻疹
Clinical manifestation 临
床表现
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Acute urticaria
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Primary lesion: wheal and
surrounding erythema（红斑）
(flare).
Distribution of lesions:
Lesions can be localized or
generalized.
Color of lesions: Depending
on background skin color,
lesions may be pale（灰白色）
to red.
An individual wheal typically
lasts for less than 24 hours.
Pruritus（瘙痒） is the most
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Clinical manifestation
临床表现
Clinical manifestation
床表现
临
Clinical manifestation
临床表现
 Clinical manifestation except skin of
acute urticaria
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Anaphylactic shock 过敏性休克
Digestive system signs or symptoms消化系统症状
Lungs for pneumonia or asthma 呼吸道表现
The presence of systemic signs or symptoms
（全身症状），particularly fever, arthralgias.（关
节痛）
Clinical manifestation
Chronic urticaria
defined as urticaria that persists for longer
than 6 weeks.
The cause of chronic urticaria often is
undetermined
Other Variants of Urticaria 特殊
类型荨麻疹
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Dermographism 皮肤划痕症（人工荨麻疹）
Cold Urticaria 寒冷性荨麻疹
Cholinergic urticaria 胆碱能性荨麻疹
Solar Urticaria 日光性荨麻疹
Pressure urticaria 压力性荨麻疹
Clinical manifestation
临
床表现
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Dermographism
皮肤划痕症
urticarial lesions
resulting from
light scratching
Clinical manifestation
临床表现
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Cold urticaria
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Genetic (家族性)，为常染色体显性遗传
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Accquired (获得性)，较常见
Clinical manifestation
床表现
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临
冷激发试验
Application of
an ice cube to the
skin may test for
cold urticaria.
Clinical manifestation
临床表现
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Cholinergic urticaria 胆碱能性荨麻疹
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More common in young.
Heat, exercise, or stress
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Clinical manifestation
临床表
现
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Small wheal
Short time
Clinical manifestation 临床表现
Cholinergic urticaria
Before exercise
After exercise
Clinical manifestation 临床表现
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Solar urticaria
日光性荨麻疹
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Sun exposure
Most is UVB (300nm )
Clinical manifestation 临床
表现
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Pressure urticaria 压力性荨麻疹
After 2-6 hours pressure
Edema of local skin
The lesion persists for 8-72 hours.
Heel and hip
Clinical manifestation 临床表现
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Angioedema血管性水肿
Acquired angioedema :
the lips, tongue, testicles（睾丸）or
larynx(喉）
Hereditary (遗传性) angioedema: is
characterized by recurrent attacks of
angioedema (without urticaria) involving the
skin, GI tract, respiratory(呼吸) tract, and
mucous membranes in a patient with a positive
family history.
The disorder is autosomal (常染色体)dominant,
Clinical manifestation 临床表现
Edema: the lips, tongue,
testicles（睾丸）or
larynx(喉）
Clinical manifestation 临床表现
Diagnosis 诊
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Lesion:Wheal
Transient(片刻） nature
Itching
断
Differential diagnosis鉴别诊断
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Popular Urticaria 丘疹性荨麻疹
pruritic papules (丘疹)and papulovesicles(丘疱疹).
The lesions tend to be grouped on exposed
areas,particularly the extensor surfaces of the
extremities(四肢).
Urticarial vasculitis 荨麻疹性血管炎
Individual urticarial lesions that are painful, long
lasting (longer than 36-48 h)
Urticarial lesions that leave residual hyperpigmentation
or ecchymosis(紫癜)upon resolution
Arthralgias, arthritis, weight changes, bone pain, or
lymphadenopathy
Laboratory Studies实验室检查
Skin prick testing
Full blood count
Urinalysis
ESR
Cryoglobulins
Thyroid function and autoantibodies
Parasitology
Challenges
Skin biopsy
Autologous serum skin test
Complement studies
Edoscopy
荨麻疹的诊断指南
Angioedema
Wheal
风团
血管性水肿
是
>24 小时?
是
活检: 血管炎?
有风团?
否
否
否
>6 周?
是
是
否
询问病史/ 体检:
与压迫相关吗?
询问病史/ 体检
是
荨麻疹性
血管炎
物理性荨麻疹
其它荨麻疹
慢性荨麻疹
急性荨麻疹
HAE = hereditary angioedema; AAE = acquired angioedema.
Reproduced with permission from Zuberbier et al. Allergy. 2005. In press.
压迫性荨麻疹
否
遗传性，获得
性血管性水肿,
或慢性荨麻疹
Treatment治疗
1.Found out the causes
2.Avoidance of some factors such as mental
stress,overtiredness, alcohol,nonsteroidal antiinflammatory drugs(NSAID) is recommended.
3. Medical Care
Treatment治疗
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Nonsedating anti-H1 antihistamines (抗组胺
药)remain the mainstay of treatment.
Vit C and Calcium(钙剂) Application of
lotions with menthol and phenol provide
prompt relief of pruritus for some patients.such
as Albe lotion.
Treatment治疗
确
定
诱
发
因
素
防
病
教
育
和
避
免
诱
发
因
6）考虑加服其它二线治疗药物，
或以其它二线治疗药物取代当前
药物，如环孢素或低剂量激素a
5）考虑加服二线治疗药物，或以二线
治疗药物取代一线药物，如抗白三烯药
物（如有血管性水肿存在，或可使用氨
甲环酸）
4）考虑晚间服用镇静抗组胺药
3）加服第二种非镇静H1抗组胺药（常规或根据需
要）
2）高于标准剂量非镇静H1抗组胺药
Treatment治疗
Antihistaminics
loratadine氯雷他定（10mg），oral，10mg Qd
cetirizine 西替利嗪（10mg），oral，10mg Q d
fexofenadine 非索非那定（30mg），oral，，60
Bid
levocetirizine 左西替利嗪（50mg），oral，
10mg Qd
Treatment治疗
Antihistaminics
Pregnancy（妊娠）
Cetirizine(西替利嗪 )and loratadine (氯雷他
定)are category B;
A first-generation antihistamine, such as
chlorpheniramine(马来酸氯笨那敏）, may be
considered the drug of choice .
Treatment治疗
H2 antihistamines, such as cimetidine（西米替
丁）
famotidine（法莫替丁） ，ranitidine（雷尼替
丁）
Antileukotrienes（抗白三烯）：
Montelukast （孟鲁斯特钠）at 10 mg/d may be
particularly helpful for patients due to aspirin or
other nonsteroidal anti-inflammatory drugs.
Treatment治疗
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Emergency Care抢救治疗
0.3-0.5 mg of epinephrine (肾上腺素)should
be administered intramuscularly
Repeated after15 min
In adults, 40-60 mg daily of prednisone for 5
days
ECG
Summary
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Clinical features（临床表现）
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Diagnosis(诊断）
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Treatment（治疗）
urtica
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