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病例漫谈8:银屑病与钱币状皮炎 [复制链接]

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        Psoriasis and nummular dermatitis share several attributes histopathologic, namely, parakeratosis that often is accompanied by serum, psoriasiform acanthosis, spongiosis, edema of the papillary dermis, and an infiltrate of lymphocytes mostly around dilated venules of the superficial plexus.
        银屑病和钱币状皮炎在某些组织病理方面具有相似的特征,即角化不全,常伴有血清、银屑样棘皮症、海绵样水肿、乳突真皮层水肿,以及淋巴细胞浸润,主要是浅表神经周围静脉扩张。

        The changes histopathologic enumerated here apply only to fully developed, active lesions of psoriasis and nummular dermatitis, i.e., scaly, reddish plaques in the case of psoriasis and papulovesicles affiliated with reddish, crusted, coin-shaped plaques in the case of nummular dermatitis. Both diseases have a wide spectrum of findings pathologic, grossly and microscopically, as would be expected for conditions whose lesions last for weeks or months (and even years in the case of some lesions of psoriasis).
        此处列举的病理组织学病变,只适用于银屑病和钱币状皮炎的充分病变的活跃区,即银屑病和丘疱疹的鳞屑样红斑,以及钱币状皮炎的硬币状红色结痂斑块。这两种疾病已有大量病理研究结果,宏观和微观来看,正如所预期的情况,其病变持续几周或几个月(某些银屑病皮损部位甚至达到几年)。

        Clinically, psoriasis begins as tiny, red macules that soon enlarge to become slightly elevated and scaly. Early guttate (drop-sized) psoriatic lesions gradually enlarge centrifugally and, in time, may become extensive plaques. Nummular dermatitis starts as red macules that soon become papules which are scratched because of intense pruritus that accompanies them. In time, papules become vesicles that are eroded and crusted in lesions that are coin-shaped plaques. When rubbed persistently, lesions of nummular dermatitis become lichenified (by imposition of lichen simplex chronicus). When lesions of psoriasis and of nummular dermatitis resolve, hyperpigmentation tends to be residual. In some patients, hyperpigmentation persists for years.
        临床上,银屑病开始为细小红斑,很快变大,稍微隆起,产生鳞屑。点滴型(水滴大小)银屑病早期皮损部位呈辐射状逐渐扩大,最后就会遍布斑块。钱币状皮炎开始为红斑,很快就会剧烈瘙痒,发展成的满布划痕的丘疹。最后,丘疹变成囊泡,在硬币状斑块病变区侵蚀,结痂。如果不断地挠痒,会使钱币状皮炎病变区成苔藓样变(备受慢性单纯苔藓的折磨)。当银屑病和钱币状皮炎治愈后,皮损部位往往会残留色素沉着。在某些患者中,色素沉着可持续数年。

        Salient findings histopathologic of early guttate lesions of psoriasis are:
        点滴型银屑病早期皮损的组织病理学结果:

        1.    Mounds of parakeratosis that at their summit contain neutrophils and a tad of serum
        角化不全堆积,在其顶点处含有中性粒细胞和少量点血清;

        2.    Neutrophils in discrete (Munro) or spongiform (Kogoj) pustules in the epidermis
        表皮层可见中性粒细胞离散(Munro)或海绵状脓疱(Kogoj);

        3.    Normal granular zone, except beneath parakeratotic foci
        普通颗粒带(除角化不全病灶下方);

        4.    Normal suprapapillary plates
        前乳突板正常;

        5.    Slight acanthosis
        轻度棘层肥厚;

        6.    Slight spongiosis
        轻度海绵样病变;

        7.    Marked edema of the papillary dermis
        乳突真皮层水肿明显;

        8.    Superficial perivascular infiltrate of lymphocytes, and neutrophils, accompanied by extravasated erythrocytes around widely dilated capillaries and venules, and scatter of neutrophils in dermal papillae; a few erythrocytes may be present focally in the epidermis.
        浅表血管周围淋巴细胞浸润、中性粒细胞浸润,伴随红细胞外渗、大量毛细血管和小静脉扩张,并有乳突真皮层中性粒细胞散布;表皮层可见少量红细胞分布。

        Early lesions of nummular dermatitis are characterized histopathologically by:
        钱币状皮炎早期皮损的组织病理学特征:

        1.    Normal or focally parakeratotic cornified layer that contains serum
        角质层包含血清,正常或灶性角化不全;

        2.    Spongiosis in foci; sometimes spongiosis more diffuse
        灶性海绵样病变,有时成弥漫状;

        3.    Slight acanthosis
        轻度棘层肥厚;

        4.    Edema of the papillary dermis
        乳突真皮层水肿;

        5.    Superficial infiltrate of lymphocytes and often many eosinophils in perivascular and interstitial locale; those cells also present in the papillary dermis.
        浅表淋巴细胞浸润,血管周围和间质可见大量嗜酸性粒细胞,乳突真皮层也可见这些细胞。

        Sections from a biopsy specimen from the center of a longstanding resolving plaque of psoriasis show the following:
        长期治疗的银屑病斑块中心的活检标本切片显示:

        1.    Confluent compact orthokeratosis with only focal parakeratosis
        过度正角化只可合并灶性角化不全;

        2.    Granular zone mostly of normal thickness
        颗粒带厚度大多正常;

        3.    Supra-papillary plates of normal thickness
        前乳突板厚度正常;

        4.    Psoriasiform acanthosis with rete ridges of approximately equal length and breadth
        银屑病棘皮症的表皮突长度和宽度大致相等;

        5.    Tortuous capillaries in dermal papillae
        乳突真皮层毛细血管迂曲;

        6.    Sparse to moderately dense superficial perivascular infiltrate of lymphocytes.
        浅表血管周围淋巴细胞浸润自稀疏至中度密集分布。

        Late lesions of nummular dermatitis are marked histopathologically by these changes:
        钱币状皮炎晚期皮损的组织病理学病变显示:

        1.    Compact orthokeratosis with focal parakeratosis
        过度正角化合并灶性角化不全;

        2.    Uneven psoriasiform acanthosis
        银屑病棘层不均匀;

        3.    Papillary dermis thickened by coarse bundles of collagen arranged in vertical streaks parallel to elongated rete ridges, i.e., signs of lichen simplex chronicus
        乳突真皮层增厚,粗胶原束按平行于细长表皮突的垂直条纹排列,即,慢性单纯性苔藓的特征;

        4.    Moderately dense superficial perivascular mixed-cell infiltrate of lymphocytes, histiocytes (including melanophages), plasma cells, and eosinophils.
        浅层血管周围淋巴细胞、组织细胞(包括噬黑素细胞)、浆细胞和嗜酸性粒细胞中度密集分布,呈混合细胞浸润。

        Lichen simplex chronicus often is imposed on longstanding lesions of nummular dermatitis and less often on those of psoriasis. In those instances, the evidence histopathologic of persistent rubbing, namely, a papillary dermis thickened markedly by coarse bundles of collagen arrayed in vertical streaks, may obscure the findings fundamental of nummular dermatitis or psoriasis. Clues helpful to recognizing the underlying process as nummular dermatitis are slight spongiosis in the unevenly psoriasiform epidermis, crusts as well as scales, and some eosinophils in the infiltrate in the dermis. Clues to the fundamental nature of the psoriatic process are neutrophils in parakeratotic foci, tortuous capillaries in dermal papillae, and some thin rete ridges.
        钱币状皮炎长期病变往往会引发慢性单纯性苔藓,而银屑病较少引发。基于此,不断瘙痒后留下的组织病理学证据,即,由粗胶原束按垂直条纹排列造成的乳突真皮层显著增厚,可能会掩盖钱币状皮炎或银屑病的基本结果。帮助辨别钱币状皮炎基本病因的有利线索是银屑病表皮不均匀,轻度海绵样病变,结痂,鳞屑,以及某些真皮层可见嗜酸性粒细胞浸润。银屑病的根本病因线索是灶性角化不全的中性粒细胞,乳突真皮层毛细血管曲折,某些表皮突较薄。

        A few lines should be devoted to two interesting expressions morphologic of psoriasis, namely, the pustular and the erythrodermic. Pustular psoriasis is merely explosive psoriasis in which the process is accelerated so greatly that it bypasses guttate macules and papules and proceeds directly to pustules. Erythrodermic psoriasis is universal, exhibiting redness and scaling over the entire integument. The findings histopathologic in the erythroderma are just like those of a lesion of psoriasis developed fully, except that there is little, if any, scale as a consequence of exfoliation of clumps of parakeratosis.
        银屑病具有两种有趣的形态,即,脓疱型和红皮病型。脓疱型银屑病是突发性疱疹,发病迅速,绕过点滴型斑疹和丘疹,直接形成脓疱。红皮病型银屑病较为普遍,整个皮肤会出现红肿和鳞屑。红皮病的病理组织学研究结果显示,与充分病变的银屑病一样,会由于角化不全团块脱落,从而形成少许鳞屑。


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