【医学英语第6期】临床篇之皮肤病学（二）
本期为皮肤疾病的第二讲，主要讨论银屑病和基底细胞癌两种常见皮肤科疾病。
银屑病俗称牛皮癣，是一种慢性炎症性皮肤病，病程较长，有易复发倾向，有的病例几乎终生不愈。该病发病以青壮年为主，对患者的身体健康和精神状况影响较大。临床表现以红斑，鳞屑为主，全身均可发病，以头皮，四肢伸侧较为常见，多在冬季加重。
基底细胞癌转移率低，比较偏向于良性，故又称基底细胞上皮瘤。基于它有较大的破坏性，又称侵袭性溃疡。基底细胞癌多见于老年人，好发于头、面、颈及手背等处，尤其是面部较突出的部位。开始是一个皮肤色到暗褐色浸润的小结节，较典型者为蜡样、半透明状结节，有、高起卷曲的边缘。中央开始破溃，结黑色坏死性痂，中心坏死向深部组织扩展蔓延，呈大片状侵袭性坏死，可以深达软组织和骨组织。
案例分析
Case 1：A 22-year-old man presents with a 6-month history of a red, non-pruritic rash over the trunk, scalp, elbows, and knees. These eruptions are more likely to occur during stressful periods and have occurred at sites of skin injury. The patient has tried topical hydrocortisone without benefit. On examination, sharply demarcated plaques are seen with a thick scale. Pitting of the fingernails is present. There is no evidence of synovitis. What is the best first step in the therapy of this skin disease?
a. Photochemotherapy (PUVA)
b. Oral methotrexate
c. Topical calcipotriene
d. Oral cyclosporine
e. Topical betamethasone
案例1：22岁男性主诉6个月皮肤病史，躯干、头皮、肘膝可见红色、非丘疹样皮疹。皮损在压力大或有皮肤外伤时更易出现，患者自诉局部使用过氢化可的松无效。体检可见界限分明的斑块伴有厚皮屑，指甲可见凹陷，没有证据显示有滑膜炎。该疾病的最佳初步治疗是：
a. 光化学疗法
b. 口服甲氨蝶呤
c. 局部卡泊三醇
d. 口服环磷酰胺
e. 局部倍他米松
1. What is the most likely diagnosis?
Classic manifestation of psoriasis. A common chronic inflammatory skin disorder.
银屑病（牛皮癣）：常见皮肤病，为慢性炎症性皮肤疾病
2. What are the characteristic features?
Including sharply bordered papules or plaques with silver scale. Located on knees, elbows, and scalp. Stress and skin injury commonly exacerbate the disease.
诊断要点: 为分界明显的皮疹或丘疹，部位多在膝肘和头皮。压力和皮损会加重皮损。
3. What is the appropriate treatment?
Topical corticosteroid of moderate or high potency are the first agents to try in psoriasis without joint involvement.
Topical Vit D such as calcipotriene may be combined with topical steroids in refractory cases. However, they are less effective and much more expensive than topical steroids ONLY.
PUVA are reserved for moderate to severe widespread cases.
Methotrexate, cyclosporine are useful in difficult cases but with high risk of side effects.
治疗方法: 局部皮质类固醇→中重度皮损但不累计关节时首选；局部Vit D如卡泊三醇+局部类固醇→难治性皮损；局部类固醇→有效+廉价；PUVA→中重度广泛性皮损时使用，以减少皮肤鳞状细胞癌的可能；甲氨蝶呤、环磷酰胺等免疫抑制剂→难治性病例，但副作用较大。
本题答案：e
Case 2: A 46-year-old construction worker is brought to the clinic by his wife because she has noticed an unusual growth on his left ear for the past 8 months. The patient explains that ,except for occasional itching, the lesion does not bother him. Physical examination noticed an 8-mm pearly papule with central ulceration and a few small dilated blood vessels on the border. What is the natural course of this lesion if left untreated?
a. This is benign lesion and will not change.
b. Local invasion of surrounding tissue.
c. Regression over time.
d. Local invasion of surrounding tissue and metastasis via lymphatic spread.
e. Disseminate infection resulting in septicemia.
案例2：46岁男性发现过去8个月左耳有异常赘生物生长，除了偶有瘙痒外无其他异常。体检可见8 mm梨形丘疹，中央有溃疡，边缘有小血管扩张。如果不治疗，该病变的自然进程如何？
a. 良性病变无改变
b. 局部侵袭周边组织
c. 日久退变
d. 局部侵袭周边组织，经由淋巴管转移
e. 弥漫性感染导致败血症
1. What is the most likely diagnosis?
Classic manifestation of basal cell carcinoma. It is a malignant neoplasm of the epidermal basal cells that presents as a pearly papule or nodule with a central ulceration, raised borders and telangiectasias.
基底细胞癌：为上皮基底细胞恶性肿瘤。典型表现为梨形丘疹+中央溃疡+边缘隆起+毛细血管扩张
2. What is the natural courses if left untreated and major differentiate diagnosis?
Locally invasive and rarely metastasize (<0.1%). Invasion of surrounding tissue and metastasis are more frequently seen in squamous cell carcinoma, which is more aggressive than basal cell carcinoma, grows rapidly, and metastasize via lymphatic duct.
疾病自然进程及鉴别诊断：基底细胞癌多为局部侵袭，极少转移。主要鉴别诊断鳞状细胞癌，后者恶性度高、生长快、经由淋巴管转移。
本题答案 b
词汇拾零
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