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1、姑息关怀中的皮肤护理 Skin care in palliative care,Dr. Z. Zylicz Hospice in the Weald Pembury, Tunbridge Wells, UK,皮肤护理 Skin care,放射治疗过程中的皮肤护理skin care during radiotherapy皮肤瘙痒 / 瘙痒症 itchy skin / pruritus蕈状瘤，出血 fungating cancer, bleeding患处疼痛painful wounds,某些因素可加剧放疗后皮肤反应，包括： There are some things that can make t
2、he skin reactions to radiotherapy more severe. These include:,在接受放疗前曾行化疗，或放化疗同时进行having chemotherapy before or at the same time as radiotherapy 体重超重being overweight 合并其它疾病 （如糖尿病）having other health problems such as diabetes光敏感肤质having sun-damaged skin 吸烟Smoking,化疗期间的皮肤护理 Skin care during radiotherap
3、y,有证据表明以下措施可以帮助减低皮肤反应的严重程度there is evidence that the following activities can help to reduce the severity of skin reactions:选用温和的皂性溶液或清洁剂清洗皮肤Wash: with a mild soap or cleansing agent使用温和的的润肤霜增加皮肤湿度Moisturise: with a light moisturising cream,为了缓解症状病人能做些什么？ What can patient do to relieve symptoms?,如果皮
4、肤出现发红，发痒，变干，起水疱，医生（或护士）建议使用乳剂涂搽并加以敷料覆盖患处，以缓解症状，使病人感觉更舒适。if skin becomes red and dry, itchy, or develops blisters, the doctor or nurse can recommend creams and dressings to help reduce your symptoms and make the patient more comfortable.,选用3%尿素洗液作为增湿剂用于皮肤保护 Skin protection by moisturing with 3% urea
5、lotion Momm F et al. 2003,瘙 痒 症 Pruritus = itch,瘙痒症的分类 Classification of Itch,周围性 Peripheral 皮肤性（瘙痒感受性的） cutaneous (pruritoceptive) 神经病性，例如多发性硬化，神经损伤neuropathic, e.g. MS, nerve damage 中枢性 Central 神经病性，例如 脑脓肿/脑肿瘤neuropathic, e.g. brain abscess/tumour 神经源性，例如 服用阿片类药物，胆汁淤积neurogenic, e.g. opioid, chole
6、stasis 精神性 Psychogenic混合性 Mixed 尿毒症性 Uraemic,Twycross et al. 2003,术 语 Terminology,神经病性瘙痒：指瘙痒感源于皮肤感受性发生改变的区域，通常是由于局部神经结构遭破坏而引起。neuropathic pruritus: pruritus experienced in the area of changed sensitivity, usually by damage of the neural structure神经源性瘙痒症：指由能够干扰痒觉传导及神经系统功能的瘙痒介质所致瘙痒症neurogenic pruritus
7、: pruritus caused by pruritic mediators interfering with itch transmission and the functioning of the nervous system,癌症相关的瘙痒症状 Pruritic syndromes associated with cancer,胆汁淤积（胰源性，胆管癌，转移性肝癌）cholestasis (pancreatic, bile-duct cancer, liver mets) 皮肤转移癌（乳腺癌）cutaneous mets (breast cancer) 副癌综合征Paraneoplas
8、tic合并皮肤病（类天疱疮）with dermatosis (parapemphigus) 不合并皮肤病without dermatosis,瘙痒是全身性癌病罕见而重要的症状 Pruritus, an uncommon but important symptom of systemic carcinoma Cormia FE. Arch Dermatol 1965;92:36-39.,肺癌 Lung 乳腺癌 Breast 胃癌 Stomach 前列腺癌 Prostate 子宫肿瘤 Uterus 结肠癌 Colon 鼻咽癌 Nasopharynx,一名72岁的老年女性乳腺癌患者，7年前曾接受过乳
9、癌手术治疗。现因肿瘤皮内扩散，而饱受极度疼痛和瘙痒的折磨。 Woman, 72 years of age, intracutaneous spread of breast cancer. Originally treated with surgery 7 years earlier. She experienced extreme pain and pruritus.,恶性肿瘤引起的神经源性瘙痒(1) Neurogenic pruritus in malignancy (i),疱疹后瘙痒症Liddell K. Post-herpetic pruritus. Br Med J 1974;4:16
10、5.前列腺癌可表现为阴囊及会阴区的持续性瘙痒Cancer of the prostate may manifest by persistent itching at the scrotal and perineal region大脑肿瘤可引起鼻孔区的瘙痒Pruritus of the nostrils is associated with brain tumours.,恶性肿瘤引起的神经源性瘙痒(2) Neurogenic pruritus in malignancy (ii),有报道表明宫颈癌患者可出现外阴瘙痒Pruritus vulvae have been reported in pat
11、ients with carcinoma of the cervix直肠，乙状结肠，结肠癌可以伴发肛门区瘙痒pruritus ani may accompany rectal, sigmoid or colon cancer,造血系统疾病 Hematopoietic disorders,（真性红细胞增多症） Policythemia vera 58% （何杰金氏病） Hodgkins disease 5-10% （蕈样真菌病 ） mycosis fungoides 100% （塞扎里综合征 ） Sezary syndrome 100% （多发性骨髓瘤偶尔发生瘙痒） myeloma multip
12、lexoccasionally （瓦氏巨球蛋白血症） Waldenstrom macroglobulinaemia （良性r球蛋白病 偶尔发生） benign gammopathy, occasionally （肥大细胞增多症 偶尔发生） Mastocytosis, occasionally （缺铁 偶尔发生） iron defficiency, occasionally,疼痛 Pain,瘙痒 Itch, H O Handwerker,疼痛Pain,瘙痒Itch,内源性阿片类 endogeneous Opioids, H O Handwerker,疼痛Pain,瘙痒 Itch,内源性阿片类 e
13、ndogeneous Opioids, H O Handwerker,椎管内注射阿片类药物： Spinaopioids 节段性或全身性；segmental or generalised; 机理 ： mechanisms: 局部兴奋（5-HT）或激活2受体local excitation (5-HT) or stimulation of 2receptors PGE ?治疗 ： treatment:5-HT3 拮抗剂 5-HT3 antagonists异丙酚 Propofol2受体拮抗剂 2 antagonism ?双氯芬酸 diclofenac,全身性应用阿片类药物 Systemic opio
14、ids: 全身性 ； generalised; 机理 ： mechanisms: 非阿片类药物依赖的组胺释放，特异质反应，或阿片类药物介导的opioid-independent histamine release, idiosyncratic reaction or opioid-mediated治疗： treatment: H 1受体拮抗剂 H1 receptor antagonist 阿片类受体通道调节剂 opioid switch ?5-HT3 拮抗剂 5-HT3 antagonists,SSRI,阿片类药物诱发的瘙痒Opioid induced pruritus,瘙痒的潜在化学介质（1
15、） Potential chemical mediators of pruritus (i),氨类：组胺，五羟色氨，多巴胺，肾上腺素，去甲肾上腺素，N-乙酰-5-氧基色胺 Amines: histamine, serotonin, dopamine, adrenaline, noradrenaline, melatonin蛋白酶类：纤维蛋白溶酶，糜蛋白酶， 羟肽酶，木瓜蛋白酶，激肽释放酶 Proteases: tryptases, chymases, carboxypeptidases, papain, kallikrein神经肽类：降钙素基因相关蛋白，缓激肽，内皮素，神经激肽 A&B，生长抑素，血管活性肠肽，胆囊收缩素， - & -促黑色素，神经降压素，蛙皮素等 Neuropeptides: SP, CGRP, bradykinin, endothelin, neurokinin A & B, somatostatin, CRF, VIP, CCK, - & -MSH, neurotensin, bombesin, others,
