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4 курс / Дерматовенерология / Dermatologia_i_venerologia_KGMU_g_Simferopol_2012_g

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Jle1'eH.ue: npH nopruKeHHH KpaiiHe:H ID\OTH IJOKa3aHo XHpyp- l'H'ieCKOe Ae'ieHHe - o6 p e3a1u-re, H B CAY'iaenopa:m:eHHSI l'OAOBKH no-

AOBOI' 'iAeHaH BeHe'iHOH6op03.ll.bl - KpHO.ll.eCTPYKlJ:H.II. McnOAh3yeT-

C.II 5 % 5-qITOpypau:HAOBruI HAH 30 % npOCilHAHHOBfill Ma3H. IlpH HHBa3HBHOH ¢opMe 3a60AeBaHHSI H nopruKeHHH AHMcPaTWieCKHX Y3AOB IlOKa3a HO y.n.a.r.eHHe perno HapHbIX AHMcPOY3AOB H 6AH3KOcPOK)'CHas:l peHTreHOTepanHH .

2. Ba3aALHO-KAeTO'iHbIH paK KOJKH (BKP)

.6a3aALHOKACTO'IHbIHp aK (6a3aAHOMa) - cpe,n:M KapU.HHOM

KO:>KH cocTaBll..lleT 70-75 %. Brrepsbre 3a6o.r.esaHHe on11ca.r. A. Jaco b B

1872 r. T epMHH

•6a3a.r.110Ma* npeJl.AO)frnA B 1901 r. L. N ecam, a

E . Krompec her s

1903 r . rrpH'iHCAHA 6a3aAHOMY K p aKaM KO)f{H , ,n:o-

Ka3aB ee 311HTeAHat.bHoe npoHcxo:>K,neHHe. BKP so3HHKaeT o.n.11HaKoso

'ia~o y My.!K'IHHH )f{eHl:I.J.HH, rrpeHMYlll;eCTBeHHO y AHU: 3p eAoro H n o-

)f{HJ\01'0so3pacra (s cpe.n.HeM

s B03pacTe 51-61 ro.n.), p e:iKe BCTp e'ia-

eTcsr y MOAO,ll,bIX AfO.ll.eH . ,[(AsI

onyxoAH xapaKTepeH Me.ll.AeHHblH TeMn

pocTa· (HHOr,n:a ro,n:aMH), MeCTHO-)l,eCTPYKTHBHhIH HHB.a3HBHbIH poCT

6e3 TeH,n:eHU:HH K MeTaCTa3uposaHHIO, 'iaCTOCKllOHHOCTh K p eu:HAH- BHpOBaHHI-0. OnyxoAb noAHMop¢Horo CTpoeHH.H B03HHKaeT H3 3IlH-

.n.epMHCa H npH,n:aTKOB KO:>KH . J\oKaAH3yeTCH npeHMYlll;eCTBeHHO Ha AHU:e, wee, BOAOCMCTo il '!aCTHroAOBbI. IIo .n.aHHbIM psi.n.a asTopos co-

AHTapHbie (o,nHHO'iHbre)¢opMLI BKP scTpe'!a roTC.H npHMepHo s 85 %

CAY'iaes , n epBH'iHO-MHO:lKeCTBeHHble - B 15 % .

namozeH.e3. <PaKTopaMH, cnoco6cTsyrom;HMM pa3BMTHIO onyXOAH, HB/l..IIIOTCSI: ,llAHTeAbHaH H H36bITO'IHa.II COAHe'IHa.II HHCO/l..IIUH.II, II03Jl.HHH p eHTreHOBCKHH .n.epMaTHT, nHrMeHTHa.H Kcepo.n.epMa, Jl.HCIIJ\aCTH'ieCKfill ¢opMa seppyu.11¢opMHOH 3IlHJ1.epMO,ll,HCID\a3HH J\e-

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.K.nuH.urca. KAaccH'!eCaH 6 a3M.HOMa Ha'IHHaeTcH c noHsAeHMSI CBeTAOp030BOI'O Hl\.H 6 e.AeCOBaToro y3eAKa, Hepe,n,KO HailOMMHarom;ero )f(eM'iY:>KHHY;y3eAKH B03HHKaIOT Ha HeBOCIJaAeHHOM OCHO-

276

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B 3aBHCHMOCTH OT KAHHH"l:eCKHX npoHBAenu.H: pa3AHT·IaJOT: IlOBepxHOCTttyIO, orryxoAeByIO , 5l3BeHHy!O, IIHrMeHTHYIO H CKAepo,zr.epMOil0,ZI.06Hyro cPOpMhI.

1.IloaepXHOCTHaJI 6a.3aJIHOMa l1MeeT BMA IUIOCKoro, 'leTKOO'lep'IeHHOrO IUITHa 11Jll1 6 m1mKvr KpacnoaaToro 1.weTa OBaJihHol1 l1.ITT1 oKpyrnofi ¢opMbL no Kparo o •.iara HMeIOTOI MeJIKHe, IIJIOTHhie Y3MKH, no611ecKl1:- Ba10m;11e nplil 6oKOBOM OCBem;eHl111, c MaTOB&I M, rrepJI.aMfTPOBblM OT- TeI-JKOM, CJrn:Ba10m;weca Me)K)J.y co6oM: 11 0 6 pa3yro1D;11e BaJIJiJKoo6pa3H&rn Kpa11. TaKHe O'IarM.nopa)KeIDffi M:OryT AOCTll!TaTb 5-7 CM B )J.MaMerpe M. 6onee.

2.OnyxoneBaJI cpopMa 6a3aJIM.OM&I - )'3eJIKOBOe, 'lam;eOJJ.M.HO'!Hoe o6pa30Ba H11e pa3MepoM 1-2 CM, BbIC'l)'IlaIOID,ee HaA llOBepxHOCTblO KO)Kl1, KaK rrpaBl1JIO, c 111.a)J.KOl!I: IIOBepxHOCTbIO M. 'leTKO BffAM.Mbl.MH MeJIKli!MM. 3KTa3MpOBaHHbIMl1 cocyAaMM. l/lnor)J.a Ha IlOBepXHOCTl1 orryxoJieBoro o6pa30BaI-J.lil5.I l1MeIOTC5.I CBeTJIO-p030Bbie y'laCTKH 3p03M.l1, llOKpb!Tble KOp O'll<aMM.

3.5l3BeHHa.fl cpopMa 6a3aJil10MbI 'lam;eB03HHKa eT .KaK nepBl1'!HbH1Bap11- a HT orryxoIIM = KaK pe3)'JlbTaT yrny6neHIDI rroBepxHocreM: 3p0311H.

XapaKTepH&re KJIHHlif'IecKtterrpl13riaKl1 5!3BeHHol1: ¢opMbI - Kparepoo6pa3Hoe l13b5.13BJieHHe ne6on1>IIIM.X pa.3MepoB l1 MaccH:BHoe, crra5IHHOe c !IO)J.JJe>Kam;MM11'. TI<aHJIMH OCHOBaHHe, KOTop oe 3Ha'lHTeJibHO 60JJbDie caMow ~Bbl. Tary10 cpopMY 5.13BeHHol1 6 a3aJIH OMbI Ha3&rna10T « ulcus rodeu s». B CMJI)'. MecTHo-p;ecrpyKTHBnoro poem 5.13BeHHM ¢opMa 6o-

Jie3HH MOJKeT npHBO)J;MTb K pa3pyme ffi1IO IlO)J.JJe)K<lI.Izy!.X Mfil1<l1:X TKaHeM:

M Kocreii: 'lepen a rrp11 JIOKaJH13al(Ml1 orryxom1 Ha ronoae . IlpH JIOKaJIM3au;Ml1 513BeIIBOM ¢opMhI 6a3aJIHOMbI B o6nacnr rJia.3, BMCKOB, p acrra- )J.aIOII.(CUl:C.5.1 orryxon& MO.lKeT np11Becn1 K neTaJihHOMY 11cxoJJ.y.

4.fll1rMeIITHa51 cpopMa 6a3aJ]110MbJ x apaKTep•13yeTC.5.I p;11¢¢Y3HOW IIHr-

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QHTapHbJ.Ml1 H OBoo6pa30BaHHJIMH KO)KW.

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BocKo BHAHbIM, Mttorp;a Ha6JIIOp;aerc51 m enyIIIeHHe

oqara

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6a3aJJHOMa pacTeT O'leHbMeAJieH.Ji '

277

no nepwcpepww (ro.a;aMM). Onyx011& qarn;e B03HMKaeT Ha n6y, pe*e - Ha BMCKaX M mee.

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.n;aHHhIX: U:HTOAOrH'leCKoeHCCAe,AOBaHHe Ma3Ka-cKapHCpHKaTa c 3po3Hp0BaHHblX yqaCTKOB nopruKe HHSI npaKTH'leCKH BO scex CAyqrui:x no3BOAHeT sepmj:mu:H posaTh .n;HarHo3.

,l{mpcpepeH.Y,UWlbHYJO iJuazH.ocmuKy nosepXHOCTHOM COAHTapHOH cpopMbI 6a3MH.OMhI CAe.zzy:eT nposo,n:HTh c 6oAe3HhIO Boy3Ha, ce6opeHHblM KepaT030M, KpacHOH BOA'laHKOM; nosepXHOCTHYIO MHO- :>KeCTBeHttyIO cpOpMy - C CHHJJ:pOMOM ropAHHa-rOAhU:a, C AHCCeMHHHpoBaHHOH cpopMOH AHilOHJJ:HOI'O HeKp06H03a. OnyxoAeByw COAHTapHYIO cpopMY CAe.nyeT .n;HcpcpepeHU:HposaTh c KepaTOaKaHTOMoH:, oporo- sesaIO~M IIAOCKOKJ\eTO'!HhIM paKoM; onyxoAesyw MHO)KeCTBeHH}'ID cpopMY 6a3aAHOMbl - c Tpmco:mHTeAHOMOH H U:HAHHJJ:POMOR. 513senHYIO cpopMY 60AC3HH CAC.ZJYeT OTAH'laThOT H3'hll3BAeHHOI'OIlAOCKOKAeTO''lHOl'OpaKa. IlHrMeHTttylO tjJOpMY 6a3aAHOMbl .n:ncpcpepettu:HpyIOT c MeAaH030M Ll,106pe.H H MCAaHOMOH. CKAepo,n;epMonO)l.06ttyIO cpopMy 3a60ACBaHHSI CAe.nyeT ,ll.HcpcpepeHU:HposaTh c orpaHH'leHHOHCKAepo- ):\epMHCH.

AeiteH.ue. B 3aBHCHMOCTH OT pa3Mepos 6a3aAHOMhI, ee AOKa-

AH3au:HH H MHO:>KCCTBeHHOCTH nopa:>KCHHH HCil0Ab3ywTC5! pa3'\H'-iHbIC

MCTO)I.bl 11.C'lCHHSI. IlpH COAfITapHOH onyxoACBOH cpopMe 6a3aAHOMbl IlOKa3aHO XHpyprH'lCCKOe HCCC'lCHHC oqara rropa::m:eHHH B npe)l.eAflX

3,AOpOBblX TKaHeii (oTCzyIIHTb OT onyxoAH Ha 1 CM ); MO:lKHO npHMe - HHTb 3AeKTpo- H Aa3e po}:\eCTpyKU:HIO onyxo11.H. IIpH rAy60KHX H3Bax, pamIOAaraIOII:\HXCH y OCHOBaHH5l Hoca, nepHop6HTaAbHO, B OKOAOyuIHOH o6AaCTH, u:eAecoo6pa3HO CO'lCTaTbMeCTHOC AC'iCHHCc 6 AH3KOcpo-

KYCHOH pefiTreHoTepanneH: H sayrpHMbillle'!HbIMnpHMeHeHHeM npo -

cnHAHHa. KpHo.n:eCTpYKII:HIO MO:lKHo KoMfoiHHposaTb c rrpocnH):\HHOM . TaKoli *e IlOJ:\XOJl. o npaa.n:aH H npH Ae'ieHHH MHO::m:ecrseHKbIX 6a3aAHOM. MeCTHO noKa3aHbI B BH):\e anIIAHKaU:HH l~HTOCTaTH'leCKHe Ma3H: 5 % 5 - cpTopypau:HAOBa.H, 30-50 % npocnHJJ:HHOBrul H 30 % rAH- U:HtjJOHOBruI Ma3b.

Dpo,PwiaKmUK« 3aKAIO'JaCTCHB 3all:\HTC KO:lKHblX IIOKpOBOB OT YAbTpacpHOAeTOBOl'O 061i.yqemrn COAHU:a, rrpe,z:cyrrpe:>K,l\CHHH )l.AHTeAbHblX TpaBM O)l.HHX H TCX :>Ke yqacTKOB KO:lKH.

Heso6a3aAHOMQ (CHHJlpOM ropAHBa-I'oAJ.u:.a)npe.n:craBAHCT co6oii reHCTH'ieCKH o6yCAOBAeHeyro aHOMaAHIO KO:lKH (MHO:>KCCTBCHKble 6a3aAHOMbl) B CO'leTaHHH c pa3AH'iHblMH nopOKaMH pa3BHTHSI

278

cma0uu aa6oneeamut:

CKeAera, rAa3, HepBHOH CHCTeMbI, pe:JKe - ,llpyrHX opraHOB H CHCTeM y

AHU MOAO/];Oro B03paCTa (HHor .zi;a c po:JK)l;eHIDJ.) . Ea3aAHOMbI 'faill.eAO-

KaAH3YJOTC>I BOKpyr rAa3, HOCa H B o6AaC'rHA6a, npaKTH'ieCKHHe OT-

AH'faIOTC OT 06hI'l:HbIX6a3aAHOM. ffa n opOKOB pa3BHTHH 'laill.eBCero

Ha6AIO.l(aIOTC>I KHCTbI 3y6os H HIDKHeH '!eAlOCTH, pa3.l(BOeHne pe6ep, He.zi;opa3BHTHe M030AHC'r0roTeAa rDAOBHOro M 03ra, H3MeHeHHH rAa3, HepBHOH H 3H.LJ:OKpHH HOH CHCTeM.

Pa3AW'faIOT oee HeBOHAHYIO H He-

OITAaCTw:reCKj'IO. HeeouoHa5l CTaJJ.HH npo.no~aTcH JJ.OAro, B -re•reHHe

.zi;eCHTHAeTHH, HO 3aTeM BHe3anHO n epeXO)'.I;HT B 1-1.eon;iacmul./.ecK:.ylO, npH KOTOpOH H3-3a 3Ha'!HTeAbHbIX pa3pyrueHHH TKru:reil: MOJKeT Ha-

crynHTb Ae'raAbHbIHHCXO)l;. fIOHBAe H H e .s:I3B - He6AaronpH.s:ITHbJH nporHOCl'H'feCKHHnpH3HaK.

l{ut/JtjJepeH.yUaJtbH.y»o OuCUH.ocmu.cy npOBOA.s:J:T c UHrMeHTHbIMH HeBycaMH, T pHxo6a3aAHOMOH, CHpHHI'OMOH, tj>OAAHKJ'AS!pHbIM

.l(HCKhepaT030M . 0.l(HaKO npH CHH)l;pOMe rop AI·IHa -ro,U,ua ,AHarHOCTH- Ka ynpOill.aeTCH B CB.s:I3H c BpO:JK)l;eHHbIM xapaKTepoM 3a6oAeBaHHH H HahH'IHeMnopOKOB pa3BHTHH.

Aelf.eH.ue. EoAbHbre .AOA:JKHbI HaxO.l(HTbCH r:ra AHcnru:rcepHOM Ha6Aro,neHHH y .nepMaTOOHKOAOra. HaH6oAee KpynHhre H pacryru:He o rryxoAH Y.AaMJ:IOT.

3. IIAOCKOKACTO'IH&lH 3Da.n:epMaAJ>HlalH paK (fiKP).

3To HaH60l\ee 3AOKa'!eCTBeHHaH3IlHTeAflaAhHaH onyxOAb, OHa

COCTaBAHeT OKOAO 20 % BCex CAyqaes paKa KO:JKH. Ilo'!THB Ka:JK)l;OM cAyqae IIKP pa3BHBaeTCH Ha tj>oHe npe.AllleCTBOBaBlllHX naTOl\Orw:reCKHX H3MeHeHHH KO:JKH: npe.npaKOBblX 3a6ol\eBal:rHH (aKTHHH'leCKHH K e paT 03, nHrMe HTHaH KCepo.zi;epMa, 1103.ZJ;HHH AY'feBOH.nepMaTHT, AeH-

KOilAaKHH, OpaAbHbIH rranHAAOMaT03 ), BH)'TpH3IIH,nepMahbHOro paKa

(6ol\e3Hb Eoy3Ha, 3pHTpoilha3HH Keil:pa, BHeMaMMapHaH Q:>opMa 6oAe3HH Ile)l.JKeTa), O'laroBpy6:u:osoil: aTpOQ:>HH, HBAfllOill.HXCSI HCXO)l;OM Ty6epKJ'Ae3HOH BOA'laHKH, 3 pHTeMaT03a, xpOHH'ieCKOH SI3BeHHOH IlHO,AepMHH, X pOHH'feCKHXTpoQ:>H'IeCKHXH3B, 6opOJJ;aB'faTOI'OKpaCHOro IlAOCKOro AHllirul, ncopHa3a, Ha py6uax IlOCAe o:lKOrDB H TpaBM, OCTeOMHeAHTHhIX CBHIII.eH, oco6eHHO HIDKHHX KOHe'IHOCTeiL IIKP qa- m.e B03HHKae'rB B03paCTe cra p we 50 Ae'r(3a HCKJUO'feHHeMCAyqaes 3a601>.eBaHHSI y 60AbHbIX c IIHrMeHT HOH KCepoJJ;epMOH); MY:JK'fHHhI60ACIOT 'law.e, 'fe M :a<eHI.U_lUfbI. 3Ha'IHTeAbffYIO pOAb B pa3BHTHH 3TOH onyxoAH HrpalOT: Y<l>-H3AyqeHHe COAHUa, HOHH3HpYIOIII.aH pa,AHaUHSI, XHMH':reCKHeKar:rueporeHbI, Il03TOMY HOB006pa30BaHHe qau~e AOKMH3Ye'rCSI Ha OTKpbITbIX yqaCTKax KO:JKH - Ha AiiUe, oco6eHHO HH:JKHeH

279

ry6e H CIIHHKe HOCa, CK}'AOBOH;:iyre, wee, BOAOCHCTOH qacTH roAOBbl , a TruoKe Ha yrnHbIX paKOBHHax H TbIAe KHCTeli . PHCK pa3BHTHSI TIKP IIOBbIIUaeTC.H B IIO:lKHAOM B03pacre, rrpH HaAH'IHHHMMYHHbIX H reHe- TH'IeCKJ-IX HapyIIIeHHH.

OT 6a3MHOMbI TIKP OTAH'laeTcn 6bICTpbIM HHcpHAbTpHpy;o- rn:HM pOCTOM H crroco6HOCThlO MeTaCTa3HpOBaTh (B OCHOBHOM AHMcporeHHbIM nyTeM) . TiopIDKeHH5I AHMcpaTH'IeCKHX Y3AOB Ha6A10,n:aroTCSI

rrpHMepao s 18 % CA)"!aes. HaH60Aee orraCHbIMH s acrreKTe MeTacTa-

3HpoBaHH5! .HBMIIOTC.H paK HH:lKHeH ry6hI, YIIIHOH paKOBHHbI, IIOAOBOro

. 'IAeHa. I'eMaToreHHb!e MeTaC'fa3bl Kpa}!He pe,n:KH, IIOpIDKaIOT 'Iall1.e

KOCTH H AerKHe . B 85 % CA)"laeB MeTat."Ta3HpOBaHHe rrponcxo,n:HT B

perHOHapHbie AHMCpaTH'leCKHe Y3Abl H B 15 % - B BHCU:epaAbHbie opraHhI.

K.nUHUJCa. Pa3AH'laIOT,n:se OCHOBHbie Kl\.HHH'leCKHe cpopMbl TIKP: 3K30cpHTHJ'10 (rrarrHAA5IpHy10, onyxoAesyro) H 3H,n:o¢11ney10 (n3- BeHHO-HHcpHAbTHBttyIO) . Ha<JMO onyxoAH xapaKTepw3yeTc.H noasAeHHeM 6opo.n:as<JaTOI'Oo6pa30BaHHSI HAH y3eAKa, KOTOpb!H 6bICTpO yBe- 1\WfHBaeTC.H B pa3Mep ax, rrpH AerKOH TpaBMe KpOBOTO'IHT. IlpH 3K-

3ocl>HTHOH (onyxoAeBoii) cpopMe o~rar nopIDKeHH5I no Mepe pocTa

Ha'JHHaeT 3Ha'IHTeAbHOB03BbII.UaThCR Ha,n: rrosepXHOCThJO KO::>KM, pacIIO/laranCh Ha IlIHpOKOM OCHOBaHHH H OJJ;HOBpeMeHHO paCTeT Br11y6h TKaHeH. B pe3yAbTaTe ero OCHOBaHI·le CTa.HOBHTC5I Il/IOTHb!M H orryxOAh MaJ\OITOABJDKHOH. Tio3JKe HaCTyna10T HeKp03 H H3'bH3B11.e1·rHe onyxoAH.

IlpH 3H..a.ocl>HTHOH (H3BeHHOH) cl>opMe rrepBH'IHhIHy3eAOK 6bICTpO

H3'bst3BAfleTCSI, 06pa3yeTCR KpaTepoo6pa3HaH 5l3Ba HerrpaBHAhHOH cpopMbl, c rrpHnO,AIDl.TblMH, HepoBHbIMH Kpa.sIMH H HepOBHhIM AHOM IIAOTHOH KOHCHCTeHU.HH. 5bsa yBe/\.H'IHBaeTCH B r11.y611Hy H BlllHpb, o6pa3y.H )l.O'IepHHey 3 eAKH, KOTOpbie, B CBOIO oqepe,n:b, pacrra,n:aIOTCR, yse11.H'!Hsru1 pa3Meph1 H3'bH3BAeHH>I. Tio3:>Ke orryxollh pacrrpoc TprurneTc.si: Ha 6AH3Ae:lKalIJ,He TKaHH (MbllllU:h I , cpacLiHH, xparn:H, KOCTH) H pa3pymaer HX. B AMhHeihneM rrpH o6eMx cpopMax TIKP rrpoMcxo,n:HT MeTacTa3MposaHHe s perHoHapHbie AMMcpaTM'IecKMeY31lbI.

,l{ua~H03 IIKP yCTaHaB11.HsaeTCR aa ocHoBaHHH Kl\.HHW-IecKHx H Mop¢oAorw-qecKHx ,Aa.HHhIX. .[b-1cpcpepeHU:HMbHhrH ,n:warHo3 TIKP nposo,n:HTC.H c 6a3MHOMOH, KepaToaKaHTOMOH, 6 o Ae3HbIO EoyaHa, aKTHHH'JeCKHM KepaT030M , nces,n03TIHTeAH.OMaT03HOH rHrreprrAa3HeH 3IIH,n:epMHca, 3pHTpOIIAa3weH: Keiipa, 6oAe 3HbIO IleAJKeTa, a Ta!OKe Ty6epeyAC30M KO::>KM, rAy60KHMH MHK03aMH, ry-MM03HOH 5I3BOH rrpH TpeTH'IHOMCHcpHAHce H IIHOreHHOH rpaeyAeMOH.

280