药物不良反应之皮肤表现.pptVIP

* Erythema Multiforme, SJS/TEN Continuous spectrum or Different entity? 多型性紅斑Erythema Multiforme 史帝芬─強生徵候群(SJS) Stevens-Johnson Syndrome 毒性表皮壞死症TEN Toxic Epidermal Necrolysis Target erythema, Blisters, Tender skin, Epidermal detachment, Exfoliation, Multiple Mucosal involvement * EM→SJS(10%)→SJS/TEN→TEN(30%) * Stevens-Johnson Syndrome  Toxic Epidermal Necrolysis Category Incidence per mil-yr Drug related ratio Mortality Primary eruptions (major feature) Isolate vs Confluence Detachment (% BSA) Interface vs Necrosis Systemic symptoms TEN 0.4-1.2 80-95% 25-50% Red edema denuded Confluence 30 I Necrosis Always SJS 1.2-6 50% 5% Target dusky red Isolated 多 10 Interface N usually * Toxic Epidermal Necrolysis * Stevens-Johnson Syndrome Toxic Epidermal Necrolysis Prodromal : URI-like 1-14 days before in SJS, 1-3 days in TEN Systemic: hepatitis ADR 之比例：70-90% 服藥至發疹間隔：14-56天一般藥物為weeks, TEN 7-21days, Re-exposure 2 days) Valproate, Aromatic anticonvulsants first 2 Ms Treatment：withdraw culpit drug, Skin care Steroid, IVIG (anti sFasL) About 3 weeks for heal * Stevens-Johnson Syndrome Toxic Epidermal Necrolysis 常見原因藥物： Allopurinol, Ampicillin/Amoxicillin/Penicillins, Aromatic anticonvulsants Barbiturates, carbamazepine (ox-), phenytoin Lamotrigine, Valproic acid Phenylbutazone, Piroxicam Sulfa, sulfasalazine, Baktar * SCORTEN SEVERITY OF ILLNESS SCORE CSORTEN parameter Individual score SCORTEN Sum of score Predicted Mortality % Age 40 years Yes = 1, No = 0 0-1 3.2 Malignancy Yes = 1, No = 0 2 12.1 Tachycardia ( 120/min ) Yes = 1, No = 0 3 35.8 10%BSA Initial skin detachment Yes = 1, No = 0 4 58.3 Serum Urea 10mmol/l (60) Yes = 1, No = 0 5 90 Serum glucose 14 mmol/l(250) Yes = 1, No = 0 Bicarbonate 20 mmol/l Yes = 1, No = 0 * 080830 藥物不良反應之皮膚表現 臺北市立聯合醫院皮膚科(和平) 林瑞宜 * * 演講大綱 藥物不良反應之作用機轉 過敏與非過敏 如何診斷藥物過敏？ 藥物反應之作用之重要皮膚表現 危險徵候 * Mechanism of Adverse Drug Reactions Type A: 藥理作用相關者(Pharmacological) 依照藥理作用可預測者 為已知之作用效果之擴大表現者 常與劑量有關 必須降低劑量者. Type B: 特