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高齢者の掻痒感

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高齢者の掻痒感

  1. 1. 高齢者の掻痒感 JAMA 2013;310(22):2443-2450
  2. 2. 高齢者における掻痒感 • 高齢者では3つの機序で掻痒感を来す • 皮膚バリア機能の低下 Immunosenescence(加齢に伴う免疫機能低下) 神経症(Neuropathy) • これらの機序を理解することが治療に繋がる.
  3. 3. • 皮膚バリア機能の低下 • 皮膚の保水性は皮膚表面の脂質複合体が関与している. Care of the Aging Patient: From Evidence to Action Clinical Review & Education Pruritus in the Older Patient この複合体層は非常に薄く, テープを10-20回剥がすと全て無くなる位 Figure. The Epidermal Water Barrier Epidermal water barrier 高齢者ではこの層の修復速度, Lipid lamellae S T R AT U M C O R N E U M ( S C ) 機能自体が低下. 3 Lipid processing Corneocytes SG-SC interface Corneocyte 感想皮膚は≥65yの50%以上で Lamellar body contents 認められる所見. S T R AT U M G R A N U L O S U M ( S G ) Granular cells 2 Lipid secretion Lamellar body (containing lipids and enzymes) S T R AT U M S P I N O S U M Spinous cells 1 Lipid synthesis Granular cell S T R AT U M B A S A L E Basal cells Spinous cell DERMIS The keratinocytes of the granular cell layer make and secrete lipid into the spaces between corneocytes, the anucleate keratinocytes of the stratum corneum. This lipid is processed by enzymes into lipid bilayers that are an effective water barrier. Individuals of advanced age (>80 years) have reduced lipid synthesis and secretion. Moderately aged individuals (50-80 years) make and secrete lipid normally but have a defect in lipid processing. Patients of advanced age and, to a lesser extent, moderate age both form a less effective water barrier and repair a damaged barrier (caused by irritants such as detergents and soaps) less effectively.
  4. 4. • Immunosenescence(加齢に伴う免疫低下) • • 皮膚の前炎症状態であり, 湿疹や他の皮膚炎症反応に関与する 神経症(Neuropathy) • Sensory neuropathy (主に糖尿病によるもの)で全身性の掻痒感, Neural impingementで局所的∼全身の掻痒感を来す.
  5. 5. 掻痒感への対応 Clinical Review & Education Care of the Aging Patient: From Evidence to Actio • 先ずチェックするポイント Box 1. Evaluation and Management of Elderly Patients With Pruritus • 掻痒についての病歴, 部位 • 薬剤の評価(外用, 内服) • 疥癬, 皮膚乾燥のチェック • Lab; 肝不全, 腎不全, 電解質  甲状腺機能異常のチェック. 1. Take directed history detailing severity (on a 0-10 scale), location (localized vs generalized), and modifying factors for the patient’s itch (bathing). 2. Review medications (topical and systemic). 3. Perform physical examination for evidence of scabies (burrows, genital lesions) and dry skin (fissured, red patches on legs, flanks, and arms). 4. Order basic laboratory evaluation (complete blood cell count, fasting plasma glucose, thyrotropin, liver function tests, serum urea nitrogen/creatinine, calcium, phosphorus). 5. Treat for xerosis. 6. Treat for scabies if found. 7. If rash is present, initiate topical therapy, obtain potassium hydroxide preparation, order skin biopsy, or refer to a dermatologist if initial therapy does not improve the rash. 8. If no rash is present, initiate metabolic workup (thyroid, parathyroid, iron deficiency) and evaluate for malignancy or for neuropathy. If no rash is present and skin changes are due to scratching, assess for scabies, obtain a potassium hydroxide preparation, consider skin biopsy, pursue a metabolic workup, and evaluate for malignancy or neuropathy.
  6. 6. • • 乾燥皮膚, 疥癬があれば対応 皮疹があれば, *水酸化カリウム外用; カリ石ケン® Clinical Review & Education Care of the Aging Patient: From Evidence to Actio • まず水酸化カリウム外用を使用 改善なければ皮膚生検 or皮膚科へ. • 皮疹がなければ, • 代謝内分泌のチェック (甲状腺, 副甲状腺, 鉄欠乏) 悪性腫瘍, 神経症のチェック • 水酸化K外用を使用し, 改善なければ生検 or 皮膚科へ Box 1. Evaluation and Management of Elderly Patients With Pruritus 1. Take directed history detailing severity (on a 0-10 scale), location (localized vs generalized), and modifying factors for the patient’s itch (bathing). 2. Review medications (topical and systemic). 3. Perform physical examination for evidence of scabies (burrows, genital lesions) and dry skin (fissured, red patches on legs, flanks, and arms). 4. Order basic laboratory evaluation (complete blood cell count, fasting plasma glucose, thyrotropin, liver function tests, serum urea nitrogen/creatinine, calcium, phosphorus). 5. Treat for xerosis. 6. Treat for scabies if found. 7. If rash is present, initiate topical therapy, obtain potassium hydroxide preparation, order skin biopsy, or refer to a dermatologist if initial therapy does not improve the rash. 8. If no rash is present, initiate metabolic workup (thyroid, parathyroid, iron deficiency) and evaluate for malignancy or for neuropathy. If no rash is present and skin changes are due to scratching, assess for scabies, obtain a potassium hydroxide preparation, consider skin biopsy, pursue a metabolic workup, and evaluate for malignancy or neuropathy.
  7. 7. • 病歴での注意点; • 掻痒感の程度はVASを使用する. 6-8pt以上ならば睡眠を障害するくらいの掻痒感と捉え, 積極的に介入. • 強い掻痒感では疥癬を必ずチェック. 特に突如発症で施設入所歴が ある場合, 頭皮がスペアされる場合はさらに疑う • 入浴との関連も重要な情報. 入浴にて軽快する場合は乾燥皮膚を示唆する病歴. 入浴後分∼時間単位で再出現し, 入浴で改善すればさらに有用. • 乾燥皮膚では湿度の低い冬場で特に増悪し, 四肢, 体幹の掻痒感が多く, 湿っている腋窩, 鼠径, 顔面, 頭皮では 少ないこともポイント.
  8. 8. • 薬剤歴; 外用もチェック. • 外用薬の使用方法とそれによる症状の変化にも突っ込む. 外用による接触性皮膚炎の可能性もあり. • 内服薬による掻痒感も知られていないが多い原因 • 薬剤による一過性の発疹と掻痒感(皮疹が無い場合もあり)  ACEI, サリチル酸, クロロキン, Ca-ch阻害薬で報告あり. • 薬剤による胆汁うっ滞 • 薬剤による皮疹と掻痒感 • 薬剤開始後数週で掻痒感が生じているならば中断すべき.
  9. 9. • 掻痒感, じんま疹(+)の高齢者と 年齢をMatchさせたControl群を比較すると, • 前者ではCa-ch阻害薬の使用率が2-4倍であり, Thiazide使用率が2倍であった. • この結果よりCCBを中断してみると, 3.4ヶ月で83%が改善. 再投与した9例中8例で平均4dでじんま疹が出現した. • CCB内服開始後数年経ってから生じる例もあり, 掻痒感やじんま疹でCCB内服している患者では中止するのも良い手
  10. 10. • 薬剤とUV光線の組み合わせも重要; photodermatitis • 日光に暴露している部位の掻痒感, 皮疹, 二重に衣服をまとっている部位が保たれる場合は疑う. • Thiazide, テトラサイクリン, ACEI, CCB, NSAID, キニジン, アミオダロンは報告例が多い日光過敏を引き起こす薬剤. • 他にも原因となる薬剤は多く, 日光過敏出現から6wk以内に開始した薬剤は中止すべき.
  11. 11. Clinical Review & Education Care of the Aging Patient: From Evidence to Action Pruritus in the Older Patient Table 2. Key History and Physical Examination Elements in the Diagnosis of Pruritic Skin Conditions Common in Elderly Persons Condition History Physical Examination Xerotic eczema Improves with bathing, worse when dry; primarily affects lower legs and arms; spares the armpits, groin, face, and scalp Can have minimal changes; fissured, slightly scaly, poorly defined patches Scabies Severe pruritus; recent stay in long-term care facility Small papules and linear lesions of the axillae, groin (vulva and scrotum), navel, finger-webs Photodermatitis Photosensitizing medication; worse after sun exposure (eg, long car trip) Confluent patches favoring dorsal hands, brachioradial arms, “V” upper chest area, posterior neck, and face Grover disease Worse after sweating (even in winter) 2- to 4-mm slightly scaly red papules of the inframammary chest/upper abdomen and central back Bullous pemphigoid Severe pruritus Urticarial plaques or bullae favoring the inner aspects of proximal arms and thighs and flanks; surrounding erythema may or may not be present Drug-induced skin eruption New medication (eg, calcium channel blocker or hydrochlorothiazide) Many morphologies; widespread symmetrical erythema Cutaneous T-cell lymphoma (mycosis fungoides type) Long duration; pruritus minimal to severe Slightly scaly large patches with atrophy at times with pigment change; loss of hair in lesions; often begins on lower back, buttocks, upper thighs (bathing trunk distribution) Patients with end-stage renal disease who are undergoing hemodialysis commonly have chronic pruritus. Initially, dialysis should be optimized and the patient treated for xerosis. If this is ineffective, gabapentin, 300 mg, or pregabalin, 75 mg, after each dialysis session are equally effective in treating the pruritus of end-stage renal disease.33 In refractory renal pruritus, UV-B phototherapy is of- with diabetes with dysesthesia of the toes and soles, absence of the Achilles tendon reflex bilaterally, and impaired change in blood pressure with a head-up tilt test are 1.5 to 2 times more likely to report truncal pruritus.15 Except for allergic contact dermatitis, dermatological and systemic diseases tend to cause generalized or multifocal itch, so a re-
  12. 12. • 身体所見での注意点; • 掻痒部位の皮疹の有無の確認は重要. 掻爬痕なのか, 皮疹なのか • 皮疹があればそれに対して外用を使用するか, 皮膚科コンサルトするか, 皮膚生検を行うか. • 皮疹の部位が指の皺, 手首, 足の裏, 鼠径, 陰部, 乳房ならば, 疥癬の可能性が高い. • 皮疹が無い場合, 乾燥皮膚, 神経症, 全身疾患, 悪性腫瘍の可能性が上がる
  13. 13. on 掻痒感への対応 Pruritus in the Older Patient Table 1. Treatments for Pruritus and Their Costs • Pruritus Treatment by Etiology 原因と掻痒感に対する治療 Cost, $a Xerosis Moisturizers White petrolatum, 13 oz Moisturizing cream (tub-style container), 16 oz 5 10-15 Soothing topical lotions or creams Anti-itch lotions, 7 oz 8-11 Inflammation Topical steroids Triamcinolone ointment, 0.1%, 80 g/1 lb 18/49 Fluocinonide ointment, 0.05%, 60 g 50 Renal pruritus • 皮膚乾燥症への対応 γ-Aminobutyric acid analog33 Pruritus in the Older Patient Gabapentin, 300 mg, 90 pills 20 Pregabalin, 75 mg, 30 pills 95 UV-B phototherapy, per treatment34b Hepatic pruritus Box 2. Xerosis: Basic Principles of Management 1. Restrict soap to axilla, groin, scalp, and soles. 2. Perform less frequent (less than once per day) bathing with warm, not hot, bath or shower water. 3. Avoid topical alcohol (astringents) and high-concentration lactic acid (>5%). 4. Apply petrolatum or petrolatum-containing moisturizer (cream or ointment, not lotion) immediately after bathing. 50-100 Opiate antagonists35 Naltrexone, 50 mg, 30 pills Butorphanol nasal spray, 2.5 mL UV-B phototherapy, per treatment36b 105 57 50-100 Neurogenic pruritus Topical capsaicin, 1.5 oz 9-15 Capsaicin patches, 3-4 patches 6-12 Topical lidocaine ointment, 5%, 35 g Lidocaine patch, 5%, 30 patches 38 221 a All costs are from http://www.drugstore.com, either online or through Epocrates. b Cost estimated based on the Medicare physician fee schedule.37
  14. 14. • 難治性の掻痒感に対しては, 積極的な保湿が有効なことがある 特に皮膚乾燥症と炎症性皮膚炎. Older Patient Care of the Aging Patient: From Evidence to Action Clinical Review & Education Older Patient Care of the Aging Patient: From Evidence to Action Clinical Review & Education • 方法は “soak and smear” もしくは “wet wraps” ments for Pruritus and Their Costs ments for Pruritus and Their Costs ment by Etiology Cost, $a ment by Etiology Cost, $a s srolatum, 13 oz 5 rolatum, (tub-style container), 16 oz ing cream13 oz 5 10-15 ing cream (tub-style container), 16 oz topical lotions or creams 10-15 topical lotions ch lotions, 7 oz or creams 8-11 ch lotions, 7 oz 8-11 Box 3. Soak-and-Smear Method Box 3. Soak-and-Smear Method 1. Soak for 10 to 20 minutes in a tub of comfortably warm (not hot) 1. water. 10 to 20 minutes in a tub of comfortably warm (not hot) Soak for 2. Pat dry. water. 3. Apply moisturizer to affected skin. 2. Pat dry. 水気をとる 4. Occlude the moisturizer with kitchen plastic wrap or vinyl suit for 3. Apply moisturizer to affected skin. 4. at least 4the moisturizer with kitchen plastic wrap or vinyl suit for Occlude hours. 5. Frequency is twice daily for severe cases, once daily otherwise. at least 4 hours. 5. Frequency is twice daily for severe cases, once daily otherwise. oids oids olone ointment, 0.1%, 80 g/1 lb 18/49 olone ointment, 0.1%, 80 g/1 nide ointment, 0.05%, 60 g lb 18/49 50 ide ointment, 0.05%, 60 g 50 yric acid analog33 33 yric acid analogpills in, 300 mg, 90 20 in, 300 mg, 90 pills n, 75 mg, 30 pills 20 95 n, 75 mg, 30 pills therapy, per treatment34b 95 50-100 therapy, per treatment34b us 50-100 us gonists35 Box 4. Wet Wraps Box 4. Wet Wraps 1. Bathe or apply a thin film of water onto affected skin. 2. Pat dry. apply a thin film of water onto affected skin. 1. Bathe or 3. Apply moisturizer. 2. Pat dry. 4. Put onmoisturizer. 3. Apply a moist garment (eg, light sweat suit, soft long under4. wear, pajamas). garment (eg, light sweat suit, soft long underPut on a moist 5. Apply pajamas). garment a similar dry garment. wear, over moist 6. Frequency is twice daily for severe cases, once daily otherwise. 5. Apply over moist garment a similar dry garment. 6. Frequency is twice daily for severe cases, once daily otherwise.

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