Туберкулез кожи (фото)

В последние годы частота туберкулеза кожи в России увеличивается

В последние годы частота туберкулеза кожи в России увеличивается

Туберкулез кожи вызывается микобактериями человеческого и бычьего типа. Инфицирование чаще всего происходит в детском возрасте эндогенным путем, реже экзогенным при массивном инфицировании через поврежденную кожу.

Туберкулез кожи

Туберкулез кожи — это группа различных хронических заболеваний, обусловленных внедрением в кожу микобактерий туберкулеза. В последние годы частота туберкулеза кожи в России очень увеличивается. Здоровая кожа является неблагоприятной средой для микобактерий туберкулеза. Факторами, подавляющими защитные силы организма и повышающими его восприимчивость к туберкулезной инфекции, становятся: гормональная дисфункция, патология нервной системы, витаминный дисбаланс, расстройства водного и минерального обмена, сосудистые нарушения (венозный застой и др.), неудовлетворительные социально — бытовые и климатические условия, инфекционные заболевания (корь, скарлатина). Причиной снижения иммунитета также может быть ВИЧ. Микобактерии проникают в кожу экзогенным путем через поврежденный эпидермис непосредственно от больного или через какие — либо предметы обихода.Чаще всего имеет место эндогенный путь распространения, при котором возбудитель заносится в кожу гематогенно или лимфогенно из туберкулезного очага в другом органе.

Различают очаговые (туберкулезная волчанка, колликвативный туберкулез кожи, бородавчатый туберкулез кожи) и диссеминированные (папулонекротический туберкулез кожи, индуративная эритема Базена, острый милиарный туберкулез кожи, лихеноидный туберкулез, туберкулез милиарно-язвенный) формы туберкулеза кожи.

Формы туберкулеза кожи

Волчанка туберкулезная (фото)

При волчанке туберкулезной высыпания обычно локализуются на лице

При волчанке туберкулезной высыпания обычно локализуются на лице

Волчанка туберкулезная — это наиболее распространенная форма туберкулеза кожи, которая чаще всего встречается у женщин. Основной морфологический элемент — бугорок (люпома), представляющий собой инфекционную гранулему. Бугорки склонны к периферическому росту и слиянию с образованием сплошных очагов. Бугорки изъязвляются. После рассасывания инфильтрата остается рубец или рубцовая атрофия кожи. При витропрессии бугорка выявляется феномен «яблочного желе»,  бугорок западает при надавливании на него пуговчатым зондом. Высыпания обычно локализуются на лице ( как показано на фото), но могут быть на туловище и конечностях. Иногда поражается слизистая оболочка носа, твердого и мягкого неба, губ. Туберкулезная волчанка обычно протекает на фоне положительной реактивности организма и характеризуется вялым длительным доброкачественным течением.

Туберкулез кожи колликвативный (фото)

Туберкулез кожи колликвативный — вторая по частоте форма туберкулеза кожи

Туберкулез кожи колликвативный — вторая по частоте форма туберкулеза кожи

Туберкулез кожи колликвативный (скрофулодерма) — вторая по частоте форма туберкулеза кожи. Возникает преимущественно в результате занесения микобактерий в кожу из пораженных лимфатических узлов и по лимфатическим сосудам из других очагов туберкулеза. Чаще болеют женщины. Обычно поражается область шеи, реже конечности. Высыпания вначале представлены плотными безболезненными узелками, которые, быстро увеличиваясь в объеме, превращаются в спаянный с подлежащими тканями узел, который в дальнейшем размягчается и вскрывается с выделением гнойного содержимого с включениями некротизированной ткани. На месте узла образуется язва с мягкими краями и вялыми грануляциями. После ее заживления остаются «рваные» рубцы неправильной формы. Туберкулиновые реакции дают, как правило, положительный результат.

Бородавчатый туберкулез кожи (фото)

Туберкулез кожи бородавчатый характеризуется безболезненными узелками красноватого цвета

Туберкулез кожи бородавчатый характеризуется безболезненными узелками красноватого цвета

Туберкулез кожи бородавчатый характеризуется безболезненными узелками красноватого цвета с синюшным оттенком, которые увеличиваются за счет периферического роста. На поверхности сформировавшегося таким образом инфильтрата, в его центре, появляются бородавчатые разрастания, покрытые роговыми массами. Периферическая часть инфильтрата остается обычно свободной от разрастания и имеет вид красноватого ободка. В определенной степени бородавчатый туберкулез можно отнести к профессиональным заболеваниям, так как он встречается у рабочих на бойнях, ветеринаров.

Папулонекротический туберкулез кожи

Туберкулез кожи папулонекротический чаще возникает у женщин в возрасте 25—35 лет. Характеризуется красными с синюшным оттенком плотными полушаровидными папулами размером с конопляное зерно. В центральной части папулы некротические массы ссыхаются в плотно прилегающую корочку, после ее удаления образуется округлая язвочка с крутыми краями. На ее месте остается «штампованный» рубец. Папулы располагаются рассеянно на голенях, бедрах, ягодицах, разгибательных поверхностях верхних конечностей, преимущественно в области суставов. Реакция Манту у большинства больных положительная.

Индуративная эритема Базена

Эритема индуративная Базена чаще возникает у женщин. Проявляется плотными, спаянными с кожей малоболезненными узлами, которые обычно локализуются на голенях или бедрах. Кожа над ними вначале не изменяется, затем становится красной с синюшным оттенком. Регресс узла сопровождается рубцовой атрофией. Иногда узел размягчается и изъязвляется.

Острый милиарный туберкулез кожи (фото)

Острый милиарный туберкулез кожи чаще всего появляется на туловище

Острый милиарный туберкулез кожи чаще всего появляется на туловище

Туберкулез кожи милиарный острый — проявление общего милиарного туберкулеза. Характерно появление на лице, туловище (фото), конечностях мелких остроконечных папул, несколько напоминающих папулы при папулонекротическом туберкулезе кожи, но с более выраженным геморрагическим характером процесса. В папулах часто обнаруживают микобактерии.

Лихеноидный туберкулез

Туберкулез лихеноидный (лишай золотушный), обычно сопровождается туберкулезом других органов. Клинически представлен милиарными папулами желтовато — коричневого цвета или цвета нормальной кожи. Узелки мягковатой консистенции, нередко с маленькой чешуйкой в центре, могут наблюдаться плоские папулы с блестящей поверхностью, напоминающие таковые при красном плоском лишае. Заболевание поражает чаще кожу туловища, реже — конечностей и лица, высыпания склонны к группировке. После выздоровления на коже не остается следа.Туберкулезные реакции положительны.

Милиарно – язвенный туберкулез (фото)

Милиарно – язвенный туберкулез возникает вторично как результат аутоинокуляции у больных с активным туберкулезом других органов при отсутствии иммунитета

Милиарно – язвенный туберкулез возникает вторично как результат аутоинокуляции у больных с активным туберкулезом других органов при отсутствии иммунитета

Туберкулез милиарно — язвенный возникает вторично как результат аутоинокуляции у больных с активным туберкулезом других органов при отсутствии иммунитета. Обычная локализация — слизистые оболочки естественных отверстий, окружающая их кожа. Высыпания представлены узелками размером с булавочную головку, которые превращаются в гнойнички, а затем в язвы с неровным и бугристым дном. Бугристость обусловлена желтоватыми узелками, представляющими собой абсцессы — «зерна Треля».

Течение туберкулеза кожи сопровождается обострениями и рецидивами. Факторами, способствующими развитию обострений и рецидивов являются недостаточная длительность основного курса лечения, неполноценность противорецидивной терапии, плохая переносимость противотуберкулезных препаратов, развивающаяся устойчивость к ним штаммов микобактерий, которых на сегодняшний день насчитывается около 500. Туберкулез рецидивирует в зимний и осенний периоды.

Диагноз туберкулеза устанавливается по данным анамнеза (указания на перенесенный в прошлом туберкулез легких, контакт с больными), клинической картины, результатов туберкулиновых проб, гистологического и культурального исследований. Иногда прибегают к заражению лабораторных животных (морских свинок). В диагностически сложных случаях допустимо проведение пробного лечения.

Дифференциальный диагноз проводят с бугорковым сифилидом, раком кожи, лейшманиозом, глубокими микозами, васкулитом.

Лечение начинают с сочетания рифампицина и изониазида, иногда к этому добавляют пиразинамид или тиацетазон. Затем эти препараты заменяют стрептомицином, этамбутолом, ПАСК (применяется достаточно редко). Основной курс длится в среднем 10—12 мес. Для лечения язвенных дефектов используют присыпки с ПАСК, изониазидом. Патогенетическая терапия включает витамины (особенно группы В), антиоксиданты (сс-токоферол, тиосульфат натрия, дибунол), иммуномодуляторы (нуклеинат натрия, тималин), анаболические стероиды, физиотерапевтические мероприятия (УФО в субэритемных дозах и т. д.), лечебное питание. После основного курса лечения проводят противорецидивную терапию по 2 мес (весной и осенью) в течение 3 лет при очаговых формах и 5 лет при диссеминированных. При клиническом излечении требуется диспансерное наблюдение с двухкратным осмотром в год в течение 5 лет, после чего больного снимают с учета.

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