皮膚病診療 41巻9号 (2019年9月)

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・ステロイド長期内服中の高齢女性に発症したカンジダ性爪囲爪炎から,比較的まれなCandida guilliermondii(C. guilliermondii)が検出された症例を経験した.

・カンジダによる爪囲炎は日常の皮膚科診療でしばしば遭遇するが,ありふれた疾患であるため原因菌種が同定されないことが多い.

・カンジダ性爪囲爪炎の治療ガイドラインではイトラコナゾール内服が第1選択であるが,抗真菌薬による外用療法は安全かつ有効であり,罹患期間が長期化する傾向があるものの,高齢者や内服治療が困難な症例に考慮すべきである.

(「症例のポイント」より)

 

Successful treatment with topical antifungal therapy in a case of Candida onychomycosis caused by Candida guilliermondii

 

Takahashi, Hidenori1)Oyama, Noritaka2)Hasegawa, Minoru2) 1)Department of Dermatology, JCHO Fukui Katsuyama General Hospital 2)Department of Dermatology, University of Fukui

 

Cutaneous Candidosis is a diverse and heterogeneous group of disease, approximately more than 50% of whom are caused by Candida (C.)albicans. The ordinary diagnostic process and treatment regimen mostly ignore the potential importance for identification of Candida species and susceptibility to the drug. However, it may properly guide dermatologists to treat with oral antifungal drugs or empirical management, particularly in cases with non-C. albicans Candida and drug-resistant species. We herein present a Japanese elderly female with Candida onychomycosis of the ring finger during a long-term use of systemic steroid for ulcerative colitis and rheumatoid arthritis. The fungal culture and subsequent matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS)identified C. guilliermondii, an uncommon pathogen causing persisted superficial candidiasis and deep-seated infections in immunocompromised hosts. Although oral itraconazole is the first-line therapy for Candida onychomycosis, she was treated with topical luliconazole cream and obtained satisfactory results at 4-months of treatment. We revisit and discuss about the clinical benefit of Candida species identification and topical antifungal agents in Candida onychomycosis with complicated medical backgrounds in elderly.

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・近位爪甲下型の病型を呈する非白癬性爪真菌症を経験した.

・非白癬性爪真菌症の診断基準を満たし,分離菌の形態学的特徴と遺伝子検査によりFusarium oxysporum(F. oxysporum)による爪無色菌糸症と診断した.

・エフィナコナゾール爪外用液による治療で治癒した.

・わが国の1964年以降のフサリウム属による爪無色菌糸症17例を集計した.

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Ungual hyalohyphomycosis caused by Fusarium oxysporum successfully treated with topical efinaconazole

 

Hirose, Miki1)Noguchi, Hiromitsu2)Matsumoto, Tadahiko2)Hiruma, Masataro3)Yaguchi, Takashi4)Sato, Takahiro1) 1)Department of Dermatology, National Defense Medical College 2)Noguchi Dermatology Clinic 3)‌Ochanomizu Institute for Medical Mycology and Allergology and Division of Bio-resources, Medical Mycology Research Center 4)Medical Mycology Research Center, Chiba University

 

A 45-year-old male construction worker presented with a whitish discoloration at the base of the left big toenail and painful paronychia. He had borderline diabetes. Direct microscopy of nail specimen revealed chlamydoconidia and hyphae. Periodic acid-Schiff staining showed septate hyphae. Based on these morphological features and gene analysis, we diagnosed him as ungual hyalohyphomycosis caused by Fusarium oxysporum and ruled out contamination in accordance with Guputa’s criteria for non-dermatophyte mould onychomycosis. The minimum inhibitory concentrations were >16μg/ml for terbinafine, >16μg/ml for itraconazole, 0.5μg/ml for efinaconazole. Treatment with 10% efinaconazole solution cured the disease in 6 months.

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・ヒトパピローマウイルス(human papilloma virus:HPV)関連のBowen病は以前より報告があり,爪および爪周囲に生じるBowen病ではとくにHPV16型関連の報告が多い.

・自験例では爪母との連続性はなく,厳密に爪部型と定義することは困難ではあるが,ドーム状に隆起する臨床所見や,コイロサイトーシス,核内封入体,ケラトヒアリン顆粒の粗大化といった病理組織学的所見からHPV関連関連のBowen病を疑い,PCR法を実施したところHPV52型の増幅が検出された.HPV52型関連のBowen病の報告は少数で,また爪および爪周囲のBowen病は手指の報告が多く足趾は比較的珍しいため報告する.

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Bowen’s disease of the hallux associated with human papilloma virus 52

 

Toshima, Susumu1)Horikawa, Hiroto1)Yamazaki, Kazuto2)Sato, Tomotaka1) 1)Department of Dermatology, Teikyo University Chiba Medical Center 2)Department of Pathology, Teikyo University Chiba Medical Center

 

Bowen’s disease (BD) associated with human papilloma virus (HPV) has been frequently reported, especially that of the fingers and genital region. BD associated with HPV should be recognized as a sexually transmitted infection, and HPV type 16 causes the majority of BD associated with HPV. Only a few studies have reported on BD associated with HPV type 52, and studies on BD of the hallux are fewer than those on BD of the finger associated with HPV. Herein, we reported BD of the left hallux associated with HPV type 52. Further study may elucidate relationships between BD and various types of HPV and non-sexually transmitted infections.

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・皮膚石灰沈着症は①全身のカルシウム,リン酸の代謝異常を伴うmetastatic calcinosis cutis,②なんらかの基礎疾患に伴う障害された組織にカルシウムが沈着しておこるdystrophic calcinosis cutis,③ideopathic calcinosis cutis,④表皮直下に石灰沈着を認めるsubepidermal calcified noduleの4つに分類される1).

・今回われわれは,全身性強皮症に伴ったdystrophic calcinosis cutisと考えられる症例を経験したので報告する.

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A anti-centromere antibodie positive woman with dystrophic calcinosis cutis in the right index finger

 

Suzuki, Marie1)Sato, Yuni1)Sasaki, Miki1)Hosaka, Hiroomi1)Ishiwa, Mamiko2) 1)Department of Dermatology, Syowa University Nothern Yokohama Hospital 2)Ishiwa Physician and Dermatology clinic

 

58-year-old woman noticed that a white subcutaneous nodule was present on the right index finger from a year ago. X-ray of the right index finger showed diffuse subcutaneous calcification. Detailed workup, including serum calcium levels, was normal. Anti-nuclear antibodies and anti-centromere antibodies tested positive. At the time of re-examination, we confirmed hardening of the skin on her finger. She was initially diagnosed with systemic sclerosis-related calcinosis.

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・爪の萎縮を主訴として来院し,臨床所見と病理組織学的所見をもとに爪扁平苔癬と診断した1例を報告した.

・両手指の冷感と腫脹を伴い,抗セントロメア抗体陽性の所見を手がかりとして全身性強皮症早期病変を見出した.

・全身性強皮症による末梢循環不全が,爪扁平苔癬の増悪因子の1つになっている可能性が推測された.

(「症例のポイント」より)

 

Nail lichen planus associated with systemic scleroderma

 

Endo, Miki1)Matsuura, Daisuke1)Onoe, Asuka1)Suzuki, Hirotake2)Terui, Tadashi3)Ochiai, Toyoko1) 1)Department of Dermatology, Nihon University Hospital 2)Kajicho-Suzuki Dermatology Clinic 3)Department of Dermatology, Nihon University Itabashi Hospital, Nihon University, School of Medicine

 

A 61 year-old man presented with malformed nails of both hands and feet of 3 years duration. All finger and toenails except the thumbs showed thinning, atrophy, onychorrhexis, and pterygium. His fingers were cold and swollen, with redness and capillary dilation in the paronychium. Histopathology of the nail matrix revealed epidermal hypergranulosis, dermo-epidermal junction liquefaction degeneration, and band-like lymphocyte infiltration in the upper dermal layer. Antinuclear antibody was increased 160-fold, he was anticentromere antibody-positive, and had an ACR/EULAR score of 10. He was diagnosed with lichen planus and systemic scleroderma. Scleroderma-related peripheral circulation disorders may worsen nail lichen planus.

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・上部内視鏡検査で指摘された口腔内色素斑を契機に発見されたLaugier-Hunziker-Baran(LHB)症候群を経験した.

・LHB症候群では口唇,口腔内,指趾掌蹠皮膚に色素沈着を生じ,その分布からPeutz-Jeghers(PJ)症候群との鑑別が問題となる.

・LHB症候群に伴う色素沈着は悪性化しないが,個々の皮疹は悪性黒色腫との鑑別がむずかしい.LHB症候群と悪性黒色腫の合併例の報告もあるため,診断後も経過観察し,色素斑の変化があれば生検など積極的な精査が望まれる.

(「症例のポイント」より)

 

A case of Laugier-Hunziker-Baran syndrome

 

Ozasa, Miran1)Suzuki, Hikaru2)Ota, Arihito2)Yanaba, Koichi2) 1)Department of Dermatology, The Jikei University School of Medicine 2)Department of Dermatology, The Jikei University Katsushika Medical Center

 

A 77-year-old woman had several pigmented spots localized on the lips, tongue, and mucosa of the cheek. In addition, there were brown macules on the fingers and the left sole, and black streak on the nail. These were first noticed 10 years previously. On examination, no intestinal polyposis or adrenal dysfunction suggestive of Peutz Jeghers syndrome or Addison’s disease was noted. A biopsy of a pigmented macule from the lip revealed melanin pigmentation of the basal layer with melanophages in the upper dermis. We therefore diagnosed the patient as having Laugier-Hunziker-Baran syndrome.

反復性不完全爪甲脱落症 東 禹彦
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・反復性不完全爪甲脱落症の3例を報告した.

・第Ⅰ趾爪甲に次々と爪甲の不完全な脱落を認める.新生爪甲は既存の爪甲の下に生じる.爪甲が二重,三重に重なっている.最上層の爪甲も側爪郭皮膚とつながっているために,第Ⅰ趾遠位部に達するまで脱落しない.靴の履き方に注意し,非伸縮性テープで第Ⅰ趾先端を固定すると治癒する症例がある.

(「症例のポイント」より)

 

Repeated incomplete onycomadesis

 

Higashi, Nobuhiko1) 1)Higashi Dermatology Clinic

 

Three cases of repeated incomplete onychomadesis are reported. Repeated incomplete onycomadesis shows a nail plate overlaps each other twice or three times on the nail bed. The lateral side of the nail plate are fixed to the lateral nail fold. Therefore the oldest nail plate has not left out until the nail plate reaches to the distal portion of the nail bed. The treatment of the repeated incomplete onycomadesis was carried out as follows, the tip of the big toe was fixed downward using non-elastic cloth-tape in day time. One case out of three cases was cured.

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・生後1カ月より観察しえた先天性厚硬爪甲症(pachyonychia congenita:PC)を経験した.

・初診時,爪甲肥厚は明らかではなく,爪の緑褐色調変化のみであった.

・父親にも先天性厚硬爪甲症があり,遺伝子検査にてKRT6A変異が認められた.

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A case of pachyonychia congenita could observed from neonatal period

 

Yagasaki, Akiko1) 1)Yagasaki Dermatology Clinic

 

A 1-month-old female congenitally had green-brown nails in almost all fingers and toes and her nails gradually became thick and turbid from the tips with growth. She did not show any other abnormalities in her hair, tooth, and oral cavity. Her father also had thick nails in all fingers and toes, accompanying with numerous cysts in his face and trunk, plantar keratoderma, and oral leukokeratosis. We conducted genetic test and detected KRT6A mutation. Pachyonychia congenita (PC)is a rare autosomal dominant disease and abnormalities are limited in the nails and skin. Hence, dermatologist should know the early symptoms of PC to diagnose it correctly.

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・打撲が誘因となり左第Ⅲ趾に発症したacquired periungual fibrokeratoma(APF)の1例を報告した.

・側爪部に発生したこと,腫瘍内のムチン沈着が多かったことが大型の腫瘤を形成した要因と考えられた.

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A case of large acquired periungual fibrokeratoma with onset of bruising

 

Takehara, Kouhei1)Nomura, Yoshihiro1) 1)Department of Dermatology, Toyama City Hospital

 

The patient was a 39-year-old woman. Six months ago, a part of the nail of the left third toe was damaged. One week later, a mass appeared at the same site and gradually increased. Physical examination showed A 15×13 mm, smooth, pink, broad base-raised mass in the lateral nail shell of the left third ridge. It was elastic hard, but without tenderness. Histologically, horny layer thickening, disappearance of epidermal processes, collagenous fibers and fibroblasts that grow like scaly at the base of the mass, and mucin deposits were observed in some of the dermis with edema.

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・特徴的な爪症状を契機にnail-patella症候群の診断に至った.

・10歳ころより認めていた消化器症状がnail-patella症候群の症状である可能性が示唆された.

・遺伝子検査にてLMX1B遺伝子に新規スプライスサイト変異c.257+4_+7delinsGTが検出された.

・患者皮膚でのLMX1B mRNA発現量が,正常皮膚の約40%に減少していた.

(「症例のポイント」より)

 

Nail-patella syndrome with irritable bowel syndrome

 

Furukawa, Fumina1)Makino, Teruhiko1)Mizawa, Megumi1)Kita, Keiichiro2)Gejo, Ryuichi3)Shimizu, Tadamichi1) 1)Department of Dermatology, Graduate School of Medicine, University of Toyama 2)Department of General Medicine, Toyama University Hospital 3)Department of Orthopedic surgery, Graduate School of Medicine, University of Toyama

 

A 17-year-old girl presented to our hospital for the evaluation of nail deformity and irritable bowel syndrome. A physical examination revealed hypoplasia, triangular lunulae, and splitting of the nails on both hands. Plain radiography demonstrated bilateral small patellae and iliac horns. These findings were diagnostic for nail-patella syndrome. Furthermore, we hypothesized that the irritable bowel syndrome observed in the patient may have been a clinical finding of nail-patella syndrome because the disease onset in this case was much earlier than that in typical cases. The patient is being carefully observed.

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・手指に生じた爪下外骨腫を経験した.

・手術方法としては,手指という点から整容的な面も考慮し,視野確保がむずかしいとされる指尖部を横切開する腫瘍部切開法を選択したが,爪変形もなく予後良好であった.

・術中の単純X線検査で腫瘍の取り残しがないことを確認することが再発を防ぐために肝要と考えた.

(「症例のポイント」より)

 

A case of subungual exostosis of the thumb

 

Kawasaki, Yurika1)Fukuyasu, Atsuko1)Ishikawa, Takeko1)Kamata, Masahiro1)Ohnishi, Takamitsu1) Kondo, Fukuo2)Tada, Yayoi1) 1)Department of Dermatology, Teikyo University School of Medicine 2)Department of Pathology, Teikyo University School of Medicine

 

A 54-year-old female presented with a nodule with tenderness on the tip of the right thumb for the past one year. She had no history of trauma. The lesion was pinkish, keratinized, bone-like hard and poorly movable. X-ray of the hand revealed mature bone projecting from the distal end of the terminal phalanx of the right thumb. Histopathology from excised tissue from the lesion (thumb)showed evidence of mature trabecular bone with a fibrocartilaginous cap in the deep dermis. No recurrence at the postoperated site has been observed for about five years up to now.

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・左拇趾に生じた爪下外骨腫を経験した.

・X線撮影で淡い陰影が認められ,骨腫瘍であることが疑われた.

・外科的切除により治癒した.

・年齢,症状などは典型例といえる.

(「症例のポイント」より)

 

A typical case of subungual exostosis

 

Hayashi, Ayako1)Matsumoto, Kishiko1) 1)Department of Dermatology, Ube Industries Central Hospital

 

A 11 years-old girl presented with a painful nodule at the distal end of her left toe nail. A radiograph showed a pedunculated radiopaque mass on the dorsomedial surface of the distal phalanx. Subungual exostosis was suspected, and the legion was surgically removed. Histologically, the lesion showed a mature trabecular bone, consistent with the diagnosis of subungual exostosis.

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・陥入爪に伴う爪囲肉芽の悪化要因とその対処について症例を呈示し考察した.

・爪囲肉芽の悪化要因は症例によって多様であるが,1)物理刺激,2)過剰な湿潤環境,3)感染が大きく影響している.

・上記1)から3)に対処することによって職歴,運動をはじめとした生活環境,全身疾患の既往等それ以外の悪化要因の検討が容易になると考えた.

(「症例のポイント」より)

 

Exacerbating factors of periungual granulation associated with ingrown nail

 

Sato, Ryusuke1)Miura, Shinpei2)Amano, Hiroo2) 1)Sato Dermatology Office 2)Department of Dermatology, Iwate Medical University, School of Medicine

 

Periungual granulation associated with ingrown nail is a common condition, but sometimes it is difficult to cure. Here we present two such cases affecting the first toe of a 24-year-old male and a 14-year-old male, which were treated by minimizing factors that might exacerbate the condition, i.e. i)physical insertion, ii)excessive moisture, and iii)bacterial infection. This approach led to almost full cure of the granulations, allowing us to consider other exacerbating factors.

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・爪甲中央に色素線条を呈する爪部Bowen病を経験した.

・色素線条は不均一で臨床像からは悪性黒色腫との鑑別を要した.

・爪部Bowen病ではダーモスコピーで爪甲下に角化所見を伴う爪甲色素線条を認め,診断の補助に有用と考える.

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A case of Bowen’s disease with longitudinal melanonychia

 

Tozawa, Takahisa1)Nakamura, Ayaka2)Kakeda, Masato3)Habe, Koji2)Yamanaka, Keiichi2) 1)Department of Dermatology, Yokkaichi Municipal Hospital 2)Department of Dermatology, Mie University, Graduate School of Medicine 3)Department of Dermatology, Saiseikai Matsusaka General Hospital

 

We reported a case of a 48-year-old male with a pigmented streak on his right middle fingernail. The streak didn't contact the lateral edge of the nail plate. Dermoscopic examination of the nail plate revealed longitudinal black pigmentation with hyperkeratosis. The Hutchinson’s sign was not present. We confirmed a diagnosis of Bowen’s disease by excisional biopsy. Dermoscopy provides valuable information for the diagnosis of subungual Bowen’s disease and aids in the differential diagnosis from nail-unit melanoma.

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・爪部に生じた扁平上皮癌の1例を経験した.

・臨床的に肉芽腫様の外観を呈しており,診断確定に時間を要した.

・組織学的にはBowen病の特徴を有していた.

・骨膜への浸潤を認めたため,拇趾のIP関節離断術を行った.

(「症例のポイント」より)

 

A case of a squamous cell carcinoma of the nail

 

Takeda, Koichiro1)Tamai, Mariko1)Sato, Hiroko1)Yonekura, Kentaro1)Kanzaki, Tamotsu1) 1)Division of Dermatology, Imamura Sogo Hospital

 

We report a 65-year-old man presenting a red nodule on his lateral nail fold of the first toe. At first, it was treated with topical steroid, considering it as foreign body granuloma due to ingrown nail. Although the tumor had shrunk temporarily but then enlarged, a skin biopsy was performed and a diagnosis of SCC was made. Although the tumor was resected including the periosteum, tumor cells also infiltrated the periosteum. We performed an amputation at the IP joint of the right first toe. No recurrence has been observed three years after the operation. SCC in the nail area is a relatively rare tumor, and the clinical features are so diverse that it is often misdiagnosed as a benign disease such as granuloma, and it often takes time to confirm the diagnosis. Therefore, it is considered necessary to perform a histopathological examination actively for the tumor on nail lesion.

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・嚢胞状リンパ節転移を伴った爪床のpigmented epithelioid melanocytoma(PEM)と考えられたまれな症例を経験した.

・病理組織所見は表皮内に腫瘍細胞はみられず,真皮にメラニンを豊富に有する類円形の細胞と紡錘形の細胞が密に増殖しており,大量のメラニン顆粒のため核/細胞異型の判断が困難であり診断に苦慮した.

・メラニンを豊富に伴った細胞増殖が主体であったため,DAB(diaminobenzidine)発色法による免疫染色を施行する前に過酸化水素法によるメラニン脱色法を用いた.

(「症例のポイント」より)

 

A case of pigmented epithelioid melanocytoma on the nail bed with cystic lymph node metastasis

 

Tohgi, Natsuko1)Masuzawa, Mamiko1)Kounoike, Natsuko2)Amoh, Yasuyuki1) 1)Department of Dermatology, Kitasato University School of Medicine 2)Department of Plastic and reconstructive surgery, Kitasato University School of Medicine

 

A 70-year-old Japanese man had medical histories of maxillary sinus carcinoma, renal cell carcinoma and colon carcinoma, and an enlarged right axillary lymph node was observed by the follow-up computed tomography scan. Histopathological examination of the lymph node revealed its cystic structure and tumor cells with abundant melanin were proliferated in the cyst wall. Therefore, the lymph node was suspected as a metastasis of malignant melanoma. As a primary lesion, a black blue nodule with nail destruction was observed on subungual area of his right thumb. The histopathological findings of the subungual lesion showed spindle and epithelioid tumor cells with heavy pigmentation in only dermis. The tumor cells showed no mitotic activity and accompanied with plenty of melanophages, and necrotic change was not observed in the primary site. Hence, we diagnosed it as pigmented epithelioid melanocytoma with cystic lymph-node metastasis.

editorial

看過と紹介遅延 向井 秀樹

総説

爪の腫瘍と薬剤性障害 吉川 周佐
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爪部は種々の原因で変形や変色をきたす.外傷などの外的刺激や湿疹などによる爪の変形や変色は日常診療において比較的多く遭遇する.  本稿では爪部に生じる腫瘍および抗癌剤による爪障害について述べる.  爪部に発症する腫瘍は多種多様である.爪甲の色調変化のみを認める場合や腫瘤形成をおこし爪甲の変形や破壊を伴うものなど,多様な臨床形態をとる.  良性腫瘍としては色素細胞性母斑・グロムス腫瘍・後天性爪囲被角線維腫・毛細血管拡張性肉芽腫,指尖粘液囊腫などがある1).一方,悪性腫瘍としては悪性黒色腫,Bowen病,有棘細胞癌などがあげられる.これらの腫瘍は他の部位に発症した腫瘍と同様に視診や問診に加え,ダーモスコピーやエコーなどの侵襲のかからない検査を行うことにより多くの場合,診断確定が可能である.しかし診断に難渋するような場合においては他の部位に発症した病変と同様に生検術が必要となる.  生検を行う場合,爪部はとても小さな領域であり他の部位に比べ繊細な操作が要求されるとともに安易な切除は爪甲の変形や欠損を残すことがあるため,より慎重に行う必要があると考える.本項前半では爪部に認める腫瘍,とくに悪性腫瘍を中心に特徴と治療について述べる.  抗癌剤治療において皮膚障害はもっとも発現しやすい副作用の一つである.その中でも爪部の変化は爪甲の変形,変色に加え爪囲の炎症やさらには爪甲の陥入など日常生活に支障をきたすことも多く適切なマネジメントが必要となってくる.爪の障害が悪化することにより抗癌剤の治療が継続できなくなることは避けなければならない.本稿後半では抗癌剤による爪障害について述べるとともに,適切なマネジメントについての考え方を示す.(「はじめに」より)

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爪疾患では爪甲自体の形態や色調の変化などから分類,命名された症候名が頻用される.病理組織学的な検索が行われる機会は必ずしも多くはなく,爪の変化をきたした原因として主に腫瘍性病変や一部の炎症性疾患が想定される場合にその診断や治療のため病理組織学的検索が行われる.爪疾患の病理組織像を解釈するためには,爪甲の形成と伸長に関与する組織の構造を正しく理解したうえで,推定される病変の存在部位から標本を採取する必要がある.さらに爪部は表皮とは異なる構築をしているため,爪疾患の病理組織像を読むうえでは,正常な爪部の組織像に関する知識を有していることが重要となる.  本稿では正常な爪部の構造・病理組織像と,病理組織学的検索がなされることの多い代表的な爪疾患の病理組織像について解説する.(「はじめに」より)

私の視点

診察室の四季

斉藤 隆三

皮膚科のトリビア

第171回

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目次

編集後記・次号予告

基本情報

pd-41-9_cover.jpg
皮膚病診療
41巻9号 (2019年9月)
電子版ISSN:2434-0340 印刷版ISSN:0387-7531 協和企画

文献閲覧数ランキング(
11月23日~11月29日
)