Наиболее распространенным среди детей дерматозом аллергического генеза является экзема. По последним данным, различные варианты экземы составляют от 30 до 40% всех кожных заболеваний. Название данного дерматоза объясняется характерным свойством экзематозных пузырьков быстро вскрываться, наподобие пузырьков кипящей воды (по-гречески eczeo - вскипать).
Истинная экзема. Истинная, или идиопатическая, детская экзема встречается наиболее часто, развиваясь обычно в возрасте от 3 до 6 месяцев. По наблюдениям Л. А. Штейнлухта, у 80% детей заболевание возникло в период от 2 до 6 месяцев, причем у 9 % - на втором месяце и у 23 % - на третьем.
Процесс чаще всего начинается на лице, в области щек. В клинической симптоматике преобладает яркая, сочная, отечная
эритема с располагающимися на ее фоне серозными папулами, микровезикулами, которые быстро вскрываются, образуя типичные эрозии. Их называют «серозными колодцами» из-за выделения по каплям серозной жидкости. Сливаясь, эрозии образуют крупные мокнущие участки, местами покрытые серозными корками. Начавшись на лице, экзематозный процесс распространяется на туловище, ягодицы, верхние и нижние конечности. Истинной экземе свойственны появление новых эффлоресценций на любом участке кожного покрова и положительная изоморфная реакция.
Себорейная экзема. Эту форму характеризует расположение высыпаний на волосистой части головы, ушных раковинах - (и позади них), на лице, груди, спине. В отличие от истинной экземы мокнутие и микровезикуляция отсутствуют, если же они возникают, то только в период резкого прогрессировать или при локализации сыпи в складках. В отношении нозологической сущности себорейной экземы до сих пор нет единства мнений: ее рассматривают как комбинацию себореи и экземы, себореи и пиодермии или как
стрептодермию.
Микробная экзема. Значительная обсемененность стафилококками и стрептококками кожи детей сопровождается явлениями гиперчувствительности немедленно-замедленного типа. Ф. А. Зверькова установила у детей, больных экземой, более высокий уровень сенсибилизации к стафилококковому аллергену по сравнению со стрептококковым. Резко выраженная сенсибилизация к стрепто- и стафилококкам у больных микробной экземой подтверждается высокими титрами стрептолизина О, стафилолизина, антистрептокиназы и антистрептогиалуронидазы.
Процесс сенсибилизации к стафилококкам, стрептококкам и продуктам их жизнедеятельности при микробной экземе совершается на фоне специфического и неспецифического иммунодефицита. Снижение титра комплемента, активности лизоцима, недостаточность как завершенного, так и незавершенного фагоцитоза свидетельствуют о слабости иммунных резервов при высокой сенсибилизирующей активности кокковой флоры. Способность микробов проявлять аллергизирующие свойства особенно усиливается при нервно-эндокринных регуляторных сдвигах, обменных нарушениях и сенсибилизации к собственным тканевым антигенам.
Сложное комплексное сочетание вышеперечисленных факторов определяет своеобразие клинических проявлений микробной экземы. Заболевание начинается с пиогенного элемента - стрептококковой или стафилококковой пустулы - и может возникнуть вокруг места ожога, ссадины, царапины. Вследствие нерационального лечения, расчесов или травматизации появляются отечно-эритематозные пятна с папуло-везикулами, образуются мокнущие эрозии, серозно-гнойные корки. Расположение элементов сплошное, без прослоек здоровой кожи. Границы очагов четкие, контуры овальные или правильно округлые, по краям их хорошо виден эпидермальный венчик, представляющий собой остатки стрептококковой фликтены.
В окружности очагов микробной экземы могут появляться остиофолликулиты, стрептогенное импетиго или сухие шелушащиеся участки типа pityriasis simplex. Очаги микробной экземы округлой формы с четкими контурами именуют нуммулярной экземой. У детей с микробной экземой обычно наблюдаются другие стрепто-стафилококковые заболевания: заеды, конъюнктивиты, отиты, хронические тонзиллиты, гаймориты.
При прогрессирующем течении экземы усиливается воспалительная реакция вторичных высыпаний с обильными везикулами, быстро образующими обширные мокнущие эрозии. В таких случаях говорят о трансформации микробной экземы в истинную. Микробная экзема у детей локализуется чаще на тыле кистей, в области голеней, бедер, плеч и предплечий. Выделение микробной экземы важно не только с теоретической точки зрения (особенности патогенеза), но и с практической - терапия микробной экземы антибиотиками, дезинфицирующими, антисептическими средствами обычно весьма успешна, тогда как другие разновидности экземы от такого лечения чаще обостряются.
Диагноз экземы в любом клиническом варианте сравнительно прост и основывается на данных аллергологического анамнеза, островоспалительном полиморфном характере высыпаний, хроническом рецидивирующем течении.
Дифференциальный диагноз. Диффузный нейродермит, как и детская почесуха и экзема, характеризуется хроническим рецидивирующим течением, алиментарной гиперчувствительностью немедленно-замедленного типа. Однако при нейродермите и детской почесухе превалируют симпатергические процессы (белый стойкий дермографизм, высокий тонус пиломоторного рефлекса). При нейродермите преобладает инфильтративный компонент воспаления с выраженной лихенизацией, отсутствует полиморфизм первичных элементов, не наблюдается спонтанного, длительного мокнутия, а если оно и возникает, то лишь в результате расчесов или при обострении, сочетается с основными симптомами дерматоза и держится недолго.
При детской почесухе возможно образование везикул, они располагаются на папулезном инфильтративном основании, не склонны к слиянию и образованию сплошных очагов с мокнутием и «серозными колодцами», преимущественно локализуются на разгибательных поверхностях; конечностей. Дерматит Дюринга может весьма напоминать экзему. Однако групповое расположение эффлоресценций, отсутствие спонтанного мокнутия и «серозных колодцев», наличие эозинофилии в содержимом везикул и положительная проба Ядассона дают необходимые основания для правильной диагностики.
Лечение экземы. Учитывают конституциональные особенности ребенка, степень выраженности нейроэндокринных, иммунных и обменных нарушений, клиническое течение болезни. Желательно выявить факторы, способствующие возникновению экземы, и принять меры к их устранению, что часто сопряжено с большими трудностями и не всегда осуществимо. Поэтому основным направлением в лечении детской экземы является использование гипосенсибилизирующих и противовоспалительных средств, назначаемых наряду с симптоматическими.
Принимая во внимание значительный дефицит кальция и выраженную порозность сосудов, на первом этапе рекомендуют препараты кальция в сочетании с витаминами, антигистаминными и противовоспалительными средствами. Кальция глюконат, лактат или глицерофосфат назначают в порошках или таблетках по 0,25-0,5 г 2-3 раза в день или в 2-5 % растворе по 1 чайной, десертной или столовой ложке в зависимости от возраста ребенка. Натрия салицилат дают грудным детям из расчета 0,1 г на 1 кг массы тела в сутки или в 1-2 % растворе по 1 чайной или десертной ложке 2-3 раза в день после еды. Для детей старше 2 лет суточная доза натрия салицилата составляет 0,25 г на каждый год жизни. Детям с 5-летнего возраста можно назначать кальция глюконат внутримышечно по 2-3-5 мл 5% или 10% раствора. Мягким гипосенсибилизирующим и противовоспалительным действием обладает натрия тиосульфат, который дают внутрь по 0,25 г -0,5 г 2-3 раза в день или внутривенно - 10-20 % раствор по 5-8 мл через день в количестве 8-10 вливаний.
В комплексе с десенсибилизирующими назначают антигистаминные средства, обладающие не только антигистаминным, но и антибрадикининовым и антисеротониновым действием (димедрол, диазолин, фенкарол, бикарфен, супрастин, пипольфен, тавегил, перитол, сандостен и др.), Их применяют в соответствии с возрастом ребенка и кратковременно, циклами по 7- 10 дней. Вечерний прием этих препаратов желательно приурочить к ужину, за 1-2 ч до сна. Весьма целесообразно одновременно давать витамин С, что позволяет несколько уменьшить дозу антигистаминных препаратов (аскорбиновая кислота их синергист).
При упорном течении экземы используют седативные средства: мепротан (андаксин, мепробамат). При выраженной вегетодистонии, невротических расстройствах, нарушении сна применяют холинолитики и транквилизаторы (амизил, тазепам) в возрастных дозировках, а также отвары из корня валерианы, пустырника, череды, ромашки, боярышника - по 5-10 г на 200 мл воды, по 1 десертной или столовой ложке 3-4 раза в день в течение 1-2 недель.
У больных микробной экземой, а также при осложнении импетигенизацией истинной или себорейной экземы используют антибиотики широкого спектра действия. Тетрациклины можно применять детям только с 9-летнего возраста, так как они отрицательно влияют на развитие скелета, откладываются в дентине и эмали зубов. Наиболее употребимы макролиды (эритромицин) или полусинтетические пенициллины (ампициллин, оксациллин), действующие на грамотрицательную и грамположительную флору и обладающие менее аллергизирующим влиянием.
В случае упорного, тяжелого течения заболевания с тенденцией к частичной или полной эритродермии назначают глюкокортикоиды - преднизолон, дексаметазон или урбазон. Дозы гормонов и методика их применения варьируют в соответствии с тяжестью течения процесса, возрастом ребенка, наличием сопутствующих заболеваний - с учетом противопоказаний и возможных осложнений.
У детей с торпидно протекающей экземой, с тенденцией к трансформации в нейродермит могут быть применены гемотерапия и плазмотерапия. По данным Ю. К. Скрипкина, в упорных случаях хронически протекающих экзем с выраженной инфильтрацией, лихенификацией показаны пирогенные препараты (пирогенал, продигиозан). У больных себорейной экземой, наряду с гипосенсибилизирующими и антигистаминными средствами, дают рибофлавин в сочетании с пиридоксаль-фосфатом и пангаматом кальция.
Лечение всех клинических разновидностей экземы у детей проводят на фоне диеты, ибо алиментарная сенсибилизация может нивелировать эффект медикаментозного лечения.
В стадии регресса высыпаний используют УФО эритемными или субэритемными дозами, общие или по зонам, до 15- 20 облучений на курс. При хронической экземе с ограниченными очагами целесообразны фонофорез с суспензией гидрокортизона или аевитом, УВЧ-терапия. При значительной лихенификации применяют аппликации озокерита, парафина, лечебные грязи. В период ремиссии или в регрессивной стадии детям старше 3 лет показано курортное лечение (Пятигорск, Кемери, Сочи-Мацеста, Белокуриха, Цхалтубо, а также использование местных санаторно-курортных возможностей).
Наружное лечение проводят с учетом степени воспалительной реакции, стадии течения и распространенности процесса. При остром воспалении с наличием мокнутия назначают примочки, содержащие противовоспалительные, дезинфицирующие препараты в малой концентрации: 1 - 2% раствор амидопирина, 0,25% раствор цинка сульфата, 1-2% раствор жидкости Бурова или танина. Детям грудного возраста не следует назначать примочки, содержащие резорцин или борную кислоту, ввиду опасности их токсического действия при абсорбции через эрозии. Хорошо уменьшают гиперемию и отечность примочки из отвара чая, ромашки, подорожника, корня алтея.
При лечении экземы необходимоучитывая возможность абсорбции гормонов кожей, В. И. Кулагин рекомендует смешивать глюкокортикоидные мази с кремом Унны, кремом «Шалфей» или 5-10% карофиленовой мазью: детям грудного возраста в соотношении 1:10-1:8, от 1 года до 3 лет - 1 : 7 - 1 : 6, от 3 до 5 лет - 1 : 4, от 5 до 10 лет - 1 : 3 и старше 10 лет - 1 : 2 или 1 : 1. Такая тактика назначения глюкокортикоидных мазей усиливает их действие без риска вызвать какие-либо побочные проявления.
Прогноз экземы вполне благоприятен как для жизни и работоспособности ребенка, так и для выздоровления, особенно при правильно используемых профилактических мероприятиях.
Профилактика. В развитии детской экземы, особенно у детей грудного возраста, одну из главных ролей играет сенсибилизирующее влияние пищевых продуктов (материнского или коровьего молока, содержащих казеиноген, а также яиц, цитрусовых, клубники, земляники и др.). Еще внутриутробно ребенок приобретает повышенную чувствительность к аллергенам, циркулирующим в крови матери, так как плацента проходима для высокомолекулярных протеинов. Такая внутриутробная сенсибилизация к пищевым продуктам возможна в случае, если мать употребляет большое количество молока, сластей, яиц. Поэтому в профилактике экземы у детей существенное значение имеет рациональный режим питания беременных: экзематогенные вещества с молоком матери попадают после рождения ребенка на уже подготовленную почву.
В первые месяцы жизни ребенка мать продолжает соблюдать диету. Ребенка надо кормить в строго определенные часы, нельзя его перекармливать, а также вводить ранний прикорм углеводами. Следует разъяснить матери, что слишком частое кормление вредно, так как приводит к недостаточности ферментативной деятельности желудочно-кишечного тракта, переполнению кишечника, неполному расщеплению белковых продуктов и перегрузке организма ребенка токсическими экзематогенными веществами, которые могут быть в ее молоке. Нельзя чрезмерно кутать ребенка, так как это может привести к перегреванию и возникновению
потницы.
Гость, 12.02.2011 15:32:43 |
АД и экзема излечиваются только методом народной медицине лекарственными растениями,основательно и без побочных действий
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Жанна, 17.02.2011 11:37:43 |
Добрый день. Подскажите пожалуйста, что делать? Сыну полтора года за последние 14 дней стал какать один раз в три дня, при этом кал твердый, все переваринное, выдавливает из себя с трудом, на горшок стал отказываться садиться,какает стоя. На икрах появились ранки красного цвета,диаметром 2см, стали ранки вверх к бедру размножаться. Сын на ГВ, плохо очень воду пьет,только чай 50 мл.
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Анна, 17.03.2011 04:55:52 |
Здраствуйте. Моей дочке полгода, с 2-х месяцев появились розовые пятна(то сильно появляются, то коркой, то расчешет) на щеках ближе к ушам, потом на лбу, кормлю грудью. Также с 2-х месяцев проблемы со стулом(какала 1раз в 4 дня, и то я помогала - массировала анус градусником), с 4-х месяцев ввела овощное пюре, но стул нормализовался(1 раз в 1-2дня) только сейчас, но кал твердоват. Еще на затылке прям корка и маслом мазала, корка сойдет, а краснота остается, а потом опять все. Что делать незнаю, на лице пятна остаются, боюсь что кожа так и останется некрасивой, девочка же. Подскажите может кто сталкивался. Я сама уже ничего не ем, что может вызвать аллергию
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Гость, 15.02.2012 01:37:55 |
Меня тоже лечили долго от экземы, ничего не помогало избавиться, а потом я вычитала что кандидоз кожи очень похож на экзему. Как только стала лечиться от кандидоза - все прошло.
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Jkz, 22.07.2013 00:09:37 |
Мы с сынишкой намучились. Высыпания у нас начались в 2 месяца и с тех пор постоянно. Миллион кремов перепробовали, миллион врачей. Даже из Франции специально заказывали. Ничего не помогало надолго.
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