皮肤是猫咪健康状况的标志-全身性疾病的皮肤表现（3）

王帆

皮肤是猫咪健康状况的标志

SKIN AS A MARKER OF GENERAL FELINE HEALTH

全身性疾病的皮肤表现

Cutaneous manifestations of systemic disease

作者：Linda J Vogelnest

翻译：何梦婷  校对：王帆

脱毛、红斑、皮屑和/或局灶性结痂的患猫

The cat with alopecia, erythema, scaling and/or focal crusting

皮肤病表现为明显脱毛、红斑和/或皮屑，是猫中最常见的皮肤表现，并且与品种差异性有关。可能出现轻度局灶性结痂，瘙痒症状多样化（无瘙痒/不显著到严重瘙痒）。过敏反应（详见后文瘙痒的患猫）是这种表现的常见病因（图2），以及一系列原发性和继发性皮肤感染，包括皮肤癣菌、外寄生虫（蠕形螨、耳螨、姬螯螨）、继发的细菌或马拉色菌。落叶型天疱疮是猫最常见的自体免疫性皮肤病，是另一种结痂表现需要考虑的疾病。全身性疾病可导致脱毛、红斑、皮屑和/或局部结痂性皮肤病变，可能会发现一些不同的表现。

Skin disease with prominent alopecia, erythema and/or scaling is among the most common cutaneous presentations in cats, and is associated with a wide range of differentials. Mild focal crusting may be present, and variable pruritus (absent/unapparent to severe). Hypersensitivities (see ‘the cat with pruritus’ later) are common causes of this presentation( Figure 2), along with a range of primary and secondary skin infections including those caused by dermatophytes, external parasites( Demodex, Otodectes, Cheyletiella) and secondary bacteria or Malassezia species. Pemphigus foliaceus, the most common autoimmune dermatosis in cats,is another consideration for crusting presentations. Systemic diseases may produce alopecic, erythemic, scaly and/or focally crusted skin lesions, and some distinct presentations are recognised.

图2一只患特应性皮炎的喜马拉雅猫，颈背部界限清晰的脱毛、红斑和局灶性结痂。

Figure 2 Fairly well-demarcated area of alopecia, erythema and focal crusting on the dorsal neck of a Himalayan cat with atopic dermatitis

继发细菌性脓皮病和马拉色菌性皮炎

Secondary bacterial pyoderma and Malassezia species dermatitis

细菌性脓皮病目前被认为是猫的常见继发性皮肤病，尤其是潜在有过敏反应，但也与全身性疾病或药物治疗引起的免疫抑制有关。目前，已发表与非过敏性疾病有关的评估有限，但猫的脓皮病可能会出现在各种自发性或医源性免疫抑制疾病。与犬一样，猫的细菌性脓皮病可能会出现多种皮肤病变，包括脱毛、红斑、皮屑、丘疹、结节性丘疹（粟粒性皮炎）、糜烂、溃疡和结痂。病变分布通常是多灶性，常见感患病区域为面部（图3）、颈部、躯干腹部和四肢。猫很少发生表现为结节性和瘘道病变的深层脓皮病。

Bacterial pyoderma is now recognised as a common secondary skin disease in cats, particularly with underlying hypersensitivity，but is also associated with immunosuppression from systemic disease or from drug therapies.Limited assessment of non-allergic disease associations is published to date, but pyoderma in cats is likely to occur with a broad range of naturally occurring or iatrogenically induced immunosuppressive conditions. As in dogs, bacterial pyoderma in cats may present with a wide variety of skin lesions, including alopecia, erythema, scaling, papules, crusted papules (miliary dermatitis), erosions, ulceration and crusting. Distribution is usually multifocal, with the face (Figure 3), neck, ventral trunk and limbs being commonly affected areas.Deep pyoderma occurs rarely in cats, presenting as nodular and draining lesions.

图3一只家养短毛猫继发细菌性脓皮病引起的不对称界限清晰的脱毛、红斑和轻度局灶性结痂，位于鼻平面背侧和邻近面部皮肤。

Figure 3 Asymmetrical well-demarcated region of alopecia, erythema and mild focal crusting involving the dorsal nasal planum and adjacent facial skin, due to secondary bacterial pyoderma in a domestic shorthair cat

与细菌性脓皮病相比，猫的马拉色性皮炎少见。尽管早期的报道表明与全身性疾病的关系更大，包括猫免疫缺陷病毒（FIV）感染、胸腺瘤和副肿瘤性脱毛，但是现在也认为马拉色菌感染与潜在过敏反应有关。它可以表现为局灶、多灶或偶见全身性的脱毛、红斑、油腻棕色皮屑、皮肤毛色变红棕色。面部、下巴、耳廓、颈腹侧、躯干腹部、指间区和爪部皱褶是最常见的患病部位。

Malassezia dermatitis is less common in cats than bacterial pyoderma. Although early reports suggested a greater association with systemic diseases, including feline immunodeficiency virus (FIV) infection, thymoma and paraneoplastic alopecia, Malassezia infection is now also well recognised with underlying hypersensitivities. It can present with localised, multifocal or occasionally generalised areas of alopecia, erythema, greasy adherent brown scaling, and red-brown skin discolouration. The face, chin, pinnae, ventral neck, ventral trunk, interdigital areas and claw folds are the more commonly affected sites.

出现这两种感染时，存在瘙痒可能与潜在疾病无关。先进行抗菌治疗对解决继发感染很重要，并且持续控制管理潜在疾病是关键。

With both infections, pruritus may be produced independently of the underlying disease. Initial antimicrobial therapies are important to resolve many established secondary infections, and management of the underlying problem is crucial to ongoing control.

皮肤病表现为明显脱毛、红斑和/或皮屑，是猫中最常见的皮肤表现。

Skin disease with prominent alopecia, erythema and/or scaling is among the most common cutaneous presentations in cats.

蠕形螨病（猫蠕形螨）

Demodicosis (Demodex cati)

猫经典蠕形螨病是毛囊内猫蠕形螨，在猫中很罕见。然而，它是潜在的全身性疾病或药物治疗引起免疫抑制的特征，在糖尿病、FIV、猫白血病病毒（FeLV）感染、系统性红斑狼疮（SLE）、猫血支原体感染、肾上腺皮质功能亢进和全身或外用吸入性（氟替卡松）类固醇治疗中已有报道。 相比之下，戈托依蠕形螨是最近才出现的蠕形螨，引起非典型的蠕形螨病表现。与一些没有免疫抑制的健康猫接触，会引起传染性瘙痒性皮肤病。

Classical demodicosis, associated with the follicular mite Demodex cati, is rare in cats. However, it is a hallmark for immunosuppression from underlying systemic disease or drug therapies, and has been reported with diabetes mellitus, FIV , feline leukaemia virus (FeLV) infection, systemic lupus erythematosus( SLE), Mycoplasma haemofelis infection, hyperadrenocorticism, and systemic or topical inhalant (fluticasone) steroid therapy.In contrast, Demodex gatoi is a more recently emerging demodex mite that causes an atypical presentation of demodicosis, producing contagious pruritic dermatitis in some exposed healthy cats without concurrent immuno-suppression.

猫蠕形螨引起的蠕形螨病常表现为局灶性界限清晰的脱毛斑（图4），但也会发生全身性疾病。瘙痒通常是轻微到无。皮肤病通常对杀螨治疗有效，在许多猫中相对不关注，更需重视潜在疾病。

Demodicosis from D cati often presents with localised regions of well-demarcated alopecia (Figure 4), but generalised disease also occurs. Pruritus is typically mild to absent. The skin disease is usually readily responsive to miticidal therapy, and relatively inconsequential in many cats, with the underlying disease raising more concern.   

图4 猫蠕形螨导致的蠕形螨病引起的鼻平面旁不对称边界清晰的脱毛区。背侧小面积糜烂是皮肤刮片检查导致的。

Figure 4 Well-demarcated asymmetrical region of alopecia beside the nasal planum due to demodicosis (Demodex cati). The small area of erosion dorsally was produced during skin scraping

副肿瘤表现

Paraneoplastic presentations

胸腺瘤相关的表皮剥脱性皮肤病

Exfoliative dermatosis associated with thymoma

已报道全身性皮屑和斑块状脱毛，伴有或不伴红斑，在胸腺瘤患猫中罕见。皮屑通常很明显，通常是大的白色薄片。皮肤变化可能先于嗜睡、厌食和体重减轻等全身症状。通常不瘙痒，但有报道并发马拉色菌皮炎时会引起轻度瘙痒。皮肤活检组织病理学检查可提供支持性证据（界面性皮炎），然而，类似的临床和组织学检查在非胸腺瘤病例中已有报道。                                                               

Generalised scaling and patchy alopecia, with or without erythema, is reported rarely in cats with thymoma. Scaling is typically prominent, often in large white flakes. Skin changes may precede systemic signs of lethargy, anorexia and weight loss.Pruritus is usually absent, although mild pruritus associated with concurrent Malassezia dermatitis is reported. Histopathology from skin biopsies may provide supportive evidence (interface dermatitis); however, similar clinical and histological findings are reported to be unassociated with thymoma.

通过手术成功切除肿瘤，皮肤病变得以改善，在没有影像学检查支持是胸腺瘤的病例中，使用了糖皮质激素和/或环孢素治疗（多数病例）或者自愈（一只猫）。

Resolution of skin lesions has occurred with successful surgical excision of tumours, and in the absence of radio graphic evidence of thymoma is reported with glucocorticoid and/or ciclosporin therapy (multiple cases) or spontaneously (one cat).

副肿瘤性脱毛

Paraneoplastic alopecia

猫副肿瘤性脱毛被认为是一种独特的皮肤表现，通常老年猫患病（> 10岁）。猫表现出明显的脱毛，皮肤特征平坦光亮（图5）。不易梳理的脱毛区域可能有附着的棕色皮屑。脱毛通常会在数周内迅速发展，从腹部开始，逐渐到腿部和面部，大量毛发脱落（图6）。背部通常正常，但毛发可能变暗变稀疏。

Feline paraneoplastic alopecia is recognised as a unique cutaneous presentation, typically affecting older cats (>10 years). Cats present with prominent alopecia and characteristic smooth shiny skin (Figure 5). Less readily groomed alopecic regions may have adherent brown scale. The alopecia is typically rapidly progressive over a few weeks, with loss of large clumps of hair, starting from the ventrum and progressing to the legs and face (Figure 6). The dorsum is normally spared, but hair may be dull and thinning.

图5一只副肿瘤性脱毛患猫机体腹侧、四肢和头部呈现大面积光滑、有光泽的完全脱毛区。

Figure 5 Extensive smooth, shiny, complete alopecia on the ventral body, limbs and head of a cat with paraneoplastic alopecia

图6一只副肿瘤性脱毛患猫。 (a)边界不清的脱毛区，位于面部吻侧和眼周区域，伴鼻平面局灶性稀疏而有光泽的皮肤和唇部吻侧糜烂。(b)前肢的部分至完全脱毛和皮肤局部有光泽。

Figure 6 Paraneoplastic alopecia in a cat. (a) Poorly demarcated region of alopecia involving the rostral face and periocular areas, with focal thinner shiny skin on the nasal planum and erosions on the rostral lips. (b) Partial to complete alopecia and focal characteristic shiny skin on the front feet.

这一表现最常见于胰腺癌，但在肝肿瘤（胆管癌、肝细胞癌、肝脾浆细胞瘤）上也有报道，还有一例发生在转移性肠癌。大多数猫有转移性疾病，经常累及肝脏。皮肤变化的发病机制尚不清楚。皮肤变化的发病机制尚不清楚。预后谨慎，许多猫在脱毛8周内死亡或被安乐死。

This presentation is most frequently associated with pancreatic carcinoma, but has also been reported with hepatic neoplasias (bile duct carcinoma, hepatocellular carcinoma, hepatosplenic plasma cell tumour) and, in one case, with metastasizing intestinal carcinoma.The majority of cats have metastatic disease, often involving the liver. The pathogenesis of the skin changes is unknown. The prognosis is guarded; many cats die or are euthanased within 8 weeks of developing alopecia.

皮肤活检的组织病理学检查常出现特征性变化（毛囊萎缩伴毛球缩小、紧致的正角化性角化过度或角化不全性角化过度），然而，对全身性疾病的评估通常更为谨慎。

Characteristic changes (follicular atrophy with miniaturisation of hair bulbs, compact orthokeratotic and parakeratotic hyperkeratosis) are frequently present on histopathology from skin biopsies; however, evaluation of systemic disease is often more prudent.  

其他副肿瘤表现

Other paraneoplastic presentations

在人医中，已发现有超过30种与内科恶性肿瘤相关的非肿瘤性皮肤病，目前所描述的兽医综合征的表现是不典型的，在猫（和犬）中偶见。虽然常见各种形式的脱毛，但是各种病变都能可能发生，可能瘙痒或者不瘙痒。不明原因的或非典型的脱毛或皮肤病，特别是在老年猫或全身不适的猫中，都可能是内科肿瘤病的表现。

Over 30 non-cancerous dermatoses associated with internal malignancy are recognised in humans, and presentations not classical for currently described veterinary syndromes occur sporadically in cats (and dogs). Alopecia in various forms is a common change, although a variety of lesions may occur, and pruritus may be present or absent. Unexplained or atypical alopecia and/or dermatitis, especially in an older or systemically unwell cat, could be a manifestation of internal neoplasia.

利什曼病

Leishmaniosis

利什曼病在全国流行地区通常发生的人和犬中。 尽管猫感染不太常见，但人们越来越认识到，猫可能在流行病学中起重要作用。皮肤改变包括丘疹、结节、溃疡和结痂，但也会出现轻微红斑、脱毛和皮屑。头部似乎是最易患病部位。

Leishmaniosis occurs commonly in humans and dogs in endemic regions of the world. Although feline infections are less common, they are increasingly recognised, and cats may play an important epidemiological role. Skin changes include papules, nodules, ulceration and crusting, but more subtle erythema, alopecia and scaling presentations also occur. The head appears to be the most affected region.

诊断和治疗通常很复杂，尽管已经报道了猫成功治愈的案例，但在疾病流行区域，仍更倾向于采取预防策略。（有关进一步的讨论，请参阅随附的关于传染病皮肤表现的文章。）

Diagnosis and treatment is often complex, and although successful management of feline cases is reported, prevention strategies are favoured in endemic regions. (See accompanying article on cutaneous manifestations of infectious disease for further discussion.)

系统性红斑狼疮

Systemic lupus erythematosus

猫系统性红斑狼疮的病例报告和传闻很少，通常是细微的皮肤病变，包括皮屑、脱毛、糜烂和结痂。与其他物种的系统性红斑狼疮一样，猫可能会出现全身乏力、发热、食欲减退以及相关全身性疾病（肾脏、神经肌肉、造血和/或眼部）的各种症状表现。皮肤组织病理学检查可提供界面性皮炎的证据支持，诊断依赖于充足一致的多器官疾病表现。

Scant case reports and anecdotal descriptions of feline SLE recount variable, typically subtle skin lesions, including scaling, alopecia, erosions and crusting. As with SLE in other species, cats may present with malaise, pyrexia, reduced appetite and variable signs of associated systemic (renal, neuromuscular, haematopoietic and/or ocular) disease. Skin histopathology may provide supportive evidence of interface dermatitis, and diagnosis is reliant on sufficient consistent evidence of multi-organ disease.

FeLV相关性巨细胞皮肤病

FeLV-associated giant cell dermatitis

已报道与FelV感染有关的一些罕见表现是，皮屑、脱毛、结痂性皮炎，伴有一些瘙痒。通常头部患病（耳廓、耳前、口周），伴不同程度足部、爪垫和其他皮肤粘膜区域患病。皮肤活检的组织病理学检查显示表皮层和毛囊表皮细胞的气球样变特征（巨细胞）。猫伴有不明原因、治疗效果不佳或非典型性瘙痒性皮肤病，则鉴别诊断中FeLV感染可能性增加。（有关感染性疾病的皮肤表现的进一步讨论，请参阅随附的文章。）

A very rare scaling, alopecic and crusting dermatitis, with some pruritus, is reported associated with FeLV infection. The head is generally affected (pinnae, preauricular, perioral), along with variable involvement of feet, footpads and other mucocutaneous areas. Histopathology changes in skin biopsies reveal characteristic ballooning of epidermal and follicular epithelial cells (giant cells). FeLV infection in a cat with unexplained, poorly responsive or atypical pruritic dermatitis may raise suspicion for this differential. (See accompanying article on cutaneous manifestations of infections disease for further discussion.)

尽早发现皮肤变化是提示存在全身性疾病，可提高患病动物的预后。

Early recognition of some skin presentations as markers of systemic disease aids optimal patient outcomes.

诊断方法：脱毛、红斑、皮屑和/或局灶性结痂 Diagnostics: alopecia, erythema, scaling and/or focal crusting 猫的这种皮肤病表现可能存在许多鉴别诊断，其中过敏性皮肤病和一些感染性皮肤病（皮肤癣菌病、继发细菌和酵母菌感染）最为常见。诊断过敏和感染性皮肤病需要了解关键特征和/或检查，以及识别与潜在全身疾病等不常见病因相关的线索，这对准确和早期诊断至关重要。 Many differentials are possible for this skin disease presentation in cats, with hypersensitivities and some infectious dermatoses (dermatophytosis, secondary bacterial and yeast infections) most common. Knowledge of key features and/or tests required to diagnose hypersensitivities and infectious dermatoses, along with recognition of clues that increase the likelihood of the less common causes such as underlying systemic disease, are pivotal to accurate and early diagnosis with this presentation. 病变分布可能引起对某些疾病的怀疑；例如，耳廓、爪垫、乳头和面部病变，增加对落叶型天疱疮的怀疑，而耳廓、面部和不对称病变怀疑皮肤癣菌病。虽然皮肤表面细胞学检查是快速、准确识别浅表细菌和酵母菌感染的最有用的一项检查方法，但是对适当的经验性治疗（例如，单独使用抗生素或抗真菌治疗）的效果也可以确诊。虽然胶带粘帖法和/或皮肤浅刮常能快速检查到猫毛螨、耳螨和戈托依蠕形螨，但是有时很少见且很难检测到。皮肤深刮能有效检测到猫蠕形螨。梳理被毛收集皮屑和碎片，使用粪便漂浮法可以帮助检测稀疏的螨虫（如姬螯螨）。 Lesion distribution may raise suspicion for certain diseases; for example, pinnal, footpad, nipple and facial lesions raise suspicion for pemphigus foliaceus, while pinnal, facial and asymmetrical lesions raise suspicion for dermatophytosis. Skin surface cytology is the most useful single test for quickly and accurately identifying superficial bacterial and yeast infections, although response to appropriate treatment trials (eg, antibiotic or antifungal therapies alone) may also confirm a diagnosis. Fur mites, Otodectes species and D gatoi are often readily detected on adhesive tape impressions and/or superficial skin scrapings, although will sometimes be sparse and difficult to detect. Deep skin scrapings should reliably detect D cati.Scale and debris from coat combings may be examined using faecal flotation solution to help detect sparse mites (eg, Cheyletiella). 所有感染性病因的皮肤病都可能是发生了免疫抑制的结果。因此，对于任何感染性皮肤病，筛选可能的感染源和考虑潜在免疫力降低的可能性都是很重要的。 All infectious causes of skin disease may occur as a consequence of immunosuppression. Thus screening for the likely source of infection, and considering the likelihood of underlying immunocompromise in that scenario, is important with any infectious dermatosis. 皮肤活检通常对猫脱毛、红斑、皮屑和/或局灶性结痂没有帮助，因为它们不能明确诊断过敏，或者通常对感染性疾病的检查不是必要的或不完全敏感。但皮肤活检对某些皮肤病（如落叶型天疱疮）的诊断很重要，并可能为某些全身性疾病（如副肿瘤性脱毛）提供有用的组织病理学检查证据，在考虑进行皮肤活检之前，要先对整体健康进行谨慎评估（例如实验室血液和尿液检查、影像检查）。 Skin biopsies are often not helpful for the cat presenting with alopecia, erythema, scaling and/or focal crusting, as they are not clearly diagnostic for hypersensitivities, or usually necessary or completely sensitive for infectious differentials. Although they are important for diagnosis of some dermatoses (eg, pemphigus foliaceus) and may provide helpful histopathology for some systemic diseases (eg, paraneoplastic alopecia), evaluation of general health (eg, laboratory blood and urine testing, body imaging) is often prudent prior to considering skin biopsies for this presentation.

常见皮肤学诊断方法 <皮肤浅刮（戈托伊蠕形螨、姬螯螨、耳螨） <皮肤深刮（猫蠕形螨） <胶带粘贴法（细菌性脓皮病、马拉色菌性皮炎、皮肤癣菌病、姬螯螨） <毛发检查（皮肤癣菌病） <真菌培养（根据病史、可能的接触史或病变表现[如耳廓、不对称推荐检查）

Commonly indicated skin diagnostics for this presentation < Superficial skin scraping (D gatoi, Cheyletiella, Otodectes) < Deep skin scraping (D cati) < Tape impressions (bacterial pyoderma, Malassezia dermatitis, dermatophytosis, Cheyletiella) < Trichogram (dermatophytosis) < Fungal culture (if suggested by history, possible exposure or lesional clues [eg, pinnae, asymmetry])

皮角

Cutaneous horns

皮角（圆锥形或圆柱状的角蛋白）很罕见，虽然常在爪垫有报道，但在鼻平面和眼睑也偶见。 它们可能与FeLV感染（多发性皮角）有关，或可能仅构成局部皮肤病（单个或多个，由乳头状瘤病毒、光化性角化病、原位鳞状细胞癌、鳞状细胞癌、角化棘皮瘤引起）。有皮角的猫必须筛查FeLV疾病。

Cutaneous horns –conical or cylindrical collections of keratin –are rare, and most often reported on the footpads, although they occasionally arise on the nasal planum or eyelids. They may be associated with FeLV infection (multiple horns), or may constitute localised cutaneous disease only (single or multiple, due to papillomavirus, actinic keratosis, squamous cell carcinoma [SCC] in situ, SCC, keratinising acanthoma). Screening for FeLV status is warranted in cats presenting with cutaneous horns.

肝皮综合征（坏死性游走性红斑、代谢性表皮坏死）

Hepatocutaneous syndrome (necrolytic migratory erythema, metabolic epidermal necrosis)

在犬上偶见肝脏或胰腺疾病的皮肤表现，有一例在猫上报告过。这只猫出现了疼痛的结痂和爪垫大量皮屑，这是在犬也会出现的症状。同时出现全身性疾病（虚弱、厌食、呕吐）。检测到产生胰高血糖素的肝癌。

A cutaneous presentation of liver or pancreatic disease occurs sporadically in dogs, and one case has been reported in a cat.This cat presented with painful crusting and excessive scaling of footpads, characteristic of the syndrome in the dog. There were concurrent signs of systemic illness (weakness, anorexia, vomiting). A glucagon-producing hepatic carcinoma was detected.

药物反应

Drug reactions

猫的皮肤药物反应有很多，包括荨麻疹/血管性水肿、伴有或不伴有皮屑的红斑、斑丘疹病变、结节、皮肤萎缩和瘙痒引起的自损性病变。已经涉及到许多不同的药物，包括抗生素（β-内酰胺、磺胺类）、抗真菌药（灰黄霉素）、外用药（皮肤和耳部）和预防性疫苗。全身症状包括萎靡、发热和厌食，可能有明显表现。近期用药史是任何皮肤病患病动物临床史总结的一个有价值的部分，特别是疾病表现不典型时。药物反应的明确诊断需要停药和刺激发试验，这对于严重症状表现的病例有困难。

A wide range of cutaneous drug reactions are sporadically reported in cats, including urticaria/angioedema, erythema with or without scaling, maculopapular lesions, nodules, skin atrophy and self-trauma lesions from pruritus. Many different drugs have been implicated, including antibiotics (β-lactams, sulphonamides), antifungals (griseofulvin), topical medications (skin and ear) and prophylactic vaccines. Systemic signs including malaise, pyrexia and anorexia may be evident. Recent drug administration is a valuable part of clinical history summation for any patient presenting with skin disease, particularly when the presentation is not typical for recognised diseases. Definitive diagnosis of a drug reaction requires withdrawal and provocation testing, which is problematic for severe presentations.

最近的药物管理是猫咪皮肤病临床史总结的一个有价值的部分，特别是对非典型的表现

Recent drug administration is a valuable part of clinical history summation for a cat with skin disease, particularly with atypical presentations.

宇智波、麦兜