本帖最后由 巴哥控 于 2019-7-13 23:58 编辑
犬肢端舔舐性皮炎的诊断和治疗（1） Diagnosis and Treatment of Canine Acral Lick Dermatitis 作者:Amy K. Shumaker, DVM
翻译：刘宏锋 校对：刘欣
关键词 •肢端舔舐性皮炎 •强迫症 •犬 关键点 •肢端舔舐性皮炎是一种常见的、令人沮丧的疾病，其特征是不断的舔舐行为导致溃疡性、坚硬的斑块。 •该疾病是由潜在原发病因引起的(过敏疾病、骨科或神经系统疾病、传染病、寄生虫病、肿瘤或精神疾病)。 •继发性感染通常使疾病复杂化，需要适当处理。 •行为问题(可能是原发或并存病因）可能需要通过行为改变和精神药理学药物干预来治疗。 KEYWORDS
•Acral lick dermatitis •Obsessive-compulsive disorder •Dog
KEY POINTS
•Acral lick dermatitis is a common, frustrating disease characterized by incessant licking
behavior resulting in ulcerative, firm plaques.
•The disease is caused by underlying primary triggers (allergic disorders, orthopedic or
neurologic disorders, infectious disease, parasitic diseases, neoplasia, or a psychogenic
disorder).
•Secondary infections commonly complicate the disorder and need to be appropriately
addressed.
•A behavioral component (either primary or contributory) may need to be treated by behavioral modification and potentially psychopharmacologic drug interventions.
介绍 INTRODUCTION
犬肢端舔舐性皮炎 (ALD)，也称为肢端舔舐性肉芽肿或肢端瘙痒结节，在犬上是一种常见的疾病，本病在一项559例皮肤病学病例研究中的发病率为2.9%。由于不断的舔舐行为，这可能是一种令人沮丧的疾病，会影响患犬和主人的生活质量。ALD已被发现在牛、各种动物园、外来动物以及人类身上。尽管这种疾病很常见，但关于这种令人沮丧的疾病的诊断和治疗的报道却很少。大多数的出版物提到的治疗都集中在行为矫正或行为矫正药物上。虽然许多病例中，心理因素可能最终在疾病的发展过程中发挥作用，但潜在的原发疾病往往是诱因，大多数皮肤科医生怀疑过敏是主要的致病因素。在这两种情况下，继发性细菌感染往往与ALD有关，并继续持续导致瘙痒和舔舐行为。成功地治疗ALD需要了解这种情况的多因素原因。 Acral lick dermatitis (ALD), also referred to as acral lick granuloma or acral pruritic nodule, is a common disease in dogs, occurring in 2.9% of 559 dermatologic cases in one study.1 Caused by incessant licking behavior, this can be a frustrating disorder, having an impact on the quality of life of the patient as well as the owners. ALD has been described in cattle, various zoo and exotic animal species, as well as humans.2–5 As common as this disorder is, there has been little published on the diagnosis and treatment of this frustrating disease. Most publications have focused on behavioral modification or behavior-modifying drugs for treatment. Although many cases may have a psychogenic component that ultimately plays a role later in the disease process, an underlying primary organic disease is often the inciting trigger, with an allergic disorder being the leading causative factor suspected by most dermatologists. In either case, secondary bacterial infections often are associated with ALD6 and continue to perpetuate the pruritus and licking behavior. Successful management of ALD requires an understanding of the multifactorial cause of this condition.
描述 PRESENTATION
ALD在任何年龄的犬均可发病，关于典型的发病年龄有相互矛盾的报道，其中一项研究对31只年龄在1至12岁之间的犬进行了研究，中位发病年龄为4岁。大型犬类更容易发病，据报道，杜宾、大丹犬、拉布拉多猎犬、金毛猎犬、德国牧羊犬、拳师犬、魏玛犬和爱尔兰赛特犬是易感犬种。病变表现为边界清楚、隆起、无毛、硬质的糜烂至溃疡性斑块，常位于肢体远端的背侧，但也有其他部位的报道。Shumaker和他的同事们发现雌性犬的易感倾向，虽然统计学上不显著，但这与其他报告没有性别易感性或雄性易感的报告形成了对比。当只有单侧病变时，左腕背侧区域是主要位点。 ALD can affect dogs of any age, and there are conflicting reports regarding typical age of onset, with one study of 31 dogs having an age range of 1 to 12 years and median age of onset of 4 years.6 Large breeds tend to be more affected, with the Doberman pinscher, Great Dane, Labrador retriever, golden retriever, German shepherd, boxer, Weimaraner, and Irish setter as reported predisposed dog breeds.7,8 Lesions appear as well-circumscribed, raised, alopecic, indurated, often erosive to ulcerative plaques on the cranial distal extremities but have been reported at other sites. Shumaker and colleagues,6 noted a trend toward a female predisposition, although not statistically significant, which was found to be in contrast with other reports in which no predilection or a male sex predilection was reported. When only a unilateral lesion was present, the cranial left carpal region was predominantly affected.
发病机理 PATHOGENESIS
肢端舔舐病变的形成往往是多因素的，随着时间的推移而演变。经常舔舐发病部位，最初可能导致毛发损伤，可能伴随红斑、结垢、结痂，然后发展到脱毛和糜烂。表皮深层、真皮层和感觉神经纤维的暴露会引起瘙痒，并使痒和舔的周期持续下去。随着时间的推移，出现明显的真皮纤维化和表皮增生，形成斑块样病变。毛囊炎和疖病经常出现，是舔舐行为(压迫毛发深入病变)和继发性感染的结果。在许多情况下，汗腺炎和毛上汗腺扩张与破裂可能存在。毛囊炎、疖病、游离角质和腺体分泌物破裂会引起异物反应，进入持久的恶性循环。 The creation of an acral lick lesion is often multifactorial, with the lesion evolving over time. Frequent licking at an affected site initially may result in a haired lesion with underlying erythema, scaling, and crusting, progressing to alopecia and erosion. Exposure of the deeper layers of the epidermis, dermis, and the sensory nerve fibers elicits pruritus and perpetuates the itch-lick cycle. With chronicity, marked dermal fibrosis and epidermal hyperplasia develop, creating the plaque appearance of the lesion. Folliculitis and furunculosis are often present and are a consequence of both the licking behavior (hairs forced deep into the lesion) and secondary infection. In many cases, hidradenitis and epitrichial gland dilatation and rupture may be present.6 The presence of folliculitis, furunculosis, free keratin, and ruptured glandular secretions create foreign body reactions, additionally perpetuating the cycle.
与耳病一样，ALD可被视为有原发病因和持久病因。尽管原发病因是暂时的，例如过敏反应，但其作为启动因素开启了ALD的发展，而持久病因作为持续驱动力促使舔舐发病区域。原发病因包括过敏性疾病(异位性疾病、皮肤食物不良反应、跳蚤过敏性皮炎);细菌性或真菌性疾病(包括皮肤癣菌病)、寄生虫病(蠕形螨病、疥螨)、外伤、关节疾病、异物、肿瘤、神经病或激素失调。原发性精神障碍包括刻板行为或强迫症(OCD)、焦虑、无聊、寻求关注或有压力。持久病因包括因舔舐和疖病导致的继发细菌感染、角质异物，骨髓炎或骨膜炎等骨改变，以及发展出继发性强迫症/后天行为。 As in ear disease, ALD can be viewed as having primary and perpetuating factors. The primary factors are the initiating cause for the development of the ALD, with the perpetuating factors being a continuing driving force to lick the affected areas, even if the primary factor is transient, such as an allergic flare. Primary organic factors include allergic disorders (atopic disease, cutaneous adverse food reaction, flea allergic dermatitis); bacterial or fungal disease (including dermatophytosis), parasitic disorders (demodicosis, scabies), previous trauma, joint disease, foreign body, neoplasia, neuropathy, or hormonal disorders. Primary psychogenic disorders include stereotypic or obsessive-compulsive disorder (OCD), anxiety, boredom, attention seeking, or stress. Perpetuating factors include secondary bacterial infections, keratin foreign bodies as a result of licking and furunculosis, bony changes such as osteomyelitis or periostitis, and development of a secondary compulsive disorder/learned behavior.
诊断性病情检查 DIAGNOSTIC WORK-UP
与大多数皮肤病一样，需要有一份完整的病史，以最好地阐明哪些原发病因可能会触发舔舐行为，并量身定做诊断和治疗项目。表1回顾评估ALD患者时要考虑的问题，以便更好地指导诊断工作，还可能缩短原发病因。 As with most dermatologic diseases, a thorough history is necessary to best elucidate which primary factor may be involved in triggering the licking behavior and to tailor the work-up and treatment. Box 1 reviews questions to consider when evaluating patients with ALD to better direct the diagnostic work-up and perhaps shorten the list of possible primary triggers.
表1 对肢端舔舐性皮炎病例的宠主进行病史调查的问题 过敏症： 犬在其他时候是否有瘙痒表现(舔/咀嚼/摩擦/抓挠)? 过去或现在有无任何皮肤病史或耳炎病史? 有无任何支持是食物过敏导致的胃肠道病史? 如果病变持续一年或更长时间，是否出现季节性症状或季节性加重? 骨科手术/神经系统疾病： 患肢有无外伤病史? 是否有关节痛的表现(如跛行)? 行为学疾病： 是否有其他同时出现的行为症状(如分离焦虑、噪音恐惧症、追尾行为)会支持原发性强迫症/强迫症行为? 犬的生活环境有什么重大的变化吗(最近搬家了，新朋友/婴儿/宠物被带回家)? 最近是否有宠物犬死亡(家庭成员或宠物犬的伴侣)? 犬进行了多少运动(散步、玩耍)和社交?各进行多长时间？ 犬被关在室内还是室外? 这只犬在白天单独呆多久? 犬被关在(板条箱、犬舍/犬窝)里吗? 家里还有其他动物吗?与其他动物有什么关系? 什么样的玩具可供犬使用? |
彻底的皮肤病检查可能会发现身体其他部位发病的证据，表明是过敏性疾病。常与过敏有关的检查中经常漏诊的部位是爪腹侧趾间。即使在病例没有明显舔爪子的情况下，这个区域也可能发红。耳朵也应该作为皮肤病检查的一部分进行评估，在看起来无症状的犬中偶尔会发现问题。 A thorough dermatologic examination may reveal evidence of other areas of the body being affected, suggesting an allergic disorder. A frequently missed area on examination often involved in allergic disorders is the ventral interdigital aspects of paws. This region can be erythemic even in cases in which clients do not note obvious paw licking. Ears should also be evaluated as a part of every dermatologic examination, with disease occasionally noted in apparently asymptomatic dogs.
应进行骨科检查，以评估任何潜在的关节疾病的指征。如果病变覆盖了一个关节，通过屈曲/伸展将该关节放置在关节上，可能会暴露出骨裂的存在或导致可诱发的疼痛。对相对关节应进行评价，以供比较。X线片可以帮助评估是否有关节炎或其他创伤的迹象。X线片上发现骨髓炎或骨膜炎这些变化时，可能提示预后不良。 An orthopedic examination should be performed to evaluate for any indication of underlying joint disease. If the lesion overlies a joint, placing that joint through flexion/ extension may unveil the presence of crepitus or result in elicitable pain. The opposite joint should be evaluated for comparison. Radiographs can be helpful in evaluating for presence of arthritis or other signs of trauma. Osteomyelitis or periostitis may be detected on radiographs; presence of these changes can potentially be a poor prognostic indicator for satisfactory resolution.8
如果有可能出现神经功能异常，或者有过去的外伤史(例如，被汽车撞伤)，则应进行神经学检查和病情的检查。针刺肌电图(EMG)和神经传导速度研究可能有助于神经传导异常的鉴别。在一项评估三环类抗抑郁药物治疗ALD的研究中，16只犬中有9只(56%)的肌电图异常涉及病变的同侧(或双侧)。本研究中的几只犬曾有创伤史。尽管在大多数情况下并不实用或可能产生有用的信息，但在有创伤史的情况下，肌电图研究可能有助于鉴别潜在的神经根病变或神经病变。 In cases showing possible neurologic abnormalities or that have a past history of trauma (eg, hit by car), a neurologic examination and work-up should be performed. Needle electromyography (EMG) and nerve conduction velocity studies may be useful in identifying abnormalities in nerve conduction. In one study evaluating tricyclic antidepressants for treatment of ALD in which EMG studies were being performed as part of the work-up, 9 of 16 dogs (56%) had EMG abnormalities involving the same side (or sides if bilateral) of the lesion.9 Several of the dogs in this study did have prior history of trauma. Although not practical or likely to yield useful information in most cases, in those cases with a history of trauma, an EMG study may be useful in identifying an underlying nerve root lesion or neuropathy.
实验室检查(全血细胞计数、生化、甲状腺套组、尿液分析)可以帮助排除所有可能是潜在诱因的内分泌疾病。应该进行评估皮肤刮片和拔毛检查，以确定是否有螨虫。从病变内和周围采集毛发样本，在皮肤癣菌培养基上进行培养，以评估是否存在皮肤癣菌。Mackenzie牙刷技术也可以用来从病变处获得一些皮屑、结痂和毛发用于培养。皮肤癣菌培养需生长21天，每天监测平皿的生长和培养基的颜色变化。任何可疑的菌落都应该进行镜检，以识别大分生孢子，而不是仅仅根据颜色变化，因为腐生真菌生物也可以改变培养基的颜色，虽然这种颜色变化通常发生在生长后。临床医生可以将不确定的皮肤真菌压片送检实验室进行显微镜鉴别。或者，头发和皮屑样本可以提交给IDEXX进行皮肤真菌RealPCR测试，该测试可以检测更常见的皮肤真菌物种的DNA是否存在，通常在送检后3天内出结果。 Laboratory work (complete blood count, biochemistry, thyroid profile, urinalysis) can be helpful in ruling out any endocrinopathies that may be an underlying trigger. Skin scrapings and hair plucks should be performed to evaluate for presence of mites. Hair samples from within the lesion and the periphery can be obtained for culture on dermatophyte test medium to evaluate for presence of dermatophytes. The Mackenzie toothbrush technique can also be used to acquire some scale, crust, and hairs from the lesion for plating.10 Dermatophyte cultures should be allowed to grow for 21 days with daily monitoring of the plate for growth and color change of the medium. Any suspicious colonies should be evaluated microscopically to identify macroconidia and not based solely on color change because saprophytic fungal organisms can also change color on the media plates, although this color change usually occurs after growth. The plate can also be submitted to a reference laboratory for identification for clinicians who are unsure or uncomfortable about identifying dermatophytes microscopically. Alternatively, hair and scale samples can be submitted to IDEXX for a Dermatophyte RealPCR test, which tests for the presence of DNA of the more common dermatophyte species, with results typically available within 3 days of submission.
应进行细胞学检查以评估继发性感染的存在。理想情况下，应挤压病灶深层组织的液体。细胞学不仅有助于确认感染，而且有助于监测后续治疗的反应。应记录有无感染性有微生物和炎症细胞，以便进行顺序比较。然而，如果基于细胞学发现的经验抗生素治疗效果较差，则应进行培养，因为在先前的研究中发现细胞学与浅表和深层组织培养结果相关性较差。细菌培养对指导抗菌治疗的决策是有用的。然而，对于ALD病变，组织活检培养应与表面拭子培养相反，因为浅层和深层组织菌种相关性较差，两者之间仅有36%的一致性。应该选择一个没有溃疡的部位，无菌准备去除任何表面污染物，以及使用6毫米穿孔机活检获得的组织。然后将组织放入Port-A-Cul口管或含有少量无菌、非抑菌生理盐水的无菌管中，然后送检。在商业实验室对组织进行浸渍培养。 Cytology should be performed to evaluate for the presence of secondary infection. Ideally, the lesion should be squeezed to express fluid from the deeper tissue. Cytology is not only useful in helping to identify infection but can aid in monitoring response to treatment at subsequent visits. Presence or absence of infectious organisms and inflammatory cells should be recorded for sequential comparisons. However, if there is poor response to empirical antibiotic therapy based on cytologic findings, culture should be performed because cytology was found to correlate poorly with superficial and deep tissue culture results in a prior study.6 Bacterial cultures are useful in guiding decisions on antimicrobial therapy. However, in the case of ALD lesions, tissue culture by biopsy should be submitted as opposed to a swab sample from the surface because there was poor correlation between superficial and deep tissue isolates, with only 36% agreement between the two.6 A nonulcerated site should be selected, sterilely prepped to remove any surface contaminants, and tissue obtained using a 6-mm punch biopsy. The tissue is then submitted in either a Port-A-Cul tube or a sterile tube containing a small amount of sterile, nonbacteriostatic saline for transfer. The tissue is
then macerated at the reference laboratory for culture.
肿瘤增生可能是ALD或长期舔舐的潜在诱因，细胞学或组织病理学评估有助于鉴别这类病变。细针穿刺可能有助于肿瘤的诊断，但并不一定排除。细胞学检查可能会发现炎症细胞、纤维细胞，可能的感染性微生物，从而支持ALD的诊断。组织病理学活检可以区分可能的肿瘤过程或潜在的真菌疾病，或进一步支持ALD的诊断。典型的组织病理学发现见表2，其中几个组织病理学特征见图1。 Neoplasia can be an underlying trigger for ALD or chronic licking, and cytologic or histopathologic evaluation can help to differentiate these lesions. Fine-needle aspiration may be helpful in aiding in diagnosis of neoplasia, but it does not necessarily rule it out. Cytology may reveal the presence of inflammatory cells, fibrocytes, and possibly infectious organisms, supporting a diagnosis of ALD. Biopsy with histopathology can differentiate between a possible neoplastic process or underlying fungal disease, or can further support a diagnosis of ALD. Typical histopathologic findings are described in Box 2, with several of these histopathologic features highlighted in Fig. 1.
表2 肢端舔舐皮炎常见的组织病理学表现 •中度到明显的，经常发病的乳头状棘皮病 •伴有渗出物的糜烂或溃疡 •偶见中性浆细胞性结痂 •角化过度 •呈垂直条纹状的真皮纤维化 •毛囊增厚和扩张 •真皮层血管周围、毛囊周围或弥漫性的淋巴细胞、中性粒细胞、巨噬细胞和浆细胞浸润 •顶浆汗腺的扩张和增厚，常有分泌物残留 •汗腺周炎和汗腺炎，偶见腺体破裂 •毛囊炎和疖病 |
图1.肢端舔舐性肉芽肿的常见组织病理学特征，包括明显的淋巴浆细胞性炎症、毛囊破裂伴游离毛发(大箭头)、汗腺和扩张毛上汗腺，伴残留的分泌物(小箭头)(H&E，原图4倍放大)。 Fig. 1. Common histopathologic features of an acral lick granuloma, including marked lymphoplasmacytic inflammation, a ruptured hair follicle with a free hair (large arrow), hidradenitis, and dilated epitrichial glands with retained secretions (small arrow) (H&E, original magnification 4).
如前所述，ALD表现出的刻板行为或强迫症，可能是原发潜在诱因。ALD被认为是人类强迫症的动物模型。在犬，强迫症被定义为不受外界影响的重复性行为，不容易被正常刺激打断或阻止。如表1所示，当试图阐明是否有心理因素在驱动ALD舔舐时，完整的病史是至关重要的。据估计，高达70%的ALD犬可能有其他与焦虑相关的症状;因此，焦虑且没有并存的过敏或骨科症状，倾向于支持心理疾病。在一项评估20只ALD患犬的研究中，这些犬都有心理上的诱因，70%的犬仅限小范围活动，64%的犬不允许呆在居室内，没有主人与犬进行日常玩耍，70%的犬从未被牵遛，所有的主人认为他们的犬有焦虑倾向，65%的犬存在非医疗触发因素(例如，宠物犬同伴死亡)。因此，这些发现强调了详细调查历史的重要性，确定犬是否生活在孤单环境中、经历压力或冲突、或表现出任何其他共病性焦虑。 As previously mentioned, ALD can manifest as a stereotypic or obsessivecompulsive disorder as the primary underlying trigger. ALD has been proposed to serve as an animal analog for human OCD.11–14 In dogs, compulsive disorders are defined as repetitive behaviors occurring out of context and are not easily interrupted or deterred by normal stimuli.15 A thorough history, as outlined in Box 1, is critical when trying to elucidate whether a psychogenic component is driving the licking in ALD. It has been estimated that up to 70% of dogs with ALD may have other anxiety-related conditions16; therefore, a comorbid anxiety disorder with lack of concurrent allergic or orthopedic symptoms would lend support to a psychogenic disorder. In an evaluation of 20 dogs presenting with ALD with psychogenic triggers, 70% were confined to small areas, 64% were not permitted to stay inside the house, none of the owners played with their dogs on a routine basis, 70% were never taken for walks, all of the owners considered their dogs to have an anxious disposition, and 65% had a nonmedical triggering component (eg, death of a canine companion) identified.17 Thus, these findings stress the importance of determining whether the dog is environmentally deprived, undergoing stress or conflict, or displaying any other comorbid anxiety disorders via a detailed, investigative history.
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发表于 2019-7-14 00:08:40
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