% 致病機轉鑑別診斷 ( 1) ( 2) (eccrine) ( a p o c c r i n e ) (apoeccrine) ( t h e r m a l s w e a t i n g ) (emotional sweat

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柯璋束
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1 家庭醫業原發性局部多汗症辛國輝1 羅玉岱2 張春瑤3,4 江怡慧4 根據2004年美國皮膚科醫學會雜誌前言集多國專家會議建議採取以下標準診斷多汗症(hyperhidrosis)在基層醫療執原發性局部多汗症局部的可見的出汗業中並不少見雖然沒有顯著病理變過多超過六個月以上且無明顯原因並化但可能造成嚴重社交情緒與職業上含以下特點至少兩項 (1)雙側相對對的困擾臨床醫師唯有熟悉診斷及各種治稱 (2)症狀會妨礙日常活動 (3)至少每療方式方能提供患者適當治療方式及相星期發生一次 (4)25歲前發病 (5)原因關建議幫助病人面對此疾病所造成之困不明(idiopathic)之多汗症的家族病擾僅以本文介紹原發性局部多汗症史 (6)病人在睡眠時會停止局部出汗 (primary focal hyperhidrosis)的診斷和治療方式定義症狀一般症狀出現在童年或青春期且會持續一生最常見在手掌腳掌以及多汗症是排汗超過體溫調節所需的腋下偶見於頭皮和面部熱或情緒的刺生理量原因不明之多汗症常侷限於身體激會造成疾病惡化腋窩多汗症患者常主某些部位因而被稱為原發性局部多汗訴皮膚濕軟和衣服濕透手汗症患者往往症主要影響腋下手掌和腳掌但確診導致恐懼握手和弄髒紙張因而造成生前須先排除為夜汗(night sweats)及更年期潮熱(menopausal hot flashes)兩項診斷之可能性活工作及人際互動上的困擾此外多汗症容易伴隨皮膚黴菌感染點狀角質層分離(pitted keratolysis)和多汗處病毒疣等皮膚疾病 1 健仁醫院家庭醫學科住院醫師 2 健仁醫院家庭醫學科主任 3 健仁醫院社區醫學科主任 4 健仁醫院家庭醫學科主治醫師流行病學和病因關鍵詞 primary focal hyperhidrosis, Botulinum toxin A, Endoscopic thoracic sympathectomy 2004年美國以郵件統計15萬個家家庭醫學與基層醫療第二十七卷第十二期 427

定義症狀一般症狀出現在童年或青春期且會持續一生最常見在手掌腳掌以及多汗症是排汗超過體溫調節所需的腋下偶見於頭皮和面部熱或情緒的刺生理量原因不明之多汗症常侷限於身體激會造成疾病惡化腋窩多汗症患者常主某些部位因而被稱為原發性局部多汗訴皮膚濕軟和衣服濕透手汗症患者往往症主要影響腋下手掌和腳掌但確診導致恐懼握手和弄髒紙張因而造成生

2 % 致病機轉鑑別診斷 ( 1) ( 2) (eccrine) ( a p o c c r i n e ) (apoeccrine) ( t h e r m a l s w e a t i n g ) (emotional sweating) (thermosensitive preoptic sweat center) 症狀評估 (gravimetry) ( e v a p o r i m e t r y ) (Illness Intrusive Rating Scale, IIRS) (Hyperhidrosis Impact Questionare, HHIQ) (Hyperhidrosis Disease Severity Scale, HDSS)( 3)150% 280% 治療 428 家庭醫學與基層醫療第十二期

t i n g ) (emotional sweating) (thermosensitive preoptic sweat center) 症狀評估 (gravimetry) ( e v a p o

3 表 1 夜汗症之鑑別診斷惡性腫瘤淋巴瘤 Non-Hodgkin's lymphoma Hodgkin's disease 固體腫瘤 (Solid tumors) Germ cell tumors Medullary carcinoma of thyroid 前列腺癌腎細胞癌其他癌症感染結核分枝桿菌肺結核 Atypical mycobacteria 細菌 Abscess Brucellosis Endocarditis 骨髓炎黴菌感染病毒 HIV infection Chronic hepatitis C 藥物 ( 見表 2) 物質戒斷酒精 Cocaine Opioids 內分泌失調 Carcinoid syndrome 尿崩症甲狀腺功能亢進症低血糖嗜鉻細胞瘤 postorchiectomy 停經神經系統疾病自主神經反射異常自主神經病變創傷性後 syringomyelia Stroke 其他家庭醫業 Chronic fatigue syndrome 常見的臉紅食品添加劑 Gastroesophageal reflux Mastocytosis 恐慌症 Rosacea 睡眠呼吸暫停 Temporal arteritis 特發性多汗症 (Idiopathic hyperhidrosis) 資料來源 : 參考資料 6 20 (Drysol) 6.25 (Xerac) () 2.5 hydrocortisone (deodorant) (O d a b a n) (B a n) R e x o n a, S e c r e t, C r y s t a l 家庭醫學與基層醫療第十二期 429

進症低血糖嗜鉻細胞瘤 postorchiectomy 停經神經系統疾病自主神經反射異常自主神經病變創傷性後 syringomyelia Stroke 其他家庭醫業 Chronic fatigue syndrome 常見的臉紅食品添加劑 Gastroesophageal reflux

4 表 2 引起流汗及潮紅的藥物抗憂鬱藥 Bupropion Selective serotonin reuptake inhibitors (SSRIs) 三環類抗憂鬱藥 Norepinephrine reuptake inhibitors (SSNRIs) 抗偏頭痛藥物 "Triptans" serotonin 5-HT (lb/ld) agonists 解熱鎮痛藥 Acetaminophen 阿司匹林非類固醇消炎藥 (NSAIDs) 膽鹼能激動劑 (cholinergic agents) Bethanecol Pilocarpine 荷爾蒙製劑 GnRH agonists Gonadorelin Goserelin Histrelin, Leuprolide Nafarelin Aromatase inhibitors Anastrazole Exemestane Letrozole Receptor blockers Flutamide SERMs(selective estrogen receptor modulators) Raloxifene Tamoxifen 降血糖藥 Insulin Sulfonylureas 擬交感神經劑 Beta-agonists Phenylephrine 其他酒精 Beta blockers Bromocriptine Calcium channel blockers Clozapine Cyclosporine Donepezil Fluvoxamine Hydralazine Interferon alfa-2b Niacin Nitroglycerin Omeprazole Opioids Protease inhibitors Ropinirole Sildenafil Tamoxifen Theophylline Tramadol 資料來源 : 參考資料 7 (gustatory -BZD (benzodiazepine) sweating) glycopyrrolate (Iontophoresis) (anticholinergic) 家庭醫學與基層醫療第十二期

Aromatase inhibitors Anastrazole Exemestane Letrozole Receptor blockers Flutamide SERMs(selective estrogen receptor modulators) Raloxifene Tamoxifen 降血糖藥 Insulin Sulfonylureas 擬交感神經劑

5 表 3 多汗症疾病嚴重程度量表 (Hyperhidrosis Disease Severity Scale) 1 分出汗從來都不顯著, 並不會干擾我的日常生活 2 分出汗是可以容忍的, 但有時會干擾我的日常生活 3 分出汗是勉強過得去, 常常干擾我的日常生活 4 分出汗是不能容忍的, 總是干擾我的日常生活資料來源 : 參考資料 8 ( ) (FDA) Botox (Botulinum toxin A, BTX-A) onabotulinumtoxina(botox) abobotulinumtoxina (Dysport) 1 Botox 3 Dysport BTX A 320 Botox 50 94% 36 (5% vs 0 ) 200 Dysport Dysport( ) BTX - A ( T2-4 ) (Endoscopic thoracic sympathectomy, ETS) 95% 55-90% Horner's syndromegustatory sweating ETST2 T3 T4 80% (clipping) 家庭醫學與基層醫療第十二期 431

onabotulinumtoxina(botox) abobotulinumtoxina (Dysport) 1 Botox 3 Dysport BTX A 320 Botox 50 94% 36 (5% vs 0 ) 200 Dysport 100 100 200Dysport( 100 200 ) 48

6 % 72% 結論和建議 (HDSS 2 ) (HDSS 3 4 ) 參考資料 Hornberger J, Grimes K, Naumann M, et al: Recognition,diagnosis,and treatment of primary focal hyperhidrosis. J Am Acad Dermatol 2004; 51: Strutton DR, Kowalski JW, Glaser DA, Stang PE: US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004; 51: Incidence and Frequency of Endoscopic S y m p a t h e c t o m y f o r t h e T r e a t m e n t o f H y p e r h i d r o s i s P a l m a r i s i n Ta i w a n. T h e Kaohsiung Journal of Medical Sciences 2010; 26: Ro KM, Cantor RM, Lange KL, Ahn SS: Palmar hyperhidrosis: evidence of genetic transmission. J Vasc Surg. 2002; 35: Smetana GW: Approach to the patient with night sweats. UpToDate; 家庭醫學與基層醫療第十二期

Strutton DR, Kowalski JW, Glaser DA, Stang PE: US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004; 51:241-8.

7 7. S m i t h C C, P a r i s e r D : P r i m a r y f o c a l hyperhidrosis. UpToDate; S o l i s h N, B e r t u c c i V, D a n s e r e a u A e t a l : A c o m p r e h e n s i v e a p p r o a c h t o t h e r e c o g n i t i o n, d i a g n o s i s, a n d s e v e r i t y - b a s e d t r e a t m e n t o f f o c a l h y p e r h i d r o s i s: recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg. 2007; 33: Naumann M, Lowe NJ: Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial. BMJ. 2001; 323: Chang YT, Li HP, Lee JY, et al: Treatment of palmar hyperhidrosis: T(4) level compared with T(3) and T(2). Ann Surg. 2007; 246: Changes in Quality of Life at Fiveyear Follow-up and Factors Associated with Receiving a Thoracoscopic Sympathectomy for Hyperhidrosis Patients Glaser DA, Coleman WP 3rd, Fan LK, et al: A randomized,blinded clinical evaluation of a novel microwave device for treating axillary hyperhidrosis: the dermatologic reduction in underarm perspiration study. Dermatol Surg. 2012; 38: 家庭醫學與基層醫療第十二期 433

a t m e n t o f f o c a l h y p e r h i d r o s i s: recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg. 2007; 33:908-23. 9.

Bacillus botulinus 80 Clostridium botulinum Clostridium botulinum 1 1920 Herman Sommer botulinum toxin 2 開始用於治療 1954 Vernon Brooks Alan Scott 197

肉毒桿菌素的發展 Paracelsus, 1493-1541 食物中毒的出現 9 19 1802 7 Justinus Kerner, 1786-1862 1821 毒素的發現 80 34 3 Emile Pierre Van Ermengem, 1851-1922 1895 38 2013 5 485 Bacillus botulinus 80 Clostridium

% 致 病 機 轉 鑑 別 診 斷 ( 1) ( 2) (eccrine) ( a p o c c r i n e ) (apoeccrine) ( t h e r m a l s w e a t i n g ) (emotional sweat

% 致病機轉鑑別診斷 ( 1) ( 2) (eccrine) ( a p o c c r i n e ) (apoeccrine) ( t h e r m a l s w e a t i n g ) (emotional sweat