INHOUD
Hoofdstuk 1: onderzoek van de huid .....................................................................................................1
Algemene principes ..........................................................................................................................1
Efflorescenties .................................................................................................................................1
Primair .........................................................................................................................................1
Secundair .....................................................................................................................................2
Distributie en lokalisatie (predilectieplaatsen) ...................................................................................2
Afmeting, rangschikking en vorm .......................................................................................................2
Hoofdstuk 2: bulleuze dermatosen .......................................................................................................3
Inleiding huid ...................................................................................................................................3
Congenitaal: Epidermolysis Bullosa ..................................................................................................3
Epidermolysis Bullosa Simplex ......................................................................................................3
Junctionele Epidermolysis Bullosa .................................................................................................3
Dystrofische Epidermolyis Bullosa .................................................................................................4
Verworven: auto-immuun .................................................................................................................4
Pemphigus groep ..........................................................................................................................4
Pemphigus vulgaris .................................................................................................................4
Pemphigus foliaceus ...............................................................................................................5
Pemphigoid groep .........................................................................................................................5
Bulleus pemphigoid .................................................................................................................5
Lineaire IgA dermatose ............................................................................................................6
Dermatitis herpetiformis ...............................................................................................................6
Hoofdstuk 3: contactdermatitis of contacteczeem ................................................................................8
Dermatitis (eczeem) .........................................................................................................................8
Contactdermatitis (contacteczeem) ..................................................................................................8
Irritatiedermatitis ..........................................................................................................................8
Allergische contactdermatitis ........................................................................................................9
Hoofdstuk 4: atopisch en seborrheïsch eczeem................................................................................... 12
Dermatitis (eczeem) ....................................................................................................................... 12
Atopische dermatitis (atopisch eczeem) .......................................................................................... 12
Intrinsieke of genetische factoren ................................................................................................ 12
Omgevingsfactoren ..................................................................................................................... 12
Kliniek ........................................................................................................................................ 13
Diagnose .................................................................................................................................... 14
Complicaties .............................................................................................................................. 14
Behandeling eczeem ................................................................................................................... 14
Inhoud
, Algemene maatregelen .......................................................................................................... 14
Lokale behandeling ............................................................................................................... 14
Corticosteroïden ............................................................................................................... 14
Calcineurine inhibitoren .................................................................................................... 15
Lichtbehandeling .................................................................................................................. 15
Systemische behandeling ...................................................................................................... 15
Ciclosporine ..................................................................................................................... 15
Biologicals ........................................................................................................................ 15
Small molecule inhibitoren ................................................................................................ 16
Behandeling surinfecties ............................................................................................................. 16
Behandeling jeuk ........................................................................................................................ 16
Seborrheïsche dermatitis (seborrheïsch eczeem) ............................................................................. 16
Kliniek ........................................................................................................................................ 16
Behandeling ............................................................................................................................... 18
Hoofdstuk 5: psoriasis ....................................................................................................................... 19
Kliniek............................................................................................................................................ 19
Psoriasis vulgaris: plaque ............................................................................................................ 19
Psoriasis vulgaris: guttata ............................................................................................................ 19
Psoriasis vulgaris: inversa ........................................................................................................... 20
Psoriasis vulgaris: nagels ............................................................................................................ 20
Psoriasis non-vulgaris: pustulosa ................................................................................................ 20
Psoriasis non-vulgaris: erythrodermie .......................................................................................... 20
Ontstaansmechanisme .................................................................................................................. 21
Genetische aanleg ...................................................................................................................... 21
Uitlokkende factoren................................................................................................................... 21
Behandeling ................................................................................................................................... 21
Lokale behandeling ..................................................................................................................... 21
Corticosteroïden ................................................................................................................... 21
Vitamine D analogen ............................................................................................................. 22
Teerzalf ................................................................................................................................. 22
Lichtbehandeling ........................................................................................................................ 22
Systemische behandeling ........................................................................................................... 23
Acitretine .............................................................................................................................. 23
Methotrexaat ......................................................................................................................... 23
Ciclosporine ......................................................................................................................... 24
Biologicals ............................................................................................................................ 24
Small molecule inhibitoren .................................................................................................... 24
Inhoud
,Hoofdstuk 6: bacteriële infecties van de huid ...................................................................................... 26
Door overgroei van commensale flora.............................................................................................. 26
Erythrasma ................................................................................................................................. 26
Trichomycosis palmellina............................................................................................................ 26
Pitted keratolysis ........................................................................................................................ 26
Behandeling ............................................................................................................................... 26
Door pathogene kiemen .................................................................................................................. 27
Niet-bulleuze impetigo ................................................................................................................ 27
Bulleuze impetigo ....................................................................................................................... 27
Ecthyma ..................................................................................................................................... 28
Folliculitis .................................................................................................................................. 28
Furunkel ..................................................................................................................................... 29
Karbunkel ................................................................................................................................... 30
Erysipelas................................................................................................................................... 30
Cellulitis..................................................................................................................................... 31
Hoofdstuk 7: acne vulgaris ................................................................................................................. 32
Inleiding ......................................................................................................................................... 32
Klinische varianten ......................................................................................................................... 32
Behandeling ................................................................................................................................... 33
Isotretinoïne ............................................................................................................................... 34
Topisch retinoïd .......................................................................................................................... 34
Benzoylperoxide ......................................................................................................................... 35
Topische antibiotica .................................................................................................................... 35
Orale antibiotica ......................................................................................................................... 35
Orale contraceptiva .................................................................................................................... 36
Hoofdstuk 8: acne inversa – hidradenitis suppurativa ........................................................................... 37
Inleiding ......................................................................................................................................... 37
Kliniek............................................................................................................................................ 37
Behandeling ................................................................................................................................... 37
Hoofdstuk 9: rosacea ......................................................................................................................... 39
Kliniek............................................................................................................................................ 39
Behandeling ................................................................................................................................... 40
Lokale behandeling ..................................................................................................................... 40
Systeembehandeling .................................................................................................................. 40
Andere opties ............................................................................................................................. 40
Hoofdstuk 10: oppervlakkige mycosen van huid en slijmvliezen ............................................................ 41
Dermatofyten ................................................................................................................................. 41
Inhoud
, Soorten ...................................................................................................................................... 41
Diagnose .................................................................................................................................... 43
Behandeling ............................................................................................................................... 43
Gisten ............................................................................................................................................ 43
Candidose .................................................................................................................................. 44
Diagnose .................................................................................................................................... 45
Behandeling ............................................................................................................................... 45
Hoofdstuk 11: parasitaire aandoeningen ............................................................................................. 46
Inleiding ......................................................................................................................................... 46
Scabies.......................................................................................................................................... 46
Complicaties .............................................................................................................................. 47
Luizen ............................................................................................................................................ 48
Pediculosis capitis (hoofdluis) ..................................................................................................... 48
Pediculosis pubis (schaamluis) ................................................................................................... 49
Vlooien .......................................................................................................................................... 49
Teken............................................................................................................................................. 50
Fase 1: vroeg gelokaliseerd stadium (primair) ............................................................................... 50
Fase 2: vroegtijdige disseminatie (secundair) ................................................................................ 51
Fase 3: laattijdig chronische infectie (tertiair) ............................................................................... 51
Behandeling ............................................................................................................................... 51
Hoofdstuk 12: virale infecties ............................................................................................................. 53
Humane herpesvirus ...................................................................................................................... 53
Herpes Simplex type 1 ................................................................................................................. 53
Herpes Simplex type 2 ................................................................................................................. 54
Bijzondere vormen HSV ............................................................................................................... 54
Varicella Zoster Virus (VZV) .......................................................................................................... 55
Bijzondere vormen VZV ............................................................................................................... 56
Diagnose (HSV, VZV) ................................................................................................................... 57
Humaan papillomavirus.................................................................................................................. 57
Cutaan verrucae ......................................................................................................................... 57
Mucosaal verrucae ..................................................................................................................... 58
Pokkenvirus ................................................................................................................................... 60
Molluscum contagiosum virus ..................................................................................................... 60
Parapokken virus (Orf = ecthyma contagiosum) ............................................................................ 60
Seksueel overdraagbare aandoeningen (SOA) .................................................................................. 60
Syfilis ......................................................................................................................................... 60
Hoofdstuk 13: tumoren van de huid .................................................................................................... 62
Inhoud
, Goedaardige pigmentletsels ........................................................................................................... 62
Maligne melanoom ......................................................................................................................... 63
Superficieel spreidend maligne melanoom (SSMM) ...................................................................... 64
Lentigo maligne melanoom (LMM) ............................................................................................... 64
Acrolentigineus maligne melanoom (ALMM) ................................................................................. 64
Nodulair maligne melanoom (NMM) ............................................................................................. 64
Klinisch beoordelen .................................................................................................................... 65
Behandeling ............................................................................................................................... 66
Epidermale tumoren van de huid ..................................................................................................... 66
Goedaardige epidermale tumoren ............................................................................................... 66
Premaligne huidafwijkingen ......................................................................................................... 66
Maligne epidermale tumoren (non-melanoma) ............................................................................. 68
Hoofdstuk 14: huidaantasting bij systeemziekten ................................................................................ 71
Inleiding ......................................................................................................................................... 71
Lupus erythematosus (LE)............................................................................................................... 71
Acute cutane Lupus Erythematosus ............................................................................................. 72
Subacute cutane Lupus Erythematosus ....................................................................................... 72
Chronische cutane Lupus Erythematosus (= discoïde LE) .............................................................. 72
Diagnose .................................................................................................................................... 73
Behandeling ............................................................................................................................... 73
Dermatomyositis ............................................................................................................................ 74
Diagnose .................................................................................................................................... 75
Behandeling ............................................................................................................................... 75
Systeemsclerose (sclerodermie) ..................................................................................................... 76
Diagnose .................................................................................................................................... 77
Behandeling ............................................................................................................................... 77
Morphea..................................................................................................................................... 77
Vasculitis ....................................................................................................................................... 78
Small vessle vasculitis ................................................................................................................ 79
Medium vessle vasculitis ............................................................................................................. 80
Hoofdstuk 15: acuut cutane aandoeningen ......................................................................................... 82
Inleiding ......................................................................................................................................... 82
Toxisch medicamenteuze reacties .................................................................................................. 82
Maculopapuleus exantheem ....................................................................................................... 82
Acute gegeneraliseerde exanthemateuze pustulose (AGEP) .......................................................... 83
Drug reactie met eosinofilie en systemische symptomen (DRESS) ................................................. 83
Stevens-Johnson syndroom (SJS) ................................................................................................. 83
Inhoud
, Toxische epidermale necrolyse (TEN) ........................................................................................... 84
Urticaria en angioedeem ............................................................................................................. 84
Toxisch infectieuze reacties ............................................................................................................ 87
Erythema nodosum ........................................................................................................................ 89
Acuut cutaan vasculaire aandoeningen ........................................................................................... 89
Hoofdstuk 1: histologie van huid en basisbegrippen in huidpathologie ....................................................1
Anatomie van de huid .......................................................................................................................1
Epidermis .....................................................................................................................................1
Keratinocyten - stratum corneum .............................................................................................2
Keratinocyten - stratum granulosum .........................................................................................2
Keratinocyten - stratum spinosum ............................................................................................2
Keratinocyten - stratum basale .................................................................................................2
Melanocyten ...........................................................................................................................2
Langerhans cellen ...................................................................................................................3
Merkel cellen ..........................................................................................................................3
Dermis .........................................................................................................................................3
Hypodermis ..................................................................................................................................5
Basisletsels .....................................................................................................................................5
Epidermis .....................................................................................................................................5
Hyperplasie en hypoplasie .......................................................................................................5
Orthokeratose en parakeratose ................................................................................................6
Acantholyse ............................................................................................................................6
Inflammatie van de huid ..........................................................................................................6
Civatte-lichaampjes en dyskeratose .........................................................................................7
Dermis .........................................................................................................................................8
Elastose..................................................................................................................................8
Homogenisatie ........................................................................................................................8
Oedeem .................................................................................................................................8
Ontsteking ..............................................................................................................................8
Subcutis .......................................................................................................................................9
Steatonecrose .........................................................................................................................9
Panniculitis .............................................................................................................................9
Vasculitis .............................................................................................................................. 10
Patronen ........................................................................................................................................ 10
Inflammatoire huidpathologie ..................................................................................................... 10
Hoofdstuk 2: bulleuze dermatosen ..................................................................................................... 11
Intra-epidermaal ............................................................................................................................ 11
Inhoud
, Subacuut eczeem ....................................................................................................................... 11
Herpes virus infectie ................................................................................................................... 11
Pemphigus vulgaris ..................................................................................................................... 11
Intra-epidermaal ............................................................................................................................ 12
Brandwonden (2e graad) of insectenbeten .................................................................................... 12
Bulleuze lichen planus ................................................................................................................ 12
Bulleus pemphigoid .................................................................................................................... 13
Dermatitis herpetiformis ............................................................................................................. 13
Lineaire IgA-dermatose ............................................................................................................... 14
Epidermolysis bullosa acquisita .................................................................................................. 14
Hoofdstuk 3: huidtumoren ................................................................................................................. 15
Epidermis ...................................................................................................................................... 15
Melanocyten – pigmentceltumoren .............................................................................................. 15
Pathway 1: lage UV-blootstelling............................................................................................. 18
Pathway 2: hoge UV-blootstelling............................................................................................ 20
Pathway 3: hoge UV-blootstelling............................................................................................ 20
Pathway 4: variabele UV-blootstelling ..................................................................................... 21
Pathway 5: variabele UV-blootstelling ..................................................................................... 21
Pathway 6: variabele UV-blootstelling ..................................................................................... 22
Pathway 7: variabele UV-blootstelling ..................................................................................... 22
Pathway 8: variabele UV-blootstelling ..................................................................................... 22
Pathway 9: variabele UV-blootstelling ..................................................................................... 23
Keratinocyten – epidermale tumoren ........................................................................................... 24
Merkel cellen – merkelcel carcinoom ........................................................................................... 25
Adnexen – dermale tumoren (adnexieel) ....................................................................................... 26
Fibroblasten – fibrohistiocytaire tumoren ..................................................................................... 26
Langerhans cellen en immuun cellen ........................................................................................... 27
Inhoud
,DERMATOLOGIE
HOOFDSTUK 1: ONDERZOEK VAN DE HUID
Dit deel is niet te kennen
ALGEMENE PRINCIPES
- Warm lokaal, goede belichting
- Inspecteren van volledige huidoppervlak, haren, nagels en mucosa
- Palperen van huid om textuur na te gaan
- Observeren van morfologie, configuratie en distributie van individuele letsels
- Anamnese voor, tijdens en na onderzoek
- Technische hulpmiddelen en onderzoeken
EFFLORESCENTIES
Efflorescenties = huidveranderingen die typerend kunnen zijn voor een bepaalde huidziekte
PRIMAIR
Primaire efflorescenties = door huidziekte zelf
- Niet verheven
o Macula (vlek)
▪ Bv epheliden (sproetjes), vitiligo, fixed drug eruptie (erythemateus)
- Verheven
o Compacte opbouw
▪ Papel: < 5 mm - (epi)dermis
• Bv xanthomen, mollusca contagiosa, verruca vulgaris, lichen planus
▪ Nodulus: > 5 mm - subcutis
• Bv erythema nodosum, nodulair basocellulair epithelioom
▪ Plaque: vlak verheven haard
• Bv psoriasis
▪ Urticaria: vluchtige verheving (< 24u) door dermaal oedeem
o Niet compacte opbouw (holten)
▪ Vesikel: < 5 mm, helder vocht
• Bv herpes simplex vesikels, dermatitis herpetiformis
▪ Bulla (blaar): > 5 mm, helder vocht
• Subepidermaal: klieving tussen dermis en epidermis: strakke blaren
o Bv bulleus pemphigoid
• Intra-epidermaal: klieving in epiderm: fragiele blaren, snel kapot
o Bv pemphigus vulgaris
▪ Pustula: > 5 mm, seropurulent vocht
• Bv folliculitis, psoriasis pustulosa, acne vulgaris
Hoofdstuk 1: onderzoek van de huid 1
,SECUNDAIR
Secundaire efflorescenties = door verdere evolutie van primaire of reactie op primaire letsels
- Excoriaties (krabletsels)
- Squamae (schilfering, ophoping hoornlaag): pityriasiform, psoriasiform, lamellair
- Crusta (korst, opgedroogd wondvocht)
- Erosie (oppervlakkige epidermis) ulceratie (diepe epidermis en dermis)
- Fissuur (kloven, onderbreking continuïteit huid)
- Litteken = genezing van defect reikend tot in dermis
- Atrofie = versmalling epidermis of dermis
- Sclerose = verharding van huid
- Hypertrofie of pachydermie
- Dyschromie = kleurverandering
- Lichenificatie = chronische verdikking van huid, met vergroving van huidlijnen
DISTRIBUTIE EN LOKALISATIE (PREDILECTIEPLAATSEN)
Distributie = verspreiding
- Solitair
- Gegroepeerd
- Discreet gedissemineerd
- Diffuus gedissemineerd
- Gegeneraliseerd
Anatomische lokalisaties en predilectieplaatsen voor diagnose
- Acne vulgaris: gelaat en bovenste deel romp
- Atopisch eczeem: plooizijde (elleboog, knie)
- Psoriasis: strekzijde (knie)
AFMETING, RANGSCHIKKING EN VORM
- Oppervlakte meten of vergelijken met bekende grootte bv muntstuk, erwt, boon…
- Vormen: rond, ovaal, annulair, lineair, gegroepeerd
Hoofdstuk 1: onderzoek van de huid 2
, HOOFDSTUK 2: BULLEUZE DERMATOSEN
INLEIDING HUID
- Huidoppervlak van 1,8 m2 en 16% van lichaamsgewicht
- 3 lagen
o Epidermis: opperhuid, < verschillende lagen cellen
o Dermis: < steunweefsel en cellen
o Subcutis: < vetweefsel
- Adnexen
o Haren
o Zweet- en talgklieren
o Nagels
Dermo-epidermale junctie = overgangszone tussen epidermis en dermis (basale membraan zone)
- Opgebouwd uit verschillende structuren zodat epidermis vasthangt aan dermis
o Lamina lucida
o Lamina densa
o Sublamina densa
o < cytoskelet, hemidesmosomale plaque, plasmamembraan van basale keratinocyten
- Blaren = fouten in deze plakstructuur, waardoor lagen loskomen van elkaar
CONGENITAAL: EPIDERMOLYSIS BULLOSA
Ontstaan door genetische fouten in de code van verschillende structuren en/of adhesie-eiwitten in huid
→ genetica belangrijk voor diagnose
- Epidermolysis Bullosa Simplex
- Junctionele Epidermolysis Bullosa
- Dystrofische Epidermolysis Bullosa
Vooral aantasting van handpalmen en voetzolen
EPIDERMOLYSIS BULLOSA SIMPLEX
Splijting doorheen basale keratinocyten (opperhuid)
- Mechanische fragiliteit
- Blaren, erosies
- Geen verlittekening (kan nog zonder genezen)
Milde vorm
JUNCTIONELE EPIDERMOLYSIS BULLOSA
Splijting doorheen lamina lucida (helemaal los van dermis)
- Mechanische fragiliteit
- Blaren, erosies
- Verlittekening
Vaak lethaal
Hoofdstuk 2: bulleuze dermatosen 3
Hoofdstuk 1: onderzoek van de huid .....................................................................................................1
Algemene principes ..........................................................................................................................1
Efflorescenties .................................................................................................................................1
Primair .........................................................................................................................................1
Secundair .....................................................................................................................................2
Distributie en lokalisatie (predilectieplaatsen) ...................................................................................2
Afmeting, rangschikking en vorm .......................................................................................................2
Hoofdstuk 2: bulleuze dermatosen .......................................................................................................3
Inleiding huid ...................................................................................................................................3
Congenitaal: Epidermolysis Bullosa ..................................................................................................3
Epidermolysis Bullosa Simplex ......................................................................................................3
Junctionele Epidermolysis Bullosa .................................................................................................3
Dystrofische Epidermolyis Bullosa .................................................................................................4
Verworven: auto-immuun .................................................................................................................4
Pemphigus groep ..........................................................................................................................4
Pemphigus vulgaris .................................................................................................................4
Pemphigus foliaceus ...............................................................................................................5
Pemphigoid groep .........................................................................................................................5
Bulleus pemphigoid .................................................................................................................5
Lineaire IgA dermatose ............................................................................................................6
Dermatitis herpetiformis ...............................................................................................................6
Hoofdstuk 3: contactdermatitis of contacteczeem ................................................................................8
Dermatitis (eczeem) .........................................................................................................................8
Contactdermatitis (contacteczeem) ..................................................................................................8
Irritatiedermatitis ..........................................................................................................................8
Allergische contactdermatitis ........................................................................................................9
Hoofdstuk 4: atopisch en seborrheïsch eczeem................................................................................... 12
Dermatitis (eczeem) ....................................................................................................................... 12
Atopische dermatitis (atopisch eczeem) .......................................................................................... 12
Intrinsieke of genetische factoren ................................................................................................ 12
Omgevingsfactoren ..................................................................................................................... 12
Kliniek ........................................................................................................................................ 13
Diagnose .................................................................................................................................... 14
Complicaties .............................................................................................................................. 14
Behandeling eczeem ................................................................................................................... 14
Inhoud
, Algemene maatregelen .......................................................................................................... 14
Lokale behandeling ............................................................................................................... 14
Corticosteroïden ............................................................................................................... 14
Calcineurine inhibitoren .................................................................................................... 15
Lichtbehandeling .................................................................................................................. 15
Systemische behandeling ...................................................................................................... 15
Ciclosporine ..................................................................................................................... 15
Biologicals ........................................................................................................................ 15
Small molecule inhibitoren ................................................................................................ 16
Behandeling surinfecties ............................................................................................................. 16
Behandeling jeuk ........................................................................................................................ 16
Seborrheïsche dermatitis (seborrheïsch eczeem) ............................................................................. 16
Kliniek ........................................................................................................................................ 16
Behandeling ............................................................................................................................... 18
Hoofdstuk 5: psoriasis ....................................................................................................................... 19
Kliniek............................................................................................................................................ 19
Psoriasis vulgaris: plaque ............................................................................................................ 19
Psoriasis vulgaris: guttata ............................................................................................................ 19
Psoriasis vulgaris: inversa ........................................................................................................... 20
Psoriasis vulgaris: nagels ............................................................................................................ 20
Psoriasis non-vulgaris: pustulosa ................................................................................................ 20
Psoriasis non-vulgaris: erythrodermie .......................................................................................... 20
Ontstaansmechanisme .................................................................................................................. 21
Genetische aanleg ...................................................................................................................... 21
Uitlokkende factoren................................................................................................................... 21
Behandeling ................................................................................................................................... 21
Lokale behandeling ..................................................................................................................... 21
Corticosteroïden ................................................................................................................... 21
Vitamine D analogen ............................................................................................................. 22
Teerzalf ................................................................................................................................. 22
Lichtbehandeling ........................................................................................................................ 22
Systemische behandeling ........................................................................................................... 23
Acitretine .............................................................................................................................. 23
Methotrexaat ......................................................................................................................... 23
Ciclosporine ......................................................................................................................... 24
Biologicals ............................................................................................................................ 24
Small molecule inhibitoren .................................................................................................... 24
Inhoud
,Hoofdstuk 6: bacteriële infecties van de huid ...................................................................................... 26
Door overgroei van commensale flora.............................................................................................. 26
Erythrasma ................................................................................................................................. 26
Trichomycosis palmellina............................................................................................................ 26
Pitted keratolysis ........................................................................................................................ 26
Behandeling ............................................................................................................................... 26
Door pathogene kiemen .................................................................................................................. 27
Niet-bulleuze impetigo ................................................................................................................ 27
Bulleuze impetigo ....................................................................................................................... 27
Ecthyma ..................................................................................................................................... 28
Folliculitis .................................................................................................................................. 28
Furunkel ..................................................................................................................................... 29
Karbunkel ................................................................................................................................... 30
Erysipelas................................................................................................................................... 30
Cellulitis..................................................................................................................................... 31
Hoofdstuk 7: acne vulgaris ................................................................................................................. 32
Inleiding ......................................................................................................................................... 32
Klinische varianten ......................................................................................................................... 32
Behandeling ................................................................................................................................... 33
Isotretinoïne ............................................................................................................................... 34
Topisch retinoïd .......................................................................................................................... 34
Benzoylperoxide ......................................................................................................................... 35
Topische antibiotica .................................................................................................................... 35
Orale antibiotica ......................................................................................................................... 35
Orale contraceptiva .................................................................................................................... 36
Hoofdstuk 8: acne inversa – hidradenitis suppurativa ........................................................................... 37
Inleiding ......................................................................................................................................... 37
Kliniek............................................................................................................................................ 37
Behandeling ................................................................................................................................... 37
Hoofdstuk 9: rosacea ......................................................................................................................... 39
Kliniek............................................................................................................................................ 39
Behandeling ................................................................................................................................... 40
Lokale behandeling ..................................................................................................................... 40
Systeembehandeling .................................................................................................................. 40
Andere opties ............................................................................................................................. 40
Hoofdstuk 10: oppervlakkige mycosen van huid en slijmvliezen ............................................................ 41
Dermatofyten ................................................................................................................................. 41
Inhoud
, Soorten ...................................................................................................................................... 41
Diagnose .................................................................................................................................... 43
Behandeling ............................................................................................................................... 43
Gisten ............................................................................................................................................ 43
Candidose .................................................................................................................................. 44
Diagnose .................................................................................................................................... 45
Behandeling ............................................................................................................................... 45
Hoofdstuk 11: parasitaire aandoeningen ............................................................................................. 46
Inleiding ......................................................................................................................................... 46
Scabies.......................................................................................................................................... 46
Complicaties .............................................................................................................................. 47
Luizen ............................................................................................................................................ 48
Pediculosis capitis (hoofdluis) ..................................................................................................... 48
Pediculosis pubis (schaamluis) ................................................................................................... 49
Vlooien .......................................................................................................................................... 49
Teken............................................................................................................................................. 50
Fase 1: vroeg gelokaliseerd stadium (primair) ............................................................................... 50
Fase 2: vroegtijdige disseminatie (secundair) ................................................................................ 51
Fase 3: laattijdig chronische infectie (tertiair) ............................................................................... 51
Behandeling ............................................................................................................................... 51
Hoofdstuk 12: virale infecties ............................................................................................................. 53
Humane herpesvirus ...................................................................................................................... 53
Herpes Simplex type 1 ................................................................................................................. 53
Herpes Simplex type 2 ................................................................................................................. 54
Bijzondere vormen HSV ............................................................................................................... 54
Varicella Zoster Virus (VZV) .......................................................................................................... 55
Bijzondere vormen VZV ............................................................................................................... 56
Diagnose (HSV, VZV) ................................................................................................................... 57
Humaan papillomavirus.................................................................................................................. 57
Cutaan verrucae ......................................................................................................................... 57
Mucosaal verrucae ..................................................................................................................... 58
Pokkenvirus ................................................................................................................................... 60
Molluscum contagiosum virus ..................................................................................................... 60
Parapokken virus (Orf = ecthyma contagiosum) ............................................................................ 60
Seksueel overdraagbare aandoeningen (SOA) .................................................................................. 60
Syfilis ......................................................................................................................................... 60
Hoofdstuk 13: tumoren van de huid .................................................................................................... 62
Inhoud
, Goedaardige pigmentletsels ........................................................................................................... 62
Maligne melanoom ......................................................................................................................... 63
Superficieel spreidend maligne melanoom (SSMM) ...................................................................... 64
Lentigo maligne melanoom (LMM) ............................................................................................... 64
Acrolentigineus maligne melanoom (ALMM) ................................................................................. 64
Nodulair maligne melanoom (NMM) ............................................................................................. 64
Klinisch beoordelen .................................................................................................................... 65
Behandeling ............................................................................................................................... 66
Epidermale tumoren van de huid ..................................................................................................... 66
Goedaardige epidermale tumoren ............................................................................................... 66
Premaligne huidafwijkingen ......................................................................................................... 66
Maligne epidermale tumoren (non-melanoma) ............................................................................. 68
Hoofdstuk 14: huidaantasting bij systeemziekten ................................................................................ 71
Inleiding ......................................................................................................................................... 71
Lupus erythematosus (LE)............................................................................................................... 71
Acute cutane Lupus Erythematosus ............................................................................................. 72
Subacute cutane Lupus Erythematosus ....................................................................................... 72
Chronische cutane Lupus Erythematosus (= discoïde LE) .............................................................. 72
Diagnose .................................................................................................................................... 73
Behandeling ............................................................................................................................... 73
Dermatomyositis ............................................................................................................................ 74
Diagnose .................................................................................................................................... 75
Behandeling ............................................................................................................................... 75
Systeemsclerose (sclerodermie) ..................................................................................................... 76
Diagnose .................................................................................................................................... 77
Behandeling ............................................................................................................................... 77
Morphea..................................................................................................................................... 77
Vasculitis ....................................................................................................................................... 78
Small vessle vasculitis ................................................................................................................ 79
Medium vessle vasculitis ............................................................................................................. 80
Hoofdstuk 15: acuut cutane aandoeningen ......................................................................................... 82
Inleiding ......................................................................................................................................... 82
Toxisch medicamenteuze reacties .................................................................................................. 82
Maculopapuleus exantheem ....................................................................................................... 82
Acute gegeneraliseerde exanthemateuze pustulose (AGEP) .......................................................... 83
Drug reactie met eosinofilie en systemische symptomen (DRESS) ................................................. 83
Stevens-Johnson syndroom (SJS) ................................................................................................. 83
Inhoud
, Toxische epidermale necrolyse (TEN) ........................................................................................... 84
Urticaria en angioedeem ............................................................................................................. 84
Toxisch infectieuze reacties ............................................................................................................ 87
Erythema nodosum ........................................................................................................................ 89
Acuut cutaan vasculaire aandoeningen ........................................................................................... 89
Hoofdstuk 1: histologie van huid en basisbegrippen in huidpathologie ....................................................1
Anatomie van de huid .......................................................................................................................1
Epidermis .....................................................................................................................................1
Keratinocyten - stratum corneum .............................................................................................2
Keratinocyten - stratum granulosum .........................................................................................2
Keratinocyten - stratum spinosum ............................................................................................2
Keratinocyten - stratum basale .................................................................................................2
Melanocyten ...........................................................................................................................2
Langerhans cellen ...................................................................................................................3
Merkel cellen ..........................................................................................................................3
Dermis .........................................................................................................................................3
Hypodermis ..................................................................................................................................5
Basisletsels .....................................................................................................................................5
Epidermis .....................................................................................................................................5
Hyperplasie en hypoplasie .......................................................................................................5
Orthokeratose en parakeratose ................................................................................................6
Acantholyse ............................................................................................................................6
Inflammatie van de huid ..........................................................................................................6
Civatte-lichaampjes en dyskeratose .........................................................................................7
Dermis .........................................................................................................................................8
Elastose..................................................................................................................................8
Homogenisatie ........................................................................................................................8
Oedeem .................................................................................................................................8
Ontsteking ..............................................................................................................................8
Subcutis .......................................................................................................................................9
Steatonecrose .........................................................................................................................9
Panniculitis .............................................................................................................................9
Vasculitis .............................................................................................................................. 10
Patronen ........................................................................................................................................ 10
Inflammatoire huidpathologie ..................................................................................................... 10
Hoofdstuk 2: bulleuze dermatosen ..................................................................................................... 11
Intra-epidermaal ............................................................................................................................ 11
Inhoud
, Subacuut eczeem ....................................................................................................................... 11
Herpes virus infectie ................................................................................................................... 11
Pemphigus vulgaris ..................................................................................................................... 11
Intra-epidermaal ............................................................................................................................ 12
Brandwonden (2e graad) of insectenbeten .................................................................................... 12
Bulleuze lichen planus ................................................................................................................ 12
Bulleus pemphigoid .................................................................................................................... 13
Dermatitis herpetiformis ............................................................................................................. 13
Lineaire IgA-dermatose ............................................................................................................... 14
Epidermolysis bullosa acquisita .................................................................................................. 14
Hoofdstuk 3: huidtumoren ................................................................................................................. 15
Epidermis ...................................................................................................................................... 15
Melanocyten – pigmentceltumoren .............................................................................................. 15
Pathway 1: lage UV-blootstelling............................................................................................. 18
Pathway 2: hoge UV-blootstelling............................................................................................ 20
Pathway 3: hoge UV-blootstelling............................................................................................ 20
Pathway 4: variabele UV-blootstelling ..................................................................................... 21
Pathway 5: variabele UV-blootstelling ..................................................................................... 21
Pathway 6: variabele UV-blootstelling ..................................................................................... 22
Pathway 7: variabele UV-blootstelling ..................................................................................... 22
Pathway 8: variabele UV-blootstelling ..................................................................................... 22
Pathway 9: variabele UV-blootstelling ..................................................................................... 23
Keratinocyten – epidermale tumoren ........................................................................................... 24
Merkel cellen – merkelcel carcinoom ........................................................................................... 25
Adnexen – dermale tumoren (adnexieel) ....................................................................................... 26
Fibroblasten – fibrohistiocytaire tumoren ..................................................................................... 26
Langerhans cellen en immuun cellen ........................................................................................... 27
Inhoud
,DERMATOLOGIE
HOOFDSTUK 1: ONDERZOEK VAN DE HUID
Dit deel is niet te kennen
ALGEMENE PRINCIPES
- Warm lokaal, goede belichting
- Inspecteren van volledige huidoppervlak, haren, nagels en mucosa
- Palperen van huid om textuur na te gaan
- Observeren van morfologie, configuratie en distributie van individuele letsels
- Anamnese voor, tijdens en na onderzoek
- Technische hulpmiddelen en onderzoeken
EFFLORESCENTIES
Efflorescenties = huidveranderingen die typerend kunnen zijn voor een bepaalde huidziekte
PRIMAIR
Primaire efflorescenties = door huidziekte zelf
- Niet verheven
o Macula (vlek)
▪ Bv epheliden (sproetjes), vitiligo, fixed drug eruptie (erythemateus)
- Verheven
o Compacte opbouw
▪ Papel: < 5 mm - (epi)dermis
• Bv xanthomen, mollusca contagiosa, verruca vulgaris, lichen planus
▪ Nodulus: > 5 mm - subcutis
• Bv erythema nodosum, nodulair basocellulair epithelioom
▪ Plaque: vlak verheven haard
• Bv psoriasis
▪ Urticaria: vluchtige verheving (< 24u) door dermaal oedeem
o Niet compacte opbouw (holten)
▪ Vesikel: < 5 mm, helder vocht
• Bv herpes simplex vesikels, dermatitis herpetiformis
▪ Bulla (blaar): > 5 mm, helder vocht
• Subepidermaal: klieving tussen dermis en epidermis: strakke blaren
o Bv bulleus pemphigoid
• Intra-epidermaal: klieving in epiderm: fragiele blaren, snel kapot
o Bv pemphigus vulgaris
▪ Pustula: > 5 mm, seropurulent vocht
• Bv folliculitis, psoriasis pustulosa, acne vulgaris
Hoofdstuk 1: onderzoek van de huid 1
,SECUNDAIR
Secundaire efflorescenties = door verdere evolutie van primaire of reactie op primaire letsels
- Excoriaties (krabletsels)
- Squamae (schilfering, ophoping hoornlaag): pityriasiform, psoriasiform, lamellair
- Crusta (korst, opgedroogd wondvocht)
- Erosie (oppervlakkige epidermis) ulceratie (diepe epidermis en dermis)
- Fissuur (kloven, onderbreking continuïteit huid)
- Litteken = genezing van defect reikend tot in dermis
- Atrofie = versmalling epidermis of dermis
- Sclerose = verharding van huid
- Hypertrofie of pachydermie
- Dyschromie = kleurverandering
- Lichenificatie = chronische verdikking van huid, met vergroving van huidlijnen
DISTRIBUTIE EN LOKALISATIE (PREDILECTIEPLAATSEN)
Distributie = verspreiding
- Solitair
- Gegroepeerd
- Discreet gedissemineerd
- Diffuus gedissemineerd
- Gegeneraliseerd
Anatomische lokalisaties en predilectieplaatsen voor diagnose
- Acne vulgaris: gelaat en bovenste deel romp
- Atopisch eczeem: plooizijde (elleboog, knie)
- Psoriasis: strekzijde (knie)
AFMETING, RANGSCHIKKING EN VORM
- Oppervlakte meten of vergelijken met bekende grootte bv muntstuk, erwt, boon…
- Vormen: rond, ovaal, annulair, lineair, gegroepeerd
Hoofdstuk 1: onderzoek van de huid 2
, HOOFDSTUK 2: BULLEUZE DERMATOSEN
INLEIDING HUID
- Huidoppervlak van 1,8 m2 en 16% van lichaamsgewicht
- 3 lagen
o Epidermis: opperhuid, < verschillende lagen cellen
o Dermis: < steunweefsel en cellen
o Subcutis: < vetweefsel
- Adnexen
o Haren
o Zweet- en talgklieren
o Nagels
Dermo-epidermale junctie = overgangszone tussen epidermis en dermis (basale membraan zone)
- Opgebouwd uit verschillende structuren zodat epidermis vasthangt aan dermis
o Lamina lucida
o Lamina densa
o Sublamina densa
o < cytoskelet, hemidesmosomale plaque, plasmamembraan van basale keratinocyten
- Blaren = fouten in deze plakstructuur, waardoor lagen loskomen van elkaar
CONGENITAAL: EPIDERMOLYSIS BULLOSA
Ontstaan door genetische fouten in de code van verschillende structuren en/of adhesie-eiwitten in huid
→ genetica belangrijk voor diagnose
- Epidermolysis Bullosa Simplex
- Junctionele Epidermolysis Bullosa
- Dystrofische Epidermolysis Bullosa
Vooral aantasting van handpalmen en voetzolen
EPIDERMOLYSIS BULLOSA SIMPLEX
Splijting doorheen basale keratinocyten (opperhuid)
- Mechanische fragiliteit
- Blaren, erosies
- Geen verlittekening (kan nog zonder genezen)
Milde vorm
JUNCTIONELE EPIDERMOLYSIS BULLOSA
Splijting doorheen lamina lucida (helemaal los van dermis)
- Mechanische fragiliteit
- Blaren, erosies
- Verlittekening
Vaak lethaal
Hoofdstuk 2: bulleuze dermatosen 3
