異位性皮炎（濕疹），類固醇與症狀復發（Rebound）10

以下介紹的是2000年深谷元繼醫生發表於Archives of Dermatology中的論文。深谷醫生在本論文採取病例報告的形態體現戒斷Steroid addiction後患者治癒的過程。“Topical corticosteroids are a useful form of treatment for atopic dermatitis. However, patients are likely to be addicted after long-term treatment. This paradoxical phenomenon has so far been underestimated, and improvement following the temporary rebound flare after discontinuation of corticosteroid therapyhas been entirely ignored.”（外用皮質類固醇對異位性皮炎治療有效，但長期的使用有可能產生Steroid addiction。這個現象普遍有被低估的傾向，顯示症狀在戒斷皮質類固醇治療後經過Rebound，再逐漸治癒的症例更是完全被忽略。）

“Report of a Case. A 20-year-old man was affected with atopic dermatitis since early childhood. He used topical corticosteroids intermittently but found that the amount and frequency of applications had steadily increased since he turned age 18 years. The patient used 10 to 40 g per month of 0.12% betamethazone valerate ointment on his body and 0.25% predonisolone acetate ointment on his face. Total IgE was 7179 U/mL and white blood cell count showed 27.1% eosinophils.”（這是一位20歲自少患有異位性皮炎的男性患者個案。自幼小時有斷斷續續使用外用皮質類固醇，但自18歲前後開始使用量和使用頻度都出現增加的傾向。初診時，患者已在身體使用每月10至40克0.12%倍他米松戊酸酯，面上則使用0.25%醋酸潑尼松龍。IgE為7179 U/mL，白血球中嗜酸性粒細胞為27.1%。）

“He had developed patchy erythema and prurigo on his entire body before discontinuing treatment with topical steroids. One month after he discontinued steroid use, prurigo flattened and the erythema extended over his entire body. After 2 months, exudative erythema developed on his forehead and his features showed erythroderma. Four months after he stopped the steroid treatment, his rebound flare was at its worst point, especially on the face. After 6 months, the dermatitis improved, first on the face; then the exudative lesions disappeared.”（戒斷外用類固醇之前患者全身已有紅斑和癢疹的分布；戒斷類固醇1個月後癢疹的外觀變為扁平，但紅斑則擴散到全身。兩個月後前額出現滲出性紅斑，而症狀演變為紅皮病。戒斷類固醇4個月後，由Rebound引起的皮膚紅腫現象達到最高峰，面部症狀尤其惡劣。6個月後，最初面部的皮炎有了改善，其後滲出性的病變也消失。）

“After 1 year, the skin’s appearance became almost normal with the exception of some dry lesions on the elbows and wrists, which were found to be consistent with features of classic atopic dermatitis. One and a half years after treatment was stopped, the patient’s eczema subsided, and his total IgE was 3300 U/mL, while the white blood cell count showed only 7.8% eosinophils.Throughout the observation period, no systemic steroids were required, and the patient used only white petrolatum or 5% zinc oxide and antihistamines as oral drugs; 10% povidone-iodine was used to prevent secondary infection.”（經過1年之後，除肘部和手腕有些微乾燥性皮炎外，皮膚外觀基本上恢復正常，與經典的異位性皮炎症狀吻合。1年半後，患者的濕疹消退，IgE為3300 U/mL，白血球中嗜酸性粒細胞為7.8%。戒斷治療期間患者並無使用全身性類固醇；只用了白凡士林或結合5%氧化鋅與抗組胺藥做為口服之用，其餘是防止二次感染作用的10%聚維酮碘。）

深谷元繼醫生在上述論文加插如下圖圖片來記述戒斷療程的治癒過程；下圖並不是論文中患者的圖片，但戒斷的過程外觀大致相同。

國立名古屋病院時代曾經治療過數以千計異位性皮炎患者的深谷元繼醫生為每個門診患者照圖片；每次在每個門診患者身上用掉差不多5卷幻燈片膠卷，經過整理後深谷元繼醫生得到的就是類似上面一系列的圖片。這樣的圖片正好記錄了每個門診患者的症狀進展與時間上的連貫性，他承認Steroid addiction和Rebound現象都是在整理圖片時發現的。深谷元繼醫生指出正因為要看到症狀的一連貫過程才可以作出診斷，所以單憑上面任何一張圖片（換個角度看，普通診所門診就是讓醫生看患者的“某一天狀況”或“某張圖片”而已）是難以作出正確診斷的。