全身皮疹癢難耐 竟是藥物「來相害」預防勝於治療 為藥物過敏把關
2023-06-13 記者 蘇旋/報導
奇美醫療財團法人奇美醫院皮膚科暨醫學美容中心主治醫師王羽安表示，藥物疹嚴重恐因屏障功能喪失，留下長期後遺症，應警覺勿大意
40歲張先生無任何內科病史，四天前開始有咳嗽、喉嚨痛等上呼吸道感染症狀，附近診所就醫服藥後症狀逐漸緩解；但卻發現身上開始長了一些疹子，而且越來越癢，範圍不停擴散，由於皮疹進展快速，張先生擔心是否合併其他嚴重感染，趕忙至奇美醫療財團法人奇美醫院皮膚科暨醫學美容中心主治醫師王羽安門診求診。
王醫師詳細檢視疹子外觀，又看了張先生的用藥，確定診斷為藥物過敏，因為口服用藥中的非類固醇類消炎止痛藥(NSAID)，極可能是造成他皮膚過敏的原凶。除請張先生暫停服用外，並搭配低劑量類固醇治療，一週後回診時，他身上的疹子已消退大半，癢感也大幅改善。王羽安醫師將此藥物過敏的紀錄註記在張先生的健保卡內，並請張先生未來就醫時，務必主動跟醫師表明自己曾有藥物過敏，可避免再發生同樣狀況。
奇美醫療財團法人奇美醫院皮膚科暨醫學美容中心主治醫師王羽安說明，人體對藥物產生的反應可大致區分成兩種：免疫性及非免疫性。我們較為熟知的藥物副作用，如腸胃不適、嗜睡、頭暈……等，屬於非免疫性，這些症狀部分是可預期的，通常和藥品本身的特性及代謝有關，多數人都可能會產生，調整劑量或停藥後大多能立刻緩解，而藥物過敏或藥物不良反應，則屬於免疫性，主要和體質相關，體內的免疫系統辨識了藥物並產生異常的活化反應，就會造成皮疹、發燒、甚至其他臟器的損傷，這並不是每個人都會表現，且和劑量較無關聯，故相對無法預期。
依據全民健保申報資料分析，2019年國人因過敏性疾病就醫約355萬人，就診率為每十萬人口15,038人。就兩性觀察，女性就醫人數約為192萬人(占54.0%)，高於男性163萬人(46.0%)。若以年齡別分，以15至44歲就醫人數最多，約有137萬(38.6%)，45至64歲次之約為88萬人(24.8%)，而65歲以上就醫人數最少，約為52萬人(14.8%)。而因過敏性疾病死亡人數計611人，其中65歲以上的長者居多，計512人(占83.8%)。
根據奇美醫療財團法人奇美醫院藥劑部統計資料，2022年共有1,047筆藥物不良反應的通報紀錄，其中非免疫性(可預期)佔約2成，免疫性(不可預期)則佔約8成。若以嚴重度為分級，輕度(無需治療且不用停藥)有931人，中度(需治療或導致住院延長時間)有99人，重度(需加護病房治療或危及生命)有17人。而最常產生過敏的藥物為抗生素。
王羽安醫師指出，皮膚是藥物不良反應最常表現的器官且千變萬化，可以長得像蕁麻疹、血管炎，也可以形成許多水泡或膿皰，以上症狀統稱為藥物疹。藥物疹的定義為，病人以正常投與方式(外用、口服、針劑)接受了正常劑量的藥物後，在皮膚上產生不良反應，由於每個人的免疫系統有所差異，故就算吃到同一種藥物，對藥物的反應也會有所不同，輕則局部腫脹或癢疹，嚴重則全身破皮黏膜潰爛。越早發現則產生嚴重後遺症的機率越低，因此，皮膚科醫師在藥物不良反應的早期診斷中扮演十分重要的角色。
根據一篇2022年的文獻統計，近18年來在臺灣最常產生嚴重藥物不良反應的藥物包含非類固醇消炎止痛藥(NSAID)、抗癲癇藥(carbamazepine, phenytoin, lamotrigine)、磺胺類藥物、人類免疫缺乏病毒(HIV)抗病毒藥物、抗尿酸用藥(allopurinol)……等。除了西藥以外，中藥及保健食品也會造成藥物不良反應。立即性的藥物過敏在服藥後幾個小時內就會出現，如蕁麻疹或過敏性休克；延遲性的藥物疹則在服藥後3至14天後才產生，臨床表現更為多樣化。皮膚科醫師會根據藥物疹的型態及進展速度，追溯病人近期的用藥紀錄，並決定是否需要安排抽血或切片檢查，一旦抓到最懷疑的藥物，就要儘快停藥，並輔以相對應的治療。
王羽安醫師解釋，藥物疹常常由軀幹開始出現，往四肢擴散，大小不一的紅色斑塊會逐漸聚集成一整片，合併局部搔癢或疼痛。若皮疹的進程快速，僅在兩三天內就擴散至全身，就屬於較為嚴重的藥物疹，尤其是產生水泡或膿皰、合併黏膜部位(如眼睛、口腔、生殖器)腫脹破皮、發燒、倦怠等系統性症狀者，可能會影響到皮膚以外的器官，產生許多後遺症。史蒂芬強森症候群(Stevens-Johnson syndrome)是臨床上最為嚴重的藥物疹，皮膚呈現如燒燙傷大面積的水泡及壞死脫皮，黏膜嚴重潰爛，常合併敗血性休克及肝腎功能衰竭，最甚者可造成死亡。因此早期的診斷及儘快停藥更是不可或缺。
王羽安醫師表示，隨著快速的藥物發展，藥物的安全性也逐漸成為一門重要的課題，首要的步驟就是遵從醫師的指示服藥，不要擅自停藥或改變劑量，也不要服用來路不明的藥物。凡經我國核准之合法藥品，包裝上都會載有「藥品許可證字號」，如衛署藥製字等字樣，若有任何疑慮，可上食藥署「西藥、醫療器材及化粧品許可證查詢系統」，查詢藥品許可證或相關資訊，並尋求醫師或藥師的協助。
服用藥物後，需仔細觀察身體是否出現任何不適，並參考藥袋、外盒、仿單的說明，若皮膚出現大面積紅疹、黏膜疼痛、水泡、膿皰以及破皮等症狀，應立刻停藥並儘速就醫。
王羽安醫師呼籲：預防勝於治療，要避免下次藥物過敏的產生，最重要的就是記取教訓，無論是臨床醫師或病人本人，都應為藥物過敏把關。醫師會將過敏的藥物註記在醫院系統及健保卡上，病人在不同醫療場所就診時，也應主動告知醫療人員曾有藥物過敏的紀錄，另外可隨身攜帶近期內使用的藥品或藥單，讓臨床醫師可更快速及完善的評估。
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