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Бородавки на руках приногтевые бородавки

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Бородавки на руках приногтевые бородавки

Околоногтевая бородавка — это доброкачественное новообразование (нарост) на коже вокруг ногтевой пластины (изредка может появиться под самим ногтем).

Околоногтевые бородавки относятся к виду обыкновенных, зачастую они образуются в зоне рядом с ногтевой пластиной либо под ней. Это заболевание имеет вирусную этиологию и проявляется образованием на поверхности кожи папул (узелков), выступающих над эпителием. Такие опухоли представляют собой доброкачественные формирования, но в некоторых случаях могут перерождаться в злокачественные. Появление околоногтевых бородавок вызвано проникновением в организм вируса папилломы человека (ВПЧ), который насчитывает до 100 различных типов. В основном от рецидивов страдают дети, имеющие дурную привычку грызть ногти и кожицу вокруг них.

Папилломы, которые формируются возле ногтей, принято делить на два типа:

  • возникающие под ногтями – подногтевые;
  • образующиеся на поверхности кутикулы около ногтевой пластины – приногтевые либо околоногтевые.

Первые локализуются под ногтём, узелки бывают небольшого размера и по оттенку практически не отличаются от кожи. Чаще всего такие бородавки не замечают, поскольку никаких проблем они не доставляют. Неприятности начинаются только тогда, когда подногтевая папула, сформированная под ногтём, увеличивается в размере и продолжает расти. В этом случае ноготь постепенно истончается, что приводит к его деформации и, как следствие, разрушению. Также отмечают, что околоногтевые бородавки на ногах начинают причинять сильную боль из-за того, что ступня сдавливается обувью. Это приводит к тому, что пациент начинает хромать и его подвижность неизбежно будет ограничена. Поэтому, если имеется такая патология, рекомендуется обратиться к специалисту, чтобы провести диагностику и выбрать верное лечение.

Околоногтевой либо приногтевой называют бородавку, которая образовалась на руках или ногах возле самого ногтя. Такая папиллома практически сразу обнаруживается пациентом, поскольку представляет собой опухоль на поверхности эпителия, возвышающуюся в большей или меньшей мере выше его уровня. Бородавочное образование такого типа имеет плоские очертания либо может обладать корнем, основательно уходящим в ткани. Папилломы с корнем, увеличиваясь в размерах, начинают захватывать рядом растущий ноготь, чем вызывают его поражение. В результате этого искажается его поверхность, и он постепенно уничтожается.

Если детально рассмотреть околоногтевые бородавки, то на их поверхности можно заметить крошечные точечки и полоски, которые свидетельствуют о появлении тромбов в капиллярах.

Приногтевые бородавки на руках часто подвергаются травмированию. Это приводит к тому, что папула начинает кровоточить. В этом же случае происходит аутоинокуляция, то есть пациент самозаражается.

Важно отметить, что подногтевые или околоногтевые бородавки появляются гораздо реже, чем другие виды.

Причины появления околоногтевых бородавок

На фото запущенная околоногтевая бородавка

Как указывалось выше, причина возникновения таких папиллом — заражение ВПЧ, который проникает через микротравмы в кожном покрове. Это может быть случайная травма, маникюр, выполненный с нарушением санитарных норм (порезы или применение зараженного инструмента), контакт с носителем заболевания или использование вещей человека, заражённого ВПЧ. Сам вирус может попасть в организм человека даже в детстве, но не проявляться, пока для него не будут созданы «благоприятные» условия:

  • общее снижение иммунитета;
  • наличие заусениц;
  • привычка грызть ногти и кутикулу;
  • работа без защитных перчаток с бытовой химией или химическими веществами, которые способствуют раздражению кожи на руках.

Это факторы, влияющие на образование околоногтевых бородавок на руках. Если говорить о папилломах под ногтевой пластиной на ногах, то их появление может вызывать:

  • ношение чужой обуви;
  • отсутствие специальной обуви в саунах или бассейнах;
  • ношение тесной, неудобной обуви из грубых или не дышащих материалов;
  • повышенное выделение пота на ступнях;
  • наличие вросших ногтей.

Диагностика и симптомы околоногтевых бородавок

Если бородавки образовались около ногтевой пластины или под ней, то их очень просто можно спутать с характерными особенностями других заболеваний. Поэтому рекомендуется обратиться к врачу-дерматологу, который сможет правильно диагностировать новообразование и назначить соответствующее лечение для устранения папилломы. Самолечение в этом случае может привести к негативным результатам. Грамотный специалист после осмотра кожного покрова и новообразований на нём быстро поставит диагноз. Изредка врачи назначают и дополнительные исследования, чтобы исключить риск развития онкозаболеваний.

Околоногтевые бородавки очень сильно по виду напоминают омозолистость. Однако основным отличием между мозолью и папилломой является то, что на поверхности первой сохраняется кожный рисунок и в её структуре не просматриваются затромбированные капилляры. А вот на поверхности папулы отчётливо видны чёрные крапинки. Это легко отметить даже при визуальном осмотре.

При образовании бородавки под ногтевой пластиной происходит постепенное разрушение ногтя, и это очень напоминает внешне грибковое поражение. Если сравнивать фото, представленные во многих литературных медицинских источниках, то патологии по виду совершенно неотличимы. В таком случае необходимо провести посев на грибы. Если у пациента ВПЧ, он даст отрицательный результат.

При необходимости дерматолог может дополнительно порекомендовать пройти:

  • Дерматоскопию. В ходе процедуры используется аппарат дермоскоп, который отображает поверхность образования в десятикратном увеличении. Структура, симметричность и очертания контуров становятся более отчётливо видны.
  • Биопсию. В этом случае берутся крохотные части кожного узелка для исследования под микроскопом.

Лечение околоногтевых бородавок: аптечные препараты

Традиционная медицина предлагает несколько методов лечения околоногтевых бородавок. Обычно их разделяют на две группы — консервативное лечение и хирургическое вмешательство.

Под консервативной терапией подразумевается назначение лекарственных препаратов, борющихся с ВПЧ и способствующих повышению иммунитета. Обычно это медикаменты для орального приёма. Наиболее эффективные из них:

  • Циклоферон — цена стартует от 135 рублей;
  • Анаферон — от 198 руб.;
  • Изопринозин — стоимость начинается от 587 руб.

Нельзя принимать эти лекарственные препараты для самолечения. Назначить их может только специалист на основании клинической картины заболевания. В некоторых случаях дерматологи рекомендуют местное лечение.

Средства для наружного применения назначаются в зависимости от того, какое количество бородавок появилось, каковы их размеры и где они локализованы.

В список наиболее эффективных лекарств для наружного применения входят:

  • Имиквимод (от 2 019 р.) — иммуномодулятор.
  • Солкодерм (стоимость варьируется от 401 до 1 489 руб.) и Веррукацид (от 211 руб.) — медпрепараты на основе кислот, которые способствуют некротизации тканей.
  • Виферон (от 123 руб.) — противовирусная мазь.
  • Криофарма (от 859 руб.) — хладагент, замораживающий бородавки.
  • Салициловая кислота (цена от 6 руб.) и мазь Колломак (стоимость находится в пределах от 264 до 490 руб.) — кератолитические средства, разрушающие роговой слой папилломы.

Все вышеуказанные медикаменты врач назначает для лечения околоногтевых бородавок небольших размеров, которые находятся на поверхности кожи. Если же папиллома крупная, имеет глубокий корень или представляет собой застарелое образование, то рекомендуется прибегать к хирургическому воздействию.

  • Читайте также про домашние средства от папиллом для наружного применения

Удаление околоногтевых бородавок

Хирургические методы избавления от околоногтевой бородавки применяются в том случае, когда вышеуказанные препараты не принесли положительного результата, а папиллома приносит проблемы как косметические, так и физические (например, боль). В медицине на сегодняшний день есть несколько радикальных способов избавиться от околоногтевых бородавок, к ним относятся:

  1. Криодеструкция — проводится путём прижигания проблемного кожного образования жидким азотом. Обычно на прижигание бородавки отводится до минуты времени. На её месте может остаться побелевший участок, который напоминает ожог. Через несколько дней корочка отпадает и на коже остаётся небольшая выемка, зарастающая за 2–3 дня. Хоть этот метод и считается наиболее щадящим, у него есть противопоказания. Нельзя прижигать бородавки жидким азотом людям, страдающим сахарным диабетом, детям дошкольного возраста и беременным. Эффективность криодеструкции довольно высока и находится в диапазоне 70–100 %. Рецидив возможен только в 15 % случаев. За удаление одной бородавки необходимо заплатить от 300 рублей.
  2. Радиоволновой метод основан на применении аппарата Сургитрон, в котором электрический ток преобразовывается в радиоволны частотой 3,8-4,0 МГц. Под воздействием аппарата поверхность бородавки начинает испаряться. Преимущество процедуры – не выделяется кровь. Этот метод также носит название «радиоволновой нож». Эффективность удаления — в пределах 80-90 %, случаи рецидивов составляют всего 2-5 %. Стоимость удаления папулы начинается от 600 руб.
  3. Лазерокоагуляция. С помощью лазерного луча проводится выжигание папилломы, вследствие чего её ткань испаряется. На месте бородавки остаётся корочка, которая по прошествии 2-4 недель отваливается. Удаление одного узелка занимает несколько минут. Отмечается высокий уровень эффективности — 93 %. Цена начинается со 140 руб.
  4. Хирургический метод. Изредка требуется иссечение бородавки скальпелем. Однако такая операция проводится исключительно хирургами. Повреждённая часть эпителия иссекается и на ранку накладывается косметический шов, после которого останется белесый рубец. Данный метод наиболее травматичный и требует долгой реабилитации. Его назначают в том случае, когда необходимо получить ткани бородавки для исследований. Эффективность удаления составляет 50–60 %, а рецидивы происходят в 50 % случаев. Цена оперативного вмешательства начинается от 350 руб.
  5. Электрокоагуляция. В ходе процедуры используется высокочастотный ток. Патологические кожные образования срезаются петлей из проволоки, а оставшаяся ранка постепенно заживает. Также происходит обеззараживание здоровых тканей эпителия. Если говорить об эффективности данного метода, то она варьируется в диапазоне от 80 до 95 %. Цена может начинаться от 500 руб. за удаление одной околоногтевой бородавки.

Обычно такие процедуры проводятся врачами в амбулаториях и в короткий промежуток пациент может вернуться домой. Период, который отводится на реабилитацию после хирургического вмешательства, зависит от того, какой из методов был применен для избавления от околоногтевых бородавок.

Важно. При любом методе воздействия особенности ухода за местом, где была бородавка, практически ничем не отличаются – ни в коем случае нельзя отдирать сформированную корочку, а кожный покров рекомендуется обрабатывать средствами с антисептическим и антибактериальным действием.

Лечение околоногтевых бородавок в домашних условиях

Фото околоногтевых бородавок на женских пальцах

Избавиться от околоногтевых бородавок можно и самостоятельно. Издавна народные лекари рекомендовали большое количество способов, позволяющих практически безболезненно решить эту проблему. Однако здесь необходимо запастись терпением и аккуратно выполнять всё по рецепту.

Околоногтевые бородавки смазывают соком, выдавленным из стеблей чистотела. Также применяют чабрецовый, луковый, молочайный и сок из созревших рябиновых ягод. Издавна для лечения бородавочных образований используется касторовое масло и мелко натёртый хрен, смешанный с солью (читайте как использовать касторовое масло от папиллом). Популярностью также пользуются петрушка дикая, портулак и дикие яблоки, поскольку эти растительные растворы обладают высокой кислотностью. Можно смазывать появившиеся кожные новообразования соком клещевины и виноградной лозы.

Более щадящее, но не менее эффективное действие оказывают натирания розовыми лепестками, настойкой из шиповника или сока ястребинки волосистой. Из агрессивных средств выделяют уксусную кислоту, которую ежедневно наносят на околоногтевую бородавку при лечении в домашних условиях.

При использовании указанных народных рецептов было отмечено, что поверхность папилломы стала чернеть. Это свидетельствует об отмирании тканей образования. В это время не рекомендуется срезать бородавку, лучше подождать, когда она отпадёт сама. Если не придерживаться этого правила, можно спровоцировать рецидив.

Околоногтевые бородавки у детей

Околоногтевые бородавки часто образуются у детей из-за незрелости иммунитета молодого организма, а также регулярных травм. Многие из вышеуказанных методов лечения и удаления бородавок являются довольно болезненными, потому родители стараются справиться с заболеванием своими силами и прибегают к народным способам лечения таких папиллом. Однако бородавки не так просто поддаются лечению, а затягивая время, можно дождаться, что ногтевая пластина начнёт деформироваться и, как следствие, разрушаться.

Если у ребенка обнаружена единственная околоногтевая бородавка, которая не причиняет неприятностей, то даже врачи-дерматологи рекомендуют не заниматься самолечением, а немного подождать. Это связано с тем, что в детском и подростковом возрасте такое образование может исчезнуть без постороннего вмешательства. Необходимость в консультации специалиста возникает в следующих случаях:

  • количество бородавок стремительно увеличивается;
  • размеры папул растут;
  • околоногтевые бородавки стали кровоточить и часто подвергаются травмам;
  • в ходе визуального осмотра возникает сомнение, что новообразование является бородавкой.

Профилактика околоногтевых бородавок

Поскольку вирус папилломы человека попадает в организм через микротравмы на коже, стоит придерживаться следующих правил:

  1. Обязательно использовать личную обувь при посещении общественных мест (сауны, бассейны, спортзалы). По приходу домой её тщательно просушивать.
  2. Нельзя носить чужую обувь, а также носки, колготки, рукавицы и тому подобное.
  3. Делать маникюр и педикюр нужно только у проверенных мастеров в салонах, где проводится вся предписанная требованиями санитарной гигиены обработка инструментов после приёма каждого клиента.
  4. Важно бороться с вредной привычкой грызть ногти, обкусывать кутикулу и заусенцы.
  5. Если случилось минимальное травмирование кожного покрова, рекомендуется провести обработку раны антисептическими средствами.
  6. Принимать витаминные курсы.
  7. Во время работы с пищевыми продуктами (мясо, рыба или другие продукты) пользоваться перчатками.
  8. Надевать перчатки при работе с агрессивными веществами и бытовой химией.
  9. Ограничить контакты с людьми, имеющими бородавки.

Если случился рецидив и вновь стали образовываться околоногтевые бородавки, необходимо обратиться к иммунологу и попросить назначить иммунограмму. По всей вероятности, уровень защитных сил организма сильно понижен и нужно будет пропить курс иммуностимулирующих препаратов.

Как происходит удаление околоногтевой бородавки, смотрите в следующем видео:

  • Читайте про ляписный карандаш от бородавок

Красивая кожа – признак хорошего здоровья организма.

Любые изменения кожного покрова, появление высыпаний, воспалений и других нарушений свидетельствуют об ослаблении иммунной системы.

Бородавки на руках не являются исключением, их появление сигнализирует о том, что в кровь попал вирус папилломы человека (ВПЧ), который активно размножается и становится источником заражения для других людей.

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Что это

Околоногтевые бородавки – это доброкачественные образования, которые не представляют серьезной угрозы для здоровья.

Они относятся к вульгарным наростам и наиболее часто бывают вызваны вирусом 2 типа.

Как видно из названия, бородавки поражают кожу кутикулы вокруг ногтевой пластины, под ногтем на руках и ногах, представляя собой не очень приятное зрелище.

Поэтому желание избавиться от таких новообразований больше вызвано неэстетичным видом, а не опасностью их преобразования в злокачественную опухоль, как это бывает с бородавками другой локализации.

Разновидности

Существует множество видов бородавок, рост которых спровоцирован ВПЧ.

В медицине принято выделять 5 видов:

  1. вульгарные или обыкновенные наросты, возвышающиеся над кожей, серого или желтоватого цвета с грубой поверхностью. Благодаря корню они врастают в более глубокие слои кожи, что затрудняет их самостоятельное удаление. Могут появляться на тыльной стороне кистей, пальцах у ребенка и взрослого. Часто одна бородавка способна размножаться, что приводит к появлению нескольких;
  2. плоские, юношеские или ювенильные бородавки появляются в основном у подростков в пубертатном периоде жизни, имеют гладкую поверхность, серый оттенок, часто растут на лице, шее во множественном количестве;
  3. нитевидные новообразования или папилломы имеют ножку и висячую удлиненную форму. Часто растут в области подмышечных впадин, на груди у стариков, под молочными железами у женщин. На ощупь мягкие, легко травмируются, имеют телесный или розоватый цвет;
  4. старческие или себорейные бородавки формируются годами, а выглядят как большие темно-коричневые или черные наросты с маслянистой и сморщенной поверхностью. Появляются у людей преклонного возраста на спине, шее, лице и в волосистой части головы;
  5. остроконечные кондиломы считаются наиболее опасным видом, а также отличаются местом распространения. Они растут снаружи половых органов у мужчин и женщин, на слизистой оболочке влагалища, поражают отверстие ануса и являются частыми виновниками рака шейки матки и полового члена.

Почему появляются

Главная причина болезни – вирус. Попав в организм, ВПЧ может затаиться на длительный период, не выказывая своего присутствия.

Фото: привычка грызть ногти — одна из причин появления бородавок

Носителем вируса является каждый третий человек на земле, даже не догадываясь об этом.

Появление бородавок свидетельствует о негативных изменениях в организме, ослаблении иммунитета, прогрессировании сопутствующих заболеваний, изменении гормонального фона, частых стрессах.

Также провоцирует рост бородавок:

  • повышенная потливость рук;
  • повреждения кутикулы при травмах или во время маникюра;
  • частые контакты с водой без перчаток;
  • привычка грызть ногти.

Способы заражения

Фото: передача вируса происходит при тесных контактах

  • Заразиться вирусом очень легко, его передача происходит от человека к человеку наиболее часто при половых контактах, включая оральный секс и поцелуи.
  • Вирус настолько мал, что проникает в кровь через микроскопические травмы в коже или слизистой оболочке.

Заразиться ВПЧ можно:

  • в бассейне, бане, общественном душе;
  • в маникюрном салоне, если инструменты недостаточно продезинфицированы;
  • посредством рукопожатия;
  • путем самозаражения при травмах кожи вокруг ногтя.

Клинические проявления околоногтевых бородавок

Фото: поражение ВПЧ пальцев рук

  • По форме новообразования бывают плоскими или напоминают полусферу.
  • Наросты шершавые на ощупь, могут расти на поверхности околоногтевого пространства или иметь корень, сливаться друг с другом.
  • Обычно бородавки не вызывают неприятных ощущений, не болят и не зудят.

Несмотря на то, что околоногтевые бородавки не опасны, их длительное наличие у человека может создать серьезные проблемы:

Фото: деформация и разрушение ногтевой пластины

Фото: появление трещин на пальце

  • образование трещин, которые могут стать воротами для проникновения в организм различного рода инфекции;
  • поражение обширной поверхности, вызванное размножением бородавок посредством попадания вируса в микротрещины на здоровой коже.

Диагностика

Для диагностики достаточно осмотра специалиста, который в редких случаях решает отправить ткань бородавки на гистологическое исследование, чтобы удостовериться в ее доброкачественном характере.

Фото: визуальный осмотр дерматологом

Дополнительно исследуется кровь для определения наличия в организме ВПЧ.

Видео: «Удаление околоногтевой бородавки»

Лечение

Околоногтевая бородавка является только симптомом заболевания, лечение которого заключается, прежде всего, в борьбе с вирусом, а также в укреплении иммунитета.

Доктор назначает противовирусные и иммуномодулирующие препараты («Ацикловир», «Панавир», «Виферон», «Генферон», «Иммуномакс», «Ликопид»), а также витаминные и минеральные комплексы.

Однако, лечение противовирусными мазями местного действия редко приносит результаты.

Наросты обязательно удаляют, чтобы препятствовать их распространению и спасти здоровье ногтевой пластины.

Удаление

Удаление околоногтевых бородавок может быть затруднено, что связано с их расположением.

Существуют несколько методов, которые используются в современной медицине:

  • иссечение скальпелем применяется редко, после него остаются видимые шрамы, а также велика вероятность рецидивов, но эффективно при больших размерах нароста, когда нельзя применять другие методы;
  • электрокоагуляция заключается в воздействии на бородавку электрическим током. Происходит нагрев тканей, их разрушение и удалений отмершего нароста специальной петлей. Образовавшаяся на месте среза корочка отпадает самостоятельно, не оставляя шрамов;
  • выжигание бородавок лазером эффективно и происходит послойно путем направленного действия теплового луча, препятствует попаданию инфекции, бескровно, а также редко оставляет рубцы, снижает риск рецидивов;

Фото: удаление новообразований лазером

  • криодеструкция – замораживание бородавки жидким азотом, в процессе чего ткани отмирают и отпадают. Этот метод не требует обезболивания, затрат времени, но для полного избавления от наростов нужно посетить несколько сеансов. Удаление азотом противопоказано у детей до 4 лет, беременных и больных сахарным диабетом.

Фото: прижигание жидким азотом

Народные методы

В запущенных случаях болезни, когда околоногтевые бородавки распространились на значительные участки кожи, а также под ногтевую пластину лечение народными средствами вряд ли окажется эффективным.

При начальной стадии заболевания и единичных небольшого размера околоногтевых бородавках могут помочь следующие методы:

  • смазывание нароста свежим соком чистотела дважды в день, пока он не почернеет и не исчезнет;

Фото: прижигание новообразования соком чистотела

  • протирание бородавок уксусной кислотой несколько раз в день до полного их исчезновения;
  • втирание в наросты касторового, облепихового, лимонного масла, также можно использовать эфирные масла чайного дерева, иланг-иланг, розовое;
  • смазывание бородавок соком чеснока, обладающим обеззараживающим и выжигающим действием, смешанным в равных частях с любым жирным кремом;
  • прикладывание компрессов из кусочка лука, вымоченного в уксусе.

Несколько десятков лет назад, бородавки удалялись путем прикладывания на ночь специального средства из уксуса и муки.

  • Для этого несколько капель любого уксуса необходимо смешать с мукой до консистенции жидковатого теста.
  • Полученную смесь нанести на бородавку, дождаться полного высыхания и образования корочки, после чего заклеить место пластырем и забинтовать.
  • Здоровый участок ногтя и кожи, перед тем как вывести бородавку, следует ограничить, приклеив пластырь.

Процедуру нужно повторять каждый день перед сном, пока бородавка не исчезнет.

Осложнения

Около ногтя или подногтевые бородавки считаются неопасными, но всегда существует риск перерождения наростов в злокачественную форму.

Фото: перерождение в меланому

Необходимо срочно обратиться к дерматологу, если:

  • наросты воспалились, покраснели, появилось нагноение, чувствуется боль;
  • изменилась форма, цвет и внешний вид бородавки.

Прогноз

В 90% случаях при правильном подходе к лечению и соблюдении мер профилактики прогноз на выздоровление благоприятный.

Хотя не исключена вероятность рецидива, а редко – приобретение бородавками онкогенных свойств.

Профилактика

Фото: содержание рук в чистоте препятствует заражению впч

  • Чтобы оградить организм от проникновения вируса, следует тщательно соблюдать личную гигиену, чаще мыть руки, протирать порезы или травмы кутикулы раствором антисептика, избавиться от привычки грызть ногти, примерять в магазине новую обувь можно только в носках.
  • Профилактика рецидивов заключается в правильном образе жизни, прежде всего, в укреплении иммунной системы.
  • Необходимо повысить физическую активность, чаще бывать на воздухе, хорошо питаться, пить натуральные соки, вовремя лечить хронические заболевания, не злоупотреблять алкоголем и бросить курить.

Вопросы и ответы

После всей вышеописанной информации могут остаться некоторые вопросы.

Например, можно ли вылечить околоногтевые бородавки другими способами, самостоятельно в домашних условиях.

Можно ли вылечить йодом

Фото: применение йода для лечения наростов

Для удаления бородавок издавна используют обычный спиртовой раствор йода.

  • При помощи ватной палочки йод наносят на образование, после чего заклеивают пластырем.
  • Длительность лечения обычно составляет около недели.

Для избавления от множества околоногтевых бородавок метод удаления йодом вряд ли подойдет, разве что, если нарост только появился и находится вокруг ногтя, а не под ним.

Как удалить самостоятельно

Самостоятельное удаление может привести к серьезным последствиям.

Не всегда удается полностью избавиться от бородавки, а даже микроскопические оставшиеся частички нароста способны к размножению, что чревато деформацией и разрушением ногтя.

Распространение вируса трудно остановить в домашних условиях, поэтому лучше всего доверить здоровье квалифицированному специалисту, что позволит не только снизить риск появления рецидивов, но и сохранить красивый внешний вид ногтей и рук.

Отзывы

Отзывы людей, успешно удаливших околоногтевые бородавки в медицинских учреждениях, как нельзя лучше доказывают эффективность профессионального подхода к лечению.

Видео: «Удаление подошвенных бородавок Сургитроном»

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