脉冲染料激光动态联合曲安奈德治疗瘢痕疙瘩的临床效果

刘振楠; 周粤闽; 刘若璇; 李亚玲; 李晴; 张婷; 张舒曼

doi:10.3760/cma.j.cn501225-20220620-00249

脉冲染料激光动态联合曲安奈德治疗瘢痕疙瘩的临床效果

doi: 10.3760/cma.j.cn501225-20220620-00249

河南大学淮河医院整形修复外科，开封　　475000

基金项目:

河南省科技发展计划 172102410005

河南省医学科技攻关计划 201401014

详细信息

通讯作者:
周粤闽，Email：yueminzhou2@hotmail.com

计量
- 文章访问数: 2082
- HTML全文浏览量: 154
- PDF下载量: 54
- 被引次数: 0
出版历程
- 收稿日期: 2022-06-20

Clinical effects of pulsed dye laser dynamically combined with triamcinolone acetonide in the treatment of keloids

Department of Plastic and Reconstructive Surgery, Huaihe Hospital of Henan University, Kaifeng 475000, China

Funds:

Science and Technology Development Plan of Henan Province of China 172102410005

Medical Science and Technology Plan for Tackling Key Problems of Henan Province of China 201401014

More Information

Corresponding author: Zhou Yuemin, Email: yueminzhou2@hotmail.com

摘要

摘要: 目的探讨脉冲染料激光（PDL）动态联合曲安奈德在临床治疗瘢痕疙瘩中的效果。方法采用回顾性观察性研究方法。2015年4月—2020年10月，河南大学淮河医院收治符合入选标准的瘢痕疙瘩患者34例（瘢痕疙瘩46处）。根据采用的治疗方式，将患者分为曲安奈德组与动态治疗组，前一组患者共18例（瘢痕疙瘩26处），其中男8例、女10例，年龄（30±12）岁，仅进行曲安奈德注射治疗；后一组患者共16例（瘢痕疙瘩20处），其中男6例、女10例，年龄（26±11）岁，根据每次治疗前温哥华瘢痕量表（VSS）评分选择是否进行曲安奈德注射、PDL或者PDL联合曲安奈德注射治疗。首次治疗前及首次治疗后（以下简称治疗前与治疗后）12个月，采用VSS、患者与观察者瘢痕评估量表（POSAS）评估瘢痕疙瘩情况，采用皮肤病生活质量指数（DLQI）量表评估瘢痕疙瘩对患者生活质量的影响。治疗后12个月，根据VSS评分进行瘢痕疙瘩疗效评价并计算显效率。记录瘢痕疙瘩首次显效时间、达到首次显效时曲安奈德累计注射次数、治疗后12个月内随访次数与不良反应发生情况并计算不良反应发生率。对数据行配对样本t检验、独立样本t检验、Wilcoxon秩和检验、Mann-Whitney U检验、χ²检验、Fisher确切概率法检验。结果曲安奈德组、动态治疗组患者瘢痕疙瘩治疗后12个月VSS总评分均较治疗前明显降低（t值分别为7.53、8.09，P<0.01），VSS、POSAS中色泽和血管分布总分与POSAS总评分及DLQI量表评分均较治疗前明显降低（Z值分别为-3.71、-4.04、-4.21、-4.11，-3.76、-3.73、-3.92、-3.93，P<0.01）；动态治疗组患者瘢痕疙瘩治疗后12个月VSS、POSAS中色泽和血管分布总分均明显低于曲安奈德组（Z值分别为-2.03、-2.12，P<0.05）。动态治疗组患者瘢痕疙瘩治疗后12个月显效率明显高于曲安奈德组（χ²=3.88，P<0.05）。动态治疗组患者瘢痕疙瘩首次显效时间为5.5（2.0，6.0）个月，明显短于曲安奈德组的6.0（2.3，10.3）个月（χ²=4.02，P<0.05）。动态治疗组患者瘢痕疙瘩达到首次显效时曲安奈德累计注射次数为（3.2±1.7）次，明显少于曲安奈德组的（4.2±1.8）次（t=2.09，P<0.05）。动态治疗组患者瘢痕疙瘩治疗后12个月内的随访次数明显多于曲安奈德组（t=-2.94，P<0.01），总不良反应发生率低于曲安奈德组但差异无统计学意义（P>0.05）。结论与单纯曲安奈德注射比较，PDL动态联合曲安奈德治疗瘢痕疙瘩可缩短显效时间，减少曲安奈德注射次数，提高患者依从性与临床疗效。
- 瘢痕疙瘩 /
- 曲安奈德 /
- 综合疗法 /
- 脉冲染料激光
Abstract: Objective To explore the clinical effects of pulsed dye laser (PDL) dynamically combined with triamcinolone acetonide (TAC) in the treatment of keloids. Methods A retrospectively observational study was conducted. From April 2015 to October 2020, 34 keloid patients (46 keloids) who met the inclusion criteria were admitted to Huaihe Hospital of Henan University. The patients were divided into TAC group and dynamic treatment group according to their treatment methods. There were 18 patients (26 keloids) in TAC group, including 8 males and 10 females, aged (30±12) years, who were treated with TAC injection alone. There were 16 patients (20 keloids) in dynamic treatment group, including 6 males and 10 females, aged (26±11) years, who were treated with TAC injection, PDL, or PDL combined with TAC injection according to the Vancouver scar scale (VSS) score before each treatment. Before the first treatment (hereinafter referred to as before treatment) and 12 months after the first treatment (hereinafter referred to as after treatment), the keloids were assessed by VSS, patient and observer scar assessment scale (POSAS), and the effect of keloids on the quality of life of patients was evaluated with dermatology life quality index (DLQI) scale. Twelve months after treatment, the curative effect of keloid was evaluated according to the VSS score and the effective rate was calculated. The first effective time and the cumulative times of TAC injection at the first effective time, the number of follow-up and the occurrence of adverse reactions of keloids within 12 months after treatment were recorded, and the incidence of adverse reactions was calculated. Data were statistically analyzed with paired sample t test, independent sample t test, Wilcoxon rank-sum test, Mann-Whitney U test, chi-square test, and Fisher's exact probability test. Results The total VSS scores of patients' keloids in TAC group and dynamic treatment group 12 months after treatment were significantly lower than those before treatment (with t values of 7.53 and 8.09, respectively, P<0.01), and the total scores of pigmentation and vascularity in VSS and POSAS, the total POSAS score, and the DLQI scale score were significantly lower than those before treatment (with Z values of -3.71, -4.04, -4.21, -4.11, -3.76, -3.73, -3.92, and -3.93, respectively, P<0.01). The total scores of pigmentation and vascularity in VSS and POSAS of patients' keloids in dynamic treatment group 12 months after treatment were significantly lower than those in TAC group (with Z values of -2.03 and -2.12, respectively, P<0.05). Twelve months after treatment, the effective rate of patients' keloids in dynamic treatment group was significantly higher than that in TAC group (χ²=3.88, P<0.05). The first effective time of patients' keloids in dynamic treatment group was 5.5 (2.0, 6.0) months, which was significantly shorter than 6.0 (2.3, 10.3) months in TAC group (χ²=4.02, P<0.05). The cumulative times of TAC injection at the first effective time of patients' keloids in dynamic treatment group was 3.2±1.7, which was significantly less than 4.2±1.8 in TAC group (t=2.09, P<0.05). The number of follow-up of patients' keloids within 12 months after treatment in dynamic treatment group was significantly more than that in TAC group (t=-2.94, P<0.01), and the total incidence of adverse reactions was lower than that in TAC group but without statistically significant difference (P>0.05). Conclusions Compared with TAC injection alone, PDL dynamically combined with TAC in the treatment of keloid can shorten the effective time, reduce the number of TAC injection, and improve the patient's compliance and clinical efficacy.
- Keloid /
- Triamcinolone acetonide /
- Combined modality therapy /
- Pulsed dye laser
刘振楠：研究整体设计、实施研究、采集数据、论文撰写；周粤闽：研究整体设计和指导、对文章的知识性内容作批评性审阅；刘若璇、李亚玲：数据采集和分析指导；李晴、张婷、张舒曼：技术支持、论文修改、统计分析

所有作者均声明不存在利益冲突

HTML全文

参考文献(30)

[1]	LimandjajaGC,NiessenFB,ScheperRJ,et al.The keloid disorder: heterogeneity, histopathology, mechanisms and models[J].Front Cell Dev Biol,2020,8:360.DOI: 10.3389/fcell.2020.00360.
[2]	MotokiTHC,IsoldiFC,BritoMJA,et al.Keloid negatively affects body image[J].Burns,2019,45(3):610-614.DOI: 10.1016/j.burns.2018.10.009.
[3]	Morelli CoppolaM,SalzilloR,SegretoF,et al.Triamcinolone acetonide intralesional injection for the treatment of keloid scars: patient selection and perspectives[J].Clin Cosmet Investig Dermatol,2018,11:387-396.DOI: 10.2147/CCID.S133672.
[4]	GrabowskiG,PacanaMJ,ChenE.Keloid and hypertrophic scar formation, prevention, and management: standard review of abnormal scarring in orthopaedic surgery[J].J Am Acad Orthop Surg,2020,28(10):e408-e414.DOI: 10.5435/JAAOS-D-19-00690.
[5]	中国整形美容协会瘢痕医学分会常务委员会专家组.中国瘢痕疙瘩临床治疗推荐指南[J].中国美容整形外科杂志,2018,29(5):前插3-前插14.DOI: 10.3969/j.issn.1673-7040.2018.05.001.
[6]	ElsaieML.Update on management of keloid and hypertrophic scars: a systemic review[J].J Cosmet Dermatol,2021,20(9):2729-2738.DOI: 10.1111/jocd.14310.
[7]	WangJ,WuJ,XuM,et al.Combination therapy of refractory keloid with ultrapulse fractional carbon dioxide (CO2) laser and topical triamcinolone in Asians-long-term prevention of keloid recurrence[J].Dermatol Ther,2020,33(6):e14359.DOI: 10.1111/dth.14359.
[8]	宋黎,熊琳.激光及强脉冲光治疗病理性瘢痕的研究进展[J].中国美容医学,2015,24(16):76-79.
[9]	刘若璇动态量化评估体系在瘢痕疙瘩治疗中的应用郑州河南大学2020 刘若璇.动态量化评估体系在瘢痕疙瘩治疗中的应用[D].郑州:河南大学,2020.
[10]	LvK,XiaZ,Chinese consensus panel on the prevention and treatment of scars. Chinese expert consensus on clinical prevention and treatment of scar[J/OL]. Burns Trauma,2018;6:27[2022-08-22].https://pubmed.ncbi.nlm.nih.gov/30263894/.DOI: 10.1186/s41038-018-0129-9.
[11]	OuyangHW,LiGF,LeiY,et al.Comparison of the effectiveness of pulsed dye laser vs pulsed dye laser combined with ultrapulse fractional CO2 laser in the treatment of immature red hypertrophic scars[J].J Cosmet Dermatol,2018,17(1):54-60.DOI: 10.1111/jocd.12487.
[12]	谭欢,张远理,唐原,等.瘢痕疙瘩患者128例生活质量评估及影响因素分析[J].中国皮肤性病学杂志,2021,35(2):200-204.DOI: 10.13735/j.cjdv.1001-7089.202008003.
[13]	吴丽珍,后晨蓉,谢振谋,等.曲安奈德联合玻璃酸酶注射辅助浅层X线放射治疗多发性瘢痕疙瘩的有效性研究[J].中华整形外科杂志,2021,37(1):79-83.DOI: 10.3760/cma.j.cn114453-20200624-00384.
[14]	于磊,杨雅婷,刘伟.瘢痕疙瘩患者瘢痕疙瘩与其周围正常皮肤水屏障功能的差异及其相关机制[J].中华烧伤与创面修复杂志,2022,38(1):63-68.DOI: 10.3760/cma.j.cn501120-20210427-00156.
[15]	LuWS,WangJF,YangS,et al.Association of HLA-DQA1 and DQB1 alleles with keloids in Chinese Hans[J].J Dermatol Sci,2008,52(2):108-117.DOI: 10.1016/j.jdermsci.2008.04.010.
[16]	PiresJA,BragatoEF,MomolliM,et al.Effect of the combination of photobiomodulation therapy and the intralesional administration of corticoid in the preoperative and postoperative periods of keloid surgery: a randomized, controlled, double-blind trial protocol study[J].PLoS One,2022,17(2):e0263453.DOI: 10.1371/journal.pone.0263453.
[17]	YooMG,KimIH.Keloids and hypertrophic scars: characteristic vascular structures visualized by using dermoscopy[J].Ann Dermatol,2014,26(5):603-609.DOI: 10.5021/ad.2014.26.5.603.
[18]	XiaY,WangY,ShanM,et al.Advances in the pathogenesis and clinical application prospects of tumor biomolecules in keloid[J/OL].Burns Trauma,2022,10:tkac025[2022-08-26].https://pubmed.ncbi.nlm.nih.gov/35769828/.DOI: 10.1093/burnst/tkac025.
[19]	OgawaR,AkaishiS.Endothelial dysfunction may play a key role in keloid and hypertrophic scar pathogenesis - keloids and hypertrophic scars may be vascular disorders[J].Med Hypotheses,2016,96:51-60.DOI: 10.1016/j.mehy.2016.09.024.
[20]	RoquesC,TéotL.The use of corticosteroids to treat keloids: a review[J].Int J Low Extrem Wounds,2008,7(3):137-145.DOI: 10.1177/1534734608320786.
[21]	Blanco de TordM,Plana PlaA,JakaA.Big ear keloid response to PDL laser[J].Med Clin (Barc),2021,157(4):217.DOI: 10.1016/j.medcli.2020.07.045.
[22]	KhattabFM,NasrM,KhashabaSA,et al.Combination of pulsed dye laser and verapamil in comparison with verapamil alone in the treatment of keloid[J].J Dermatolog Treat,2020,31(2):186-190.DOI: 10.1080/09546634.2019.1610550.
[23]	GoldMH,BermanB,ClementoniMT,et al.Updated international clinical recommendations on scar management: part 1--evaluating the evidence[J].Dermatol Surg,2014,40(8):817-824.DOI: 10.1111/dsu.0000000000000049.
[24]	刘振楠,周粤闽.脉冲染料激光在创伤后瘢痕早期治疗中的应用研究进展[J].中华烧伤杂志,2021,37(7):688-691.DOI: 10.3760/cma.j.cn501120-20200315-00164.
[25]	陈立新,王莹,林杨杨,等.脉冲染料激光对体外瘢痕成纤维细胞中TGF-β1和TGF-β3表达的影响[J].中国中西医结合皮肤性病学杂志,2019,18(1):11-14.DOI: 10.3969/j.issn.1672-0709.2019.01.003.
[26]	NastA,GauglitzG,LorenzK,et al.S2k guidelines for the therapy of pathological scars (hypertrophic scars and keloids) - update 2020[J].J Dtsch Dermatol Ges,2021,19(2):312-327.DOI: 10.1111/ddg.14279.
[27]	KuoYR,WuWS,WangFS.Flashlamp pulsed-dye laser suppressed TGF-beta1 expression and proliferation in cultured keloid fibroblasts is mediated by MAPK pathway[J].Lasers Surg Med,2007,39(4):358-364.DOI: 10.1002/lsm.20489.
[28]	赵烨德,高萍,陈云祥,等.脉冲染料激光和曲安奈德局部注射治疗病理性瘢痕的临床体会[J].海军医学杂志,2007,28(2):102-103.DOI: 10.3969/j.issn.1009-0754.2007.02.003.
[29]	梁文,陈瑞,蒋雨薇,等.595nm脉冲染料激光联合醋酸曲安奈德治疗瘢痕疙瘩的疗效[J].中国激光医学杂志,2021,30(1):35.
[30]	MuneuchiG,SuzukiS,OnoderaM,et al.Long-term outcome of intralesional injection of triamcinolone acetonide for the treatment of keloid scars in Asian patients[J].Scand J Plast Reconstr Surg Hand Surg,2006,40(2):111-116.DOI: 10.1080/02844310500430003.

下载: 全尺寸图片幻灯片

1 例1动态治疗组患者前胸部表面皮肤毛囊炎后形成瘢痕疙瘩首次治疗前后情况。1A.治疗前，瘢痕疙瘩明显高于体表，充血明显；1B.行脉冲染料激光联合曲安奈德注射治疗后1个月，瘢痕疙瘩厚度变薄，颜色得到改善；1C.治疗后2个月，瘢痕疙瘩平整，颜色改善，达到显效

下载: 全尺寸图片幻灯片

2 例2曲安奈德组患者肩背部不明原因所致瘢痕疙瘩首次治疗前后情况。2A.治疗前，瘢痕疙瘩明显高出体表，色泽较深；2B.行曲安奈德注射治疗后1个月，瘢痕疙瘩色泽加深，厚度变厚；2C.治疗后2个月，瘢痕疙瘩稍平整，颜色改善；2D.治疗后7个月，瘢痕疙瘩颜色改善；2E.治疗后10个月，瘢痕疙瘩变平整，颜色淡，达到显效

下载: 全尺寸图片幻灯片

表1 2组瘢痕疙瘩患者首次治疗前后瘢痕疙瘩评分比较（分）

组别	瘢痕疙瘩数（个）	VSS总评分（x¯±s）		VSS中色泽和血管分布总分［M（Q₁，Q₃）］		POSAS总评分［M（Q₁，Q₃）］		POSAS中色泽和血管分布总分［M（Q₁，Q₃）］
组别	瘢痕疙瘩数（个）	治疗前	治疗后12个月	治疗前	治疗后12个月	治疗前	治疗后12个月	治疗前	治疗后12个月
曲安奈德组	26	9.1±1.2	5.3±2.7^a	4.00（4.00，4.25）	3.00（1.00，3.25）^a	60.5（54.0，65.0）	37.0（22.5，52.8）^a	14.0（13.0，17.0）	11.0（6.8，12.5）^a
动态治疗组	20	9.4±1.7	4.8±2.7^a	4.00（4.00，5.00）	1.00（1.00，2.00）^a	60.5（49.5，80.0）	30.0（22.8，38.8）^a	14.0（14.0，16.8）	6.0（3.5，9.0）^a
统计量值		t=-0.55	t=0.54	Z=-0.07	Z=-2.03	Z=-0.52	Z=-0.37	Z=-0.17	Z=-2.12
P值		0.587	0.593	0.941	0.042	0.602	0.593	0.866	0.034
注：动态治疗组疗法包括行曲安奈德注射、脉冲染料激光（PDL）或者PDL联合曲安奈德注射治疗；VSS为温哥华瘢痕量表，POSAS为患者与观察者瘢痕评估量表；与治疗前比较，^aP<0.01

下载: 导出CSV

表2 2组瘢痕疙瘩患者首次治疗后12个月内不良反应发生情况[次（%）]

组别	瘢痕疙瘩数（个）	毛细血管扩张	色素沉着	局部凹陷	药物沉渣	色素脱失	总不良反应
曲安奈德组	26	7（26.92）	4（15.38）	2（7.69）	2（7.69）	2（7.69）	17（65.38）
动态治疗组	20	2（10.00）	2（10.00）	1（5.00）	1（5.00）	1（5.00）	7（35.00）
P值		0.262	0.684	>0.999	>0.999	>0.999	0.073
注：动态治疗组疗法包括行曲安奈德注射、脉冲染料激光（PDL）或者PDL联合曲安奈德注射治疗