【摘要】：第一部分595nm可調(diào)脈寬脈沖染料激光不同脈沖寬度治療鮮紅斑痣的臨床療效和安全性評估 目的：研究595nm脈沖染料激光不同脈沖寬度治療中國鮮紅斑痣(PWS)患者的臨床療效和安全性。方法：使用595nm脈沖染料激光,按不同脈沖寬度(1.5ms、3ms、6ms、10ms)分別進行治療并隨訪。入組中國Ⅲ或Ⅳ型皮膚的PWS患者11例,男6例,女性5例,年齡15-50歲,平均24.82±9.82歲,系我院皮膚科門診患者。每個患者每次分別用不同的脈沖寬度治療皮損內(nèi)選定的4個區(qū)域,治療光斑直徑選用7mm,能量密度9-12J/cm2。每2月一次治療,共治療3-5次。治療前及最后一次治療結(jié)束后2個月拍照,并由一名獨立的皮膚科醫(yī)生根據(jù)照片進行療效評價和評分(1分,25%；2分,26%-50%；3分,51%-75%；4分,76%-100%),其中評分依據(jù)是治療前后皮損消退、面積縮小、顏色淡化等情況的總體評價,并記錄治療過程中發(fā)生的不良反應(yīng),如色素改變和疤痕等。結(jié)果：所有的PWS患者接受了3-5次激光治療,總計治療了44處皮損區(qū)域(4個脈沖寬度組)。最后一次治療后2個月隨訪時所有44處治療區(qū)總有效率和顯效率分別為47.73%和27.28%,只有7處(15.91%)治療區(qū)域無效。1.5ms、3ms、6ms、10ms四個脈沖寬度組PWS患者的總有效率分別是63.64%、63.64%、36.37%、27.27%,而相應(yīng)的治愈率為45.46%、27.27%、18.18%、18.18%。療效平均分值中1.5ms脈沖寬度組為3.00,高于其它組(2.82、2.36、2.18),而且隨著脈沖寬度增大分值下降,所有治療區(qū)域的總的療效分值是2.59。紫紅色PWS皮損較粉紅色、紅色皮損效果差,在所有顯效和有效脈沖寬度組的治療區(qū)中,粉紅色和紅色皮損占了57.14%,高于紫紅色皮損區(qū)。不良反應(yīng)：紫癜見于所有患者,少量患者出現(xiàn)色素沉著(11.36-15.91%)和色素減退(2.27-6.82%),主要見于1.5ms和3ms脈沖寬度治療組,為暫時性,都在三個月內(nèi)消退。沒有患者出現(xiàn)疤痕。結(jié)論：595nm脈沖染料激光可以有效地治療中國PWS患者,安全性高,無疤痕等明顯副作用。不同脈沖寬度的治療效果是有差異的,以1.5ms脈沖寬度組效果最好。 第二部分鮮紅斑痣的共聚焦激光掃描顯微鏡在體檢測 目的：研究應(yīng)用RCM對鮮紅斑痣患者皮損血管情況(直徑、密度等)進行初步描述和觀察,并與正常人皮膚血管情況相比較。方法：招募20例(男8例,女性12例)Ⅲ或Ⅳ型皮膚志愿者,其中無PWS皮損正常人10例,面頸部PWS患者10例,年齡在13-36歲之間(平均18.30+5.66歲)。PWS患者皮損部位選擇一處區(qū)域進行RCM檢測,正常對照者選擇同樣區(qū)域做相應(yīng)檢測。結(jié)果：PWS患者皮損內(nèi)的血管平均直徑均值為71.70±27.11μm,正常對照者對應(yīng)部位的血管平均直徑均值19.00±9.74μ m,P0.01。PWS患者皮損內(nèi)血管平均密度15.00±2.87個,正常對照者對應(yīng)部位的血管平均密度8.50±3.21個,P0.01。皮損顏色紫紅色的血管直徑偏粗大,PWS患者面部的血管平均直徑均值是80.43±25.47μ m,比頸部平均直徑均值51.33±21.73μm更粗大。結(jié)論：RCM檢測可以幫助描述PWS皮損內(nèi)異常血管和正常人皮膚內(nèi)血管情況特征,通過檢測所得數(shù)據(jù)幫助初步判斷正常和異常血管。在PWS的激光治療中,RCM可作為客觀判斷治療終止點和預(yù)后的工具。 第三部分共聚焦激光掃描顯微鏡在鮮紅斑痣臨床療效評估和預(yù)后判斷中的應(yīng)用 目的：通過共聚焦激光掃描顯微鏡(RCM)檢測鮮紅斑痣患者皮損血管直徑和密度,研究595nm脈沖染料激光不同脈沖寬度治療中國PWS患者的臨床療效與脈沖寬度參數(shù)的相關(guān)性以及對預(yù)后判斷的意義。方法：使用595nm PDL按4組不同脈沖寬度(1.5、3、6、lOms)治療并隨訪44處治療區(qū),入組11例中國Ⅲ或Ⅳ型皮膚PWS患者,男6例,女性5例,每個患者每次治療前及最后一次治療結(jié)束后2個月都進行相應(yīng)治療區(qū)的RCM檢測,包括血管直徑范圍、平均直徑、密度等,并拍照記錄,由一名獨立的皮膚科醫(yī)生根據(jù)治療前后照片進行療效評價和評分。同時記錄治療的不良反應(yīng),如色素改變和疤痕等。結(jié)果：1.RCM100μm和150μm掃描層面都顯示同一脈沖寬度組治療前后血管平均直徑和密度有明顯減小,P值均0.05。2.100μ m掃描層面不同脈沖寬度組治療后的血管平均直徑和密度變化無統(tǒng)計差異,而150μ m掃描層面1.5ms組和其它脈沖寬度組治療后的血管平均直徑有統(tǒng)計學(xué)差異(P值均0.05),但是治療后血管密度變化各組脈沖寬度的差異不明顯(P值均0.05)。3.紫紅色PWS皮損治療效果較粉紅色、紅色皮損效果差,RCM顯示紫紅色皮損處血管平均直徑偏大,100μm和150μm掃描層面平均血管直徑最大的5例患者都是紫紅色皮損,占紫紅色皮損5/7,150μm掃描層面比100μ m層面的血管更粗。4.脈沖染料激光治療后出現(xiàn)紫癜的反應(yīng)見于所有患者,1.5ms脈寬組紫癜顏色最明顯,10ms組比較輕微,可出現(xiàn)延遲性紫癜。RCM150μm掃描層面的血管直徑改變幅度的大小與紫癜反應(yīng)明顯程度有正相關(guān)性,1.5ms組治療前后血管直徑變化也最明顯(P值均0.05)。5.四組不同脈寬組三次PDL治療后,在RCM100μm和150μm掃描層面上1.5ms組血管平均直徑減小幅度最大,分別是49.69%和66.06%；而兩個掃描層面所有脈沖寬度組的血管密度減少幅度在50-69%之間,但是結(jié)果平均密度都是接近10個左右,與正常皮膚的平均血管密度(8.50±3.21個)接近。結(jié)論：RCM可無創(chuàng)、實時地檢測PWS皮損治療前后血管平均直徑和密度等情況的具體變化情況，，RCM檢測結(jié)果顯示決定淡化效果的是血管平均直徑的減小幅度。RCM檢測數(shù)據(jù)表明,通過術(shù)前檢測可以大概預(yù)測不同掃描層面血管平均直徑、密度情況的治療區(qū)的血管變化情況及相應(yīng)療效,深層血管的變化對療效判斷可能更有意義。因此,RCM檢測有助于選擇合適的PWS皮損和決定PDL治療參數(shù),有助于判斷預(yù)后和治療終止時間。
[Abstract]:Part 1 Clinical efficacy and safety of 595 nm pulsed dye laser with different pulse widths in the treatment of port wine stains
Objective: To study the clinical efficacy and safety of 595 nm pulsed dye laser (PDL) with different pulse widths in the treatment of Chinese patients with port wine stain (PWS). Each patient was treated with different pulse widths in 4 selected areas of the lesion. The diameter of the treatment spot was 7 mm and the energy density was 9-12J/cm2. The treatment was given every 2 months for 3-5 times. Photographs were taken before treatment and 2 months after the last treatment. Independent dermatologists evaluated and scored the effectiveness of the treatment according to the photos (1, 25%; 2, 26% - 50%; 3, 51% - 75%; 4, 76% - 100%). The scoring was based on the overall evaluation of skin lesions before and after treatment, area reduction, color dilution, and recorded adverse reactions such as pigmentation and scarring. All PWS patients received 3-5 laser treatments with 44 lesions (4 pulse width groups). The total effective rate and marked effective rate were 47.73% and 27.28% in all 44 treatment areas at 2 months follow-up after the last treatment. Only 7 (15.91%) treatment areas were ineffective. The effective rates were 63.64%, 63.64%, 36.37%, 27.27% respectively, and the corresponding cure rates were 45.46%, 27.27%, 18.18% and 18.18%. The average score of 1.5ms pulse width group was 3.00, higher than that of other groups (2.82, 2.36, 2.18), and the total effective score of all treatment areas was 2.59. Purple PWS skin lesions were pink. Adverse reactions: Purpura was seen in all patients, a small number of patients showed hyperpigmentation (11.36-15.91%) and hypopigmentation (2.27-6.82%), mainly in the 1.5ms and 3MS pulse width treatment group. Conclusion: 595 nm pulsed dye laser can effectively treat PWS patients in China with high safety, no scar and other obvious side effects. The therapeutic effects of different pulse widths are different, and the effect of 1.5ms pulse width group is the best.
The second part: confocal laser scanning microscopy in vivo for detection of port wine stains.
Objective: To study the vascular condition (diameter, density, etc.) of skin lesions in patients with port wine stain by RCM and compare it with that of normal people. Methods: Twenty skin volunteers (8 males, 12 females) of type III or type IV were recruited, including 10 normal persons without PWS lesions, 10 patients with PWS in the face and neck, aged 13-36 years. Results: The average diameter of blood vessels in the lesions of PWS patients was 71.70 6550 The average vessel density was 15.00 (+ 2.87), and the average vessel density was 8.50 (+ 3.21) in the corresponding parts of the normal control group, P 0.01. The average vessel diameter in the face of PWS patients was 80.43 (+ 25.47) um, which was larger than that in the neck of 51.33 (+ 21.73) um. The abnormal blood vessels in the lesion and the normal blood vessels in the skin can be identified by detecting the data. In the laser treatment of PWS, RCM can be used as an objective tool to judge the termination point and prognosis.
Part III Application of confocal laser scanning microscopy in clinical evaluation and prognosis of port wine stains
Objective: To investigate the correlation between the clinical efficacy of 595 nm pulsed dye laser (PDL) with different pulse widths and the parameters of pulse widths and the prognostic significance of different pulse widths (PWS) in Chinese patients with port wine stain (PRS). 1.5, 3, 6, lOms) were treated and followed up in 44 treatment areas. Eleven Chinese patients with type III or IV skin PWS, 6 males and 5 females, were enrolled in the study. RCM tests were performed in each treatment area before and 2 months after the end of the last treatment, including vessel diameter, mean diameter, density, etc., and photographic records were taken by an independent dermatologist. Results: 1. The mean diameter and density of blood vessel in the same pulse width group were significantly reduced at 100 and 150 micron scan levels, P values were 0.05.2.100 micron scan levels with different pulse widths. There was no significant difference in the mean diameter and density of blood vessels between the two groups after treatment, but there was significant difference in the mean diameter of blood vessels between the 1.5ms group and the other pulse width groups (P 0.05). However, there was no significant difference in the pulse width of each group after treatment (P 0.05). 3. Purple PWS was more effective in the treatment of skin lesions. RCM showed that the average diameter of blood vessels in purple skin lesions was larger than that in red skin lesions. All the 5 patients with the largest average diameter of blood vessels in 100 and 150 microns were purple skin lesions. All patients, 1.5ms pulse width group purpura color is the most obvious, 10ms group is slight, can appear delayed purpura. RCM 150 micron scan changes in the size of vascular diameter and purpura response significantly correlated, 1.5ms group before and after treatment vascular diameter changes were the most significant (P 0.05). 5. Four different pulse width groups after three PDL treatment. On RCM 100 and 150 microns, the average diameter of blood vessels decreased by 49.69% and 66.06% in 1.5 ms group, respectively, while the average density of blood vessels decreased by 50-69% in all pulse width groups on both scanning planes, but the average density was close to 10, which was close to that of normal skin (8.50 (+ 3.21). CONCLUSION: RCM is noninvasive and can be used to detect the changes of mean diameter and density of blood vessels before and after PWS treatment in real time. The results of RCM show that the decrease of mean diameter of blood vessels is the decisive factor for desalination effect. Therefore, RCM is helpful to select the appropriate PWS lesions and determine the PDL treatment parameters, and is helpful to judge the prognosis and treatment termination time.
【學(xué)位授予單位】：復(fù)旦大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R758.51

【共引文獻】

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