本文選題：火針 + 辨證取穴針刺��； 參考：《中國中醫(yī)科學院》2017年碩士論文

【摘要】：研究背景瘙癢是許多皮膚病和全身性疾病的常見癥狀,是一種能夠引起搔抓欲望的感覺,是機體對有害刺激的多維度的感受反應。瘙癢發(fā)病率高,可顯著影響患者的生活質量,嚴重者可出現(xiàn)自殺傾向。瘙癢作為一種難以忍受的癥狀長期困擾著人們的生活。中醫(yī)認為,瘙癢屬于“癢癥”的范疇,乃風、濕、熱、蟲、毒侵犯人體肌表,加上先天稟賦不耐,使皮膚氣血不和所致。目前瘙癢的治療以鎮(zhèn)靜止癢為主,并將全身治療和局部治療相結合。中醫(yī)中藥以辨證論治為特點,同病異治、異病同治,為瘙癢的治療提供了新的思路。由于瘙癢的發(fā)病原因比較復雜,病情常常反復,因此難以達到理想的治療效果,新的治療方法仍將是未來的研究熱點。針灸作為祖國醫(yī)學的瑰寶之一,具有廣闊前景及現(xiàn)實意義�；疳樈Y合辨證針刺治療作為一種非藥物療法,對于慢性瘙癢性皮膚病的療效頗佳。火針具有散寒除濕、行氣散毒、溫經活血的作用。我們通過臨床實踐發(fā)現(xiàn),火針可應用于皮膚科疾病的治療,其熱效應可以改善皮損區(qū)域的微循環(huán),加快炎癥和代謝物質的吸收�；疳樦塾诩膊〉木植空飨�,而辨證針刺則重視疾病的整體狀態(tài),審癥求因,根據疾病的不同證候分別予祛風散寒、清熱涼血、滋陰潤燥、祛濕解毒、養(yǎng)血疏肝。兩者結合可起到標本兼治的效果。火針配合辨證針刺可用于慢性瘙癢性皮膚病的治療,并且具有一定的基礎理論和臨床實踐的證據。然而火針配合針刺干預對于慢性瘙癢性皮膚病的療效、效應時間點等,都需要進一步循證醫(yī)學方法的驗證。本研究采用前瞻性病例系列研究的方法,將火針配合辨證針刺作為干預措施,以驗證火針配合辨證針刺治療對于改善慢性瘙癢性皮膚病患者癥狀與體征、焦慮及抑郁狀態(tài)、生活質量等方面的有效性,探索火針配合辨證針刺對于慢性瘙癢性皮膚病的最佳有效干預療程,評價火針配合辨證針刺治療慢性瘙癢的安全性,為該病的臨床診療提供新的思路和依據。研究目的通過觀察火針配合辨證取穴針刺對慢性瘙癢性皮膚病患者癥狀、體征的影響以及對不同原因誘發(fā)瘙癢程度的影響及其之間的比較,對慢性瘙癢性皮膚病患者病損局部紅外熱像及散斑血流的影響,對理化指標的影響,生活質量以及焦慮、抑郁狀態(tài)的影響,探討火針結合辨證取穴針刺對慢性瘙癢性皮膚病的臨床療效,為今后火針配合辨證取穴針刺的臨床應用和推廣提供試驗參考,為火針配合辨證取穴針刺治療慢性瘙癢性皮膚病進一步的機制研究提供臨床依據。研究方法本研究根據納入排除標準共選取來自針灸醫(yī)院門診2015年3月至2017年3月的81例慢性瘙癢性皮膚病患者。治療采用火針和體針相結合的綜合療法,主穴為瘙癢較重、皮膚表面有明顯的丘疹、皮膚干燥或增厚等改變的部位,使用火針點刺,配穴根據證候分類進行辨證取穴針刺。每周治療2次,共治療16次(8周)。采用癥狀積分分級法、視覺模擬評分法(Visual Analogue Scale,VAS)、紅外熱像及散斑血流檢測、理化指標檢測(包括嗜酸性粒細胞計數(shù)和血清總IgE)、漢密頓焦慮量表(Hamilton Anxiety Scale,HAMA)、漢密頓抑郁量表(Hamilton Depression Scale,HAMD)和皮膚病生活質量指數(shù)(Dermatology Life Quality Index,DLQI)為療效指標,分別在治療前、治療后、治療結束4周后隨訪時記錄各項評分,統(tǒng)計分析評分的變化,進行療效評定。研究結果(1)與0周(治療前)相比,4周(治療8次)和8周(治療16次)后,患者癌癢程度明顯減輕,而治療8周后的療效明顯優(yōu)于治療4周后,且12周(隨訪)時療效基本維持不變。(2)火針配合辨證取穴針刺對以上四種不同類型的瘙癢性皮膚病均有突出的療效,但效應的時間點不同。濕疹患者對火針配合辨證針刺的敏感度不高,當次治療后瘙癢緩解的幅度較小,但存在一定的延遲效應,每次治療前較上一次治療前相比均有明顯減輕;神經性皮炎患者敏感度較高,每次治療后與治療前相比緩解都特別明顯,然而每次治療前相比,總體呈緩慢下降趨勢;特應性皮炎患者初時每次治療后瘙癢緩解明顯,第五次治療開始瘙癢程度評分反復無常,對治療的敏感度時高時低,但總體表現(xiàn)為下降趨勢;蕁麻疹患者對火針配合辨證取穴針刺敏感度高,效應也持久,在前三次治療后瘙癢己經明顯緩解,此后每次治療前瘙癢程度不高,但治療后仍有減輕。(3)治療前皮損處紅外熱像值、散斑血流值明顯高于無皮損處,治療后伴隨皮損的逐漸恢復,高紅外熱像值減小,面積逐漸縮小,散斑血流的變化趨勢與紅外熱像相同。(4)24例慢性瘙癢性皮膚病患者進行了治療前、后外周血嗜酸性粒細胞及血清總IgE進行了檢測。從外周血嗜酸性粒細胞計數(shù)觀察,所有患者治療前、后檢測值均在正常范圍內(正常值為0.02-0.5x109/L)。從血清總IgE含量觀察,有9例患者(包括濕疹4例、神經性皮炎1例、特應性皮炎2例、蕁麻疹2例)治療前檢測值較正常值增高(正常值為1OOIU/ml),15例在正常范圍內,治療后伴隨瘙癢癥狀的改善,治療前血清總IgE含量較正常值增高的無明顯變化趨勢。(5)治療后,患者HAMA及HAMD評分較治療前均有顯著下降。在治療前,有28人(34.57%)輕度焦慮,27人(33.33%)中度焦慮,13人(16.05%)重度焦慮,1人(1.23%)極重度焦慮,僅有12人(14.82%)無焦慮,治療后患者群中焦慮狀態(tài)整體改善,無焦慮人數(shù)增加至40人(49.38%),輕度焦慮人數(shù)為26人(32.2%),中度焦慮人數(shù)為14人(17.28%),重度焦慮人數(shù)為1人(1.2%),無極重度焦慮患者。治療前,有21人(25.93%)輕度抑郁,18人(22.22%)中度抑郁,2人(2.47%)重度抑郁,僅有40人(49.38%)無抑郁,治療后患者群中抑郁狀態(tài)整體改善,無抑郁人數(shù)增加至55人(67.9%),輕度抑郁人數(shù)為16人(19.75%),中度抑郁人數(shù)為10人(12.35%),重度抑郁人數(shù)為0。治療后無焦慮人數(shù)比治療前明顯增加,中度、重度及極重度焦慮人數(shù)明顯減少,說明火針配合辨證取穴針刺后,患者瘙癢情況的緩解可以整體改善其焦慮狀態(tài)。治療后無抑郁人數(shù)較治療前也明顯增加,中度及重度抑郁人數(shù)減少,說明治療后,患者瘙癢情況的緩解亦可整體改善其抑郁狀態(tài)。(6)治療前,81例慢性瘙癢性皮膚病患者皮膚病生活質量量表(DLQI)評分平均18.41 ±3.24分。合計各條目平均得分從高到低依次為瘙癢或疼痛、皮膚護理、著裝、學習工作、尷尬或自卑、運動、性生活、購物或做家務、社交娛樂、親朋關系。治療前后DLQI評分顯著下降,平均8.94±4.52分。說明火針結合辨證取穴針刺可以通過解決患者的瘙癢困擾來提高他們的生活質量。(7)81例瘙癢性皮膚病患者在8周(16次治療)有42例達Ⅰ級改善標準(占51.85%),24例達Ⅱ級改善標準(占29.63%),15例為Ⅲ級改善(占18.52%);12周(隨訪時)療效基本保持,有44例達Ⅰ級改善標準(占54.32%),21例達Ⅱ級改善標準(占25.93%),16例為Ⅲ級改善(占17.95%)。(8)81位接受火針治療的患者中,有42人(52%)認為火針治療很舒服,樂于接受;有22人(27%)認為火針治療不痛也不癢;有15人(19%)認為火針治療有些疼痛,但可以接受;僅有2人(2%)認為火針治療難以接受。所有受試者未出現(xiàn)過暈針、斷針、血腫;治療后及隨訪時未發(fā)現(xiàn)感染等不良情況。除有1例患者因個人體質導致瘢痕消退時間較長外,未發(fā)現(xiàn)因使用火針結合辨證取穴針刺而產生的任何不良反應及毒副作用。研究結論(1)火針結合辨證取穴針刺能夠有效改善慢性瘙癢性皮膚病患者的瘙癢程度、瘙癢面積及瘙癢頻率,本研究中的最佳有效干預療程是8周;(2)火針配合辨證取穴針刺對四種不同類型的慢性瘙癢性皮膚病(包括濕疹、神經性皮炎、特應性皮炎、蕁麻疹)的效應時間點不同;(3)火針結合辨證取穴針刺可以調節(jié)慢性瘙癢性皮膚病患者皮損處的紅外熱像及散斑血流情況,可以明顯改善患者的生活質量、焦慮、抑郁狀態(tài);(4)治療前、后慢性瘙癢性皮膚病患者的理化指標(包括外周血嗜酸性粒細胞計數(shù)和血清總IgE含量)沒有明顯改變;(5)火針結合辨證取穴針刺雖然是一種微創(chuàng)療法,但只要操作規(guī)范,護理得當,治療具有安全性。
[Abstract]:Background pruritus is a common symptom of many skin diseases and systemic diseases. It is a feeling that can cause Scratch and desire. It is the multidimensional response of the body to harmful stimuli. The incidence of pruritus is high, which can significantly affect the quality of life of the patient, and the serious person can have suicide tendency. Itching is a long-term symptom. Traditional Chinese medicine believes that itching belongs to the category of "itching", which is caused by wind, wet, hot, insect, toxic invasion of the human body surface and innate inability to make the skin and blood disharmony. The treatment of itching is based on the static itching of the town and combines the whole body treatment with the local treatment. Treatment and treatment with different diseases provide new ideas for the treatment of pruritus. Because the cause of itching is complicated and the condition is often repeated, it is difficult to achieve the ideal treatment effect. The new treatment method will still be the research hotspot in the future. As one of the treasures of the motherland medicine, the acupuncture and moxibustion have broad prospects and practical significance. As a non drug therapy, acupuncture therapy has a good effect on chronic pruritus dermatosis. The fire needle has the effect of dispersing cold and dehumidification, dispersing gas and warming through blood circulation. Through clinical practice, we find that the fire needle can be used in the treatment of diseases in the Department of dermatology. The heat effect can improve the microcirculation in the area of skin damage and accelerate the inflammation and metabolic substances. Absorption. The fire needle focuses on the local signs of the disease, while the syndrome differentiation acupuncture attaches great importance to the whole state of the disease, and tries to seek the cause of the disease. According to the different syndromes of the disease, it is given to dispel the wind and cold, cool the heat, cool the blood, nourish the Yin and moisten the dryness, remove the dampness and detoxify, raise the blood and remove the liver. The combination of the acupuncture and the acupuncture can be used for the chronic itching skin. The treatment of skin disease has a certain basic theory and evidence of clinical practice. However, the efficacy and time points of the acupuncture intervention for chronic itchy dermatosis should be verified by further evidence-based medical methods. To verify the efficacy of fire needle combined with syndrome differentiation acupuncture in improving symptoms and signs, anxiety, depression and life quality of patients with chronic itchy skin diseases, and to explore the best effective intervention treatment for chronic pruritus with acupuncture and syndrome differentiation acupuncture, and to evaluate the treatment of chronic itching with acupuncture and syndrome differentiation acupuncture. The purpose of this study is to provide new ideas and basis for the clinical diagnosis and treatment of the disease. The purpose of this study is to observe the effect of the acupuncture on the symptoms and signs of the patients with chronic itchy dermatosis and the effect of the pruritus on different causes, and to compare the local infrared heat of the patients with chronic itchy dermatosis. The effect of image and speckle blood flow, the influence of physical and chemical indexes, quality of life, anxiety and depression, the clinical effect of acupuncture combined with acupuncture point acupuncture on chronic pruritus dermatosis, the clinical application and extension of acupuncture in the future with acupuncture and syndrome differentiation are discussed. A total of 81 patients with chronic itchy dermatosis from March 2015 to March 2017 were selected from the outpatient department of acupuncture and moxibustion at the treatment of acupuncture and moxibustion. The combination of fire needle and body acupuncture was used to treat patients with chronic itchy skin diseases. The main point was the heavy itching and the skin surface. There were obvious papules, dry skin or thickening of the skin, using fire needle pricking and acupuncture points according to the syndrome classification. 2 times a week for 16 times (8 weeks). The symptom integral classification, visual analog score (Visual Analogue Scale, VAS), infrared thermal image and speckle blood flow detection, physical and chemical index detection (package) Including eosinophil count and serum total IgE), the Hamilton Anxiety Scale (Hamilton Anxiety Scale, HAMA), the Hamilton Depression Scale (Hamilton Depression Scale, HAMD) and the quality of life index of the dermatosis (Dermatology Life Quality) were the therapeutic targets, respectively, before the treatment, after the treatment, 4 weeks after the end of the treatment, the records were recorded. Results (1) compared with 0 weeks (before treatment), 4 weeks (8 times) and 8 weeks (treatment 16), the patient's cancer itching was significantly reduced, and the curative effect of 8 weeks after the treatment was obviously better than that of the treatment for 4 weeks, and the curative effect was basically maintained at 12 weeks (2). (2) acupuncture combined with acupuncture points with acupuncture points with syndrome differentiation. The four different types of itchy skin diseases have prominent curative effect, but the time points of the effect are different. The patients with eczema have little sensitivity to the acupuncture combined with acupuncture, and the amplitude of the pruritus is smaller after the treatment, but there is a certain delay effect, and the neuronature before each treatment is significantly lower than that before the previous treatment. The patients with dermatitis had a high sensitivity, and the remission of the patients was very obvious after each treatment. However, compared with the treatment before each treatment, the overall decrease trend was slow. The itching of the patients with atopic dermatitis was obviously relieved at the beginning of the treatment. The initial pruritus score of the fifth treatment was repeated infrequent, and the sensitivity to the treatment was low, but the overall table was low. The patients with urticaria have high sensitivity and lasting effect on acupuncture combined with syndrome differentiation, and the pruritus has been alleviated after the first three treatments, and the itching degree is not high before each treatment. (3) the infrared thermal image of the lesions before treatment, the value of the speckle blood flow is obviously higher than that of the non skin lesion, and the treatment is accompanied by the treatment. The skin lesion gradually recovered, the high infrared thermal image decreased, the area gradually reduced, and the trend of the speckle blood flow was the same as that of the infrared thermography. (4) before treatment, 24 cases of chronic itchy skin diseases were detected in the peripheral blood eosinophils and serum total IgE. All patients were treated by eosinophil count from peripheral blood. The post detection values were in the normal range (normal value 0.02-0.5x109/L). From the total serum IgE content, 9 patients (including 4 eczema, 1 cases of neurodermatitis, 2 cases of atopic dermatitis, 2 urticaria) were compared with normal values (normal value 1OOIU/ml), 15 cases were in the normal range, and the treatment accompanied with the improvement of pruritus. There was no obvious trend in the increase of serum total IgE content before treatment. (5) after treatment, the patients' HAMA and HAMD scores were significantly lower than before treatment. Before treatment, there were 28 (34.57%) mild anxiety, 27 (33.33%) moderate anxiety, 13 (16.05%) severe anxiety, 1 (1.23%) extremely severe anxiety, only 12 (14.82%) without anxiety, after treatment. The overall anxiety state of the group was improved, the number of non anxiety increased to 40 (49.38%), the number of mild anxiety was 26 (32.2%), the number of moderate anxiety was 14 (17.28%), the number of severe anxiety was 1 (1.2%), and there were no extreme severe anxiety patients. Before treatment, there were 21 (25.93%) mild depression, 18 (22.22%) moderate depression, 2 (2.47%) severe depression and only serious depression before treatment. 38%) no depression, the overall improvement of depression in the group of patients after treatment, the number of non depression increased to 55 (67.9%), the number of mild depression was 16 (19.75%), the number of moderate depression was 10 (12.35%), and the number of severe depression was 0. after treatment, and the number of moderate, severe and severe anxiety decreased obviously, indicating that the number of moderate, severe and extreme severe anxiety was significantly reduced. After acupuncture combined with syndrome differentiation, the relieving of pruritus could improve the anxiety state as a whole. The number of non depression after treatment was significantly increased and the number of moderate and severe depression decreased. After treatment, the relieving of itching can also be improved as a whole. (6) 81 cases of chronic pruritus dermatosis before treatment. The average score of the patient's dermatology quality of life scale (DLQI) score was 18.41 + 3.24 points. The average score of the total items from high to low was pruritus or pain, skin care, dress, learning, embarrassment or inferiority, exercise, sex life, shopping or doing housework, social entertainment, relatives and friends. The score of DLQI decreased significantly before and after treatment, with an average of 8.94 + 4.52 points. (7) there were 42 cases of itchy dermatosis in 8 weeks (16 times), 42 cases (51.85%), 24 cases (29.63%), 15 cases (18.52%), and 15 (18.52%), and 81 weeks (follow up) curative effect basic. There were 44 cases of improvement of grade I (54.32%), 21 cases of grade II improvement (25.93%), 16 cases of grade III (17.95%). (8) among 81 patients receiving fire needle therapy, 42 (52%) considered fire needle treatment very comfortable and willing to accept; 22 (27%) thought fire needle treatment was not painful nor itching; there were 15 people (19%) think fire needle therapy has some pain. Pain, but it was acceptable; only 2 (2%) thought fire needle therapy was difficult to accept. All the subjects did not have a needle sickness, broken needle, hematoma, and did not find any bad conditions after treatment and follow-up. Except for 1 patients, the time of scar withdrawal caused by personal physique was longer, no one was found to be caused by the use of acupuncture combined with acupuncture point acupuncture. Research conclusions (1) acupuncture combined with acupuncture point acupuncture can effectively improve the itching degree, pruritus area and pruritus frequency of patients with chronic pruritus, and the best effective intervention course in this study is 8 weeks. (2) four different types of chronic itchy dermatosis (including acupuncture acupuncture combined with acupuncture point needle puncture). The effect time points of eczema, neurodermatitis, atopic dermatitis, urticaria are different. (3) acupuncture combined with acupuncture point acupuncture can adjust the infrared thermal image and speckle flow of the skin lesions of patients with chronic itchy skin diseases, and can obviously improve the quality of life, anxiety and depression of the patients; (4) the patients with chronic itchy skin disease before treatment. There was no obvious change in physical and chemical indexes (including eosinophil count in peripheral blood and total IgE content in serum). (5) acupuncture combined with acupuncture and acupuncture is a minimally invasive therapy, but it is safe to treat with proper operation and proper nursing.
【學位授予單位】：中國中醫(yī)科學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R246.7

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