【作者】 陈志彬；

【导师】 范瑞强；

【作者基本信息】 广州中医药大学 ， 中医外科学， 2011， 博士

【摘要】 研究目的本研究试图从痤疮及颜面皮肤生理的共同因子来探讨中医综合疗法对女性痤疮患者颜面皮肤生理的影响机制。本研究是以范瑞强教授治疗痤疮多年的经验方为主轴,配合中医外用制剂、丹参穴位注射以及液氮冷冻法,形成一套内外兼顾、上下共调的综合疗法。针对以面部皮损为主的女性痤疮患者,通过对水合度、皮脂量、pH值等皮肤生理指标的观察以及影响因素问卷调查的收集,来阐明中医中药在痤疮治疗上的作用机制。方法关于痤疮危险因子的探讨方面,采用痤疮组与健康对照组的现状流行病学调查分析方法；中医综合疗法对共同因子的影响,采用痤疮组自身前后比较的研究方法。本研究选取64名观察对象,其中痤疮组48名,为轻至中度女性痤疮患者,平均年龄25.35±3.14岁；健康对照组16名,平均年龄24.63±1.89岁；组间年龄差异无统计学意义(P=0.272>0.05)。研究中,两组皆安排颜面皮肤生理检测及问卷调查,借此收集颜面皮肤生理及痤疮诱发因素的相关资料。另外,痤疮组还接受为期4周的中医综合疗法,并在治疗结束后再次检测颜面的皮肤生理,观察治疗前后指标间的变化。最后完成痤疮患者的疗效评价,锁定中医综合疗法确切解决哪些问题。研究中,先以非参数统计Spearman’s rho系数选出影响皮肤生理的相关因子；其后使用痤疮组和健康对照组间调查项目差异性比较,筛选出可能诱发痤疮的相关因子,然后再进行非条件Logistic回归分析。找出诱发痤疮的危险因子,比较皮肤生理的相关因子和诱发痤疮的危险因子,了解之间有无主宰两方的共同因子,并评估中医综合疗法对共同因子治疗前后的变化趋势。组间差异性比较,计量资料如水合度、皮脂量、pH值等以均数±标准差((?)±s)表示,正态分布的两组数据采用独立样本t检验；分类资料使用z2检验；其余则使用Mann-Whitney U检验。另外,痤疮组治疗前后差异性比较,计量资料采用配对样本t检验；等级资料采用Wilcoxon符号秩和检验。检验水平α=0.05。结果皮肤生理指标中,水合度分别与夜尿(r=-0.253,P<0.05)、接触热源时数(r=-0.248,P<0.05)呈轻度负相关性,即夜尿、接触热源时数越多,皮肤水合度越低；皮脂量分别与渴饮程度(r=0.466,P<0.01)、睡眠质量异常(r=0.337,P<0.01)呈中度正相关性,即倾向口渴口干、睡眠问题越多者,皮脂分泌越多；pH值与月经周期异常呈中度正相关性(r=0.370,P<0.01),与经量异常呈轻度正相关性(r=0.259,P<0.05),即月经周期倾向后期、先后不定者或是月经量偏少者,pH值相对较高。水合度、皮脂量、pH值三者之中,只有皮脂量与痤疮数量呈中度正相关性(r=0.464,P<0.01),说明其能明确辨识痤疮存在及严重度。因此,在皮肤生理指标中最能代表痤疮存在(OR=1.34(95%CI：1.12-1.61),P<0.01)。问卷调查中,渴饮程度d(OR=24.55(95%CI：1.75-345.17),P<0.05)、睡眠质量异常(OR=12.19(95%CI：1.89-78.75),P<0.01),为最能代表痤疮存在的主诉,两者还与皮脂量呈中度正相关,由此可知口干口渴、睡眠质量不佳可能是痤疮发生、皮脂量增多的共同因子。轻至中度痤疮患者经4周一个疗程的中医综合疗法治疗后,基愈11人、显效13人、有效10人、无效2人,PPA总有效率为94.4%(ITT总有效率为70.8%)。皮肤生理指标治疗前后比较中,水合度由治疗前的(59.28±8.70)上升至治疗后的(61.94±8.03),t(35)=4.961,P<0.001)；治疗前后水合度平均上升2.67单位,95%可信区间在1.58至3.76之间。皮脂量由治疗前的(25.15±5.47)下降至治疗后的(22.46±3.72),t(35)=-2.440,P<0.05)。治疗前后皮脂量平均下降1.69单位,95%可信区间在-3.09至-0.28之间。pH值由治疗前的(5.43±0.20)下降至治疗后的(5.41±0.19),t(35)=-1.464,P>0.05),治疗前后pH值不具统计学意义。各级疗效与皮肤生理改善程度之间的相关性,不管是水合度、皮脂量和pH值等均未见有统计学意义(P>0.05)。共同因子治疗前后比较中,口干口渴有强烈的改善,z=-4.379,P<0.001,睡眠质量有中度的改善,z=-3.162,P<0.01。结论中医综合疗法可以调整人体脏腑的阴阳平衡,改善痤疮病人由于阴虚内热、虚阳浮越所引起的口干口渴、睡眠困难等症状；并可以改善痤疮病人颜面水合度和皮脂量等皮肤生理指标。更多还原

【Abstract】 ObjectivesThe purpose of this study is to attempt to explore the influence mechanism of the Chiense medicine comprehensive therapy on the facial skin physiology of the patients with acne vulgaris from the perspective of the common factors correlated with facial skin physiology and acne.In this study, the Chinese medical comprehensive therapy is based on the multi-year clinical experiences on acne treatment by Dr. Fan. The therapy, which offers a full-range strategy mainly adapted for the facial inflammatory lesions in female patients with acne vulgaris, consists of a herbal formula, a topical herbal preparation, salvia point injection, and liquid nitrogen vapour freezing method, capable of eliminating excessive Yang in the exterior, superior part of the human body and invigorating deficient Yin in the interior, inferior part of the human body. This study approach is to observe the numerical fluctuation of skin physiological parameters, i.e. SC hydration, sebum content and skin surface pH, before and after the treatment, as well as the questionnaire collection of influence factors for elucidating the mechanism of action of the Fan’s therapy on acne vulgaris.MethodsThe study discussed the risk factors for acne by means of the epidemiological analysis of current situation in both of the groups and the influence of the Fan’s therapy on the common factors of acne and the facial skin physiology by means of the before-after study in the acne group. A total of 64 subjects, 48 patients with mild to moderate acne vulgaris in the acne group and 16 health volunteers in the control group, aged from 18 to 40 years, were enrolled for this study. There was no significance, P=0.272>0.05, in age between the acne group, which the average age was 25.35±3.14 years old, and the control group, which the average age 24.63±1.89 years old. In the study, all of them were arranged for the facial skin physiological examination and for filling out the questionnaire surveys, and the data correlated with the facial skin physiology and predisposing factors for acne would be collected by this pathway. When testing the facial skin physiology, the supine posture was adopted, and the four sites, i. e. the midpoint of the forehead, Ju Liao, Cheng Jiang, Jia Che, respectively, were taken in the hydration test, the two sites, i. e. the midpoint of the forehead, Ju Liao, in the sebum test, the one site, i. e. the midpoint of the forehead, in the pH test. Besides, the people in the acne group would undergo the Fan’s therapy for four weeks, and, at the end of the treatment, once again receive the facial skin physiological examination for observing if the facial skin physiological parameters would change before and after treatment. Finally, assessment of efficacy of the Fan’s therapy in the ance group would be completed for making sure which problem to be solved on earth.In this research, non-parametric statistics-Spearman’s rank order correlation was first used to determine which condition, including. sweet, spicy or oily foods, acne, thirsty status, stool & urine status, hours of exposure to heat, sleep quality, mental stress, menstrual status, acne severity, could be main factor of the facial skin physiology. Then the difference analysis of the survey items between the acne group and the controlled group would be used for screening out the possible factors, which could induce acne, and the non-conditional logistic regression was further used to identify the risk factors of acne vulgaris. Comparing two sets of factors, which affect the facial skin physiology and acne, respectively, to identify the common factors, the study is to assess if the common factors would change before and after the treatment of the Fan’s therapy.In the difference between two groups, the measurement data, e.g. SC hydration, sebum content and skin surface pH, symbolize as Mean±Standard Deviation (M±SD). Independent-samples t-test was used as the data of two different groups met the normal distribution, chi-square test as the categorical data, Mann-Whitney U test as the others. On the other hand, paired-samples t-test was used in the acne group as the factors belong to the measurement data in the differences between before and after treatment; on the contrary, Wilcoxon signed rank test was used as the ranked data. The significance level was set as P<0.05 for all tests.ResultIn the correlation test of the facial skin physiological parameters, there was a slight, negative correlation between SC hydration and the frequency of night urination(r=-0.253, P<0.05) and the hours of exposure to heat (r =-0.248, P<0.05), respectively. They revealed that the more frequency of night urination or hours of exposure to heat they displayed, the lower SC hydration their face could show. There was a moderate, positive correlation between sebum content and thirsty level (r=0.466, P<0.01) and sleep quality disorder (r=0.337, P<0.01), respectively. They suggested that the more problems with the thirsty level and the sleep quality they had, the more sebum content their face could display. Skin surface pH was moderately, positively correlated with abnormal menstrual periods (r=0.370,P<0.01), and was slightly, positively correlated with abnormal menstrual flow (r=0.259, P <0.05). They showed that they could display higher skin surface pH, when they had the tendency for longer or irregular menstrual periods or decrease menstrual flow. Among the three physiological parameters, sebum was the only one, moderately positively correlated with the number of acne lesions (r 0.464, P<0.01).It suggested that sebum content could determine the existence of acne vulgaris and the cut point of acne severity, therefore sebum content is the most representative one of the facial skin physiological parameters for the existence of acne vulgaris (OR=1.34 (95%CI; 1.12～1.61), P<0.01).Among the factors investigated, thirsty level-d (desire for drinking, urgency for drinking=1, normal, no desire for drinking=0; OR=24.55 (95 %CI; 1.75～345.17), P<0.05). sleep quality disorder (OR=12.19 (95%CI; 1.89～78.75), P<0.01) were the most representative ones of various complains for the existence of acne vulgaris, and both of them simultaneously were moderately, positively correlated with sebum content. The two complains, therefore, were the common factors of acne vulgaris and sebum content.The study on the efficacy of the Fan’s therapy in the female patients with mild to moderate acne over a course of four weeks showed that 11 cases were cured,13 cases markedly effective,10 cases effective,2 cases ineffective, and the total effective rate was 94.4% in PPA or 70.8% in ITT. In the difference comparison of the facial skin physiological parameters between before and after treatment, SC hydration rose from 59.28±8.70 before the treatment to 61.94±8.03 after the treatment, t(35)=4.961, P<0.001, the average increment of SC hydration was 2.67 units,95%Ci between 1.58 and 3.76. Sebum content declined from 25.15±5.47 before the treatment to 22.46±3.72 after the treatment, t(35)=-2.440,P<0.05, the average decrement of sebum content was 1.69 units,95%CI between -3.09 and -0.28. Skin surface pH also declined from 5.43±0.20 before the treatment to 5.41±0.19, t(35)= -1.464, P>0.05s, with no statistically significance in the difference between before and after treatment.There was no significant correlation between the efficacy and the improvement level of facial skin physiology, regardless of SC hydration, sebum content or skin surface pH (P>0.05)In the difference comparison of the common factors between before and after treatment, there was a strong improvement in the thirsty level, z=-4.379, P <0.001, and a moderate improvement in the sleep quality disorder, z=-3.162, P<0.01.ConclusionThe Chinese medicine comprehensive therapy could correct the imbalance between Yin and Yang in the zang-fu organs of the human bodies with acne vulgaris, and decrease the symptoms of frequent thirst and difficulty sleeping due to Yin deficiency with internal heat and Yang deficiency with floating. The SC hydration and sebum content in the patients with acne vulgaris could be also improved by the Chinese medicine comprehensive therapy.更多还原