节点文献
艾滋病相关性痒疹的中医证候规律及临床治疗研究
【作者】 张彦敏；
【作者基本信息】 北京中医药大学 ， 中医诊断学， 2012， 博士
【摘要】 目前艾滋病相关性痒疹的中医药证候研究及治疗方面尚属空白,本研究在国家科技重大专项“十一五”计划及国家重点基础研究发展计划专项资助下,通过理论研究,分析艾滋病相关性痒疹与中医病证的相关性,了解目前国内外艾滋病相关性痒疹的研究现状和存在的问题；通过临床研究,分析艾滋病相关性痒疹患者的临床流行病学资料,对患者的症状、体征、证候及其与各因素的关系进行研究；通过临床治疗研究,探讨艾滋病相关性痒疹的中医治疗方法。目的通过理论研究探讨艾滋病相关性痒疹的病因病机、常见证候及症状；通过临床流行病学调查研究总结艾滋病相关性痒疹患者的证候规律特点；通过临床治疗研究观察中药方对艾滋病相关性痒疹患者的疗效。方法1理论研究通过查阅1980年1月-2011年12月间关于痒疹的文献、国内外艾滋病相关性痒疹的相关文献及调查艾滋病相关性痒疹的常见临床表现,探讨其病因病机、常见证候及症状,为证候的规范化、制定艾滋病相关性痒疹的中医证候调查表及对该病的临床治疗提供帮助。2临床研究(1)对来自河南、北京、云南、广州、湖北、深圳、广西等地的364例符合艾滋病相关性痒疹纳入标准的患者的症状、体征、证候及流行病学资料进行统计分析,总结其证候规律特点。(2)通过多中心、随机、对照研究,将符合纳入标准的358例艾滋病相关性痒疹患者,随机分为中药治疗组和西药对照组,疗程4周,观察每个证型相应的中药协定方对艾滋病相关性痒疹患者的疗效。结果1理论研究艾滋病相关性痒疹患者的皮损表现与非艾滋病患者痒疹的皮损症状相类似,主要表现为：皮肤瘙痒,有广泛皮损,表现为红色斑丘疹、结节、水疱,甚至糜烂渗水。舌红,苔黄、苔腻,脉滑、细、弦等。中医辨证多为血虚、风热、湿热或血热证,病位主要在脾、肝,病理因素主要有风邪、湿邪、血虚等。本病多为虚实夹杂之证,本虚主要是气血两虚,标实主要为湿毒内蕴、风热、瘀血等聚结于皮肤。2临床研究(1)临床流行病学及中医证候研究364例艾滋病相关性痒疹患者中,最低年龄18岁,最高65岁,多数患者的年龄集中在30岁-49岁之间,男女比例为1.33：1。其可能的感染途径主要是血液传播、性接触和静脉吸毒。患者的皮肤瘙痒程度主要为中度瘙痒,占总人数的47.8%。丘疹程度主要为轻度丘疹,占总人数的64.6%。所有入组的患者当中,CD4>500 cells/ul的有23例,CD4在200-499 cells/ul之间的有129例,CD4<200 cells/ul的有209例,未测的有3例。364例艾滋病相关性痒疹患者中,血热生风证173例,血虚风燥证104例,脾虚湿蕴证84例,其他证型3例。患者常见的皮肤症状(即出现频率大于50%的症状)有皮肤瘙痒、丘疹、抓痕、色素改变、结节、皮损密集、皮损位于上肢。患者常见的伴随症状(即出现频率大于30%的症状)主要有疲乏、咽干、不寐、形体异常、心中烦闷、食欲不振、腰膝无力、头晕。研究发现,CD4小于200cells/ul的艾滋病相关性痒疹患者多见脾虚湿蕴证,CD4在200-499 cells/ul的患者多见血虚风燥证。血液传播的艾滋病相关性痒疹患者多见脾虚湿蕴证,性传播的患者多见血热生风证,静脉吸毒感染的患者多见血虚风燥证。无瘙痒和丘疹的艾滋病相关性痒疹患者以性传播感染者多见；轻度瘙痒和丘疹的患者以静脉吸毒感染者多见；中重度瘙痒和丘疹的患者以血液传播感染者多见。男性以性接触和静脉吸毒感染者多见,女性以血液感染者多见。年龄方面,40岁以前的患者以性接触和静脉吸毒感染者多见,40岁以后的患者多为血液传播感染。症状表现方面,中重度瘙痒和丘疹的患者多为血液传播途径感染。年龄越大、CD4计数越低、丘疹越严重者,瘙痒程度也越严重。轻中度瘙痒的患者多见血虚风燥证,重度瘙痒的患者多见脾虚湿蕴证；轻度丘疹的患者多见血虚风燥证,中重度丘疹的患者多见脾虚湿蕴证。随着年龄的增大,中医证候量表积分及PPE临床表现量表积分都逐渐增高。中医证候积分由高到低依次为脾虚湿蕴证患者、血热生风证患者、血虚风燥证患者。提示证候越复杂,症状表现越重。PPE临床表现量表积分和中医证候积分由高到低依次为血液途径感染患者、性接触患者、静脉吸毒感染患者。PPE临床表现量表与中医证候积分量表、PPE临床表现量表与皮肤生活质量指数量表、皮肤生活质量指数量表与中医证候积分量表之间有弱正相关性。说明患者皮肤症状越严重,其整体症状表现也越严重,皮肤生活质量也越差。(2)临床治疗研究选取符合诊断标准的358例艾滋病相关性痒疹患者,随机分为中药治疗组和西药对照组,疗程4周,观察患者的CD4计数、中医证候积分、生存质量积分、PPE临床表现量表积分、皮肤生活质量指数量表积分等。结果显示,每个证型相应的中药协定方对艾滋病相关性痒疹患者疗效显著,不仅可减轻患者皮疹及瘙痒带来的痛苦,而且能调整机体阴阳平衡,增强抗病能力,提高患者的生活质量,且安全性好。结论1本次研究的艾滋病相关性痒疹患者以男性青壮年为主。感染途径主要是性接触、血液传播和静脉吸毒。大多数患者瘙痒程度为中度瘙痒,丘疹程度为轻度丘疹。CD4计数多在200 cells/ul以下。2艾滋病相关性痒疹患者的证型主要有血热生风证、血虚风燥证、脾虚湿蕴证3种,不同人群,其证型分布有差异。3 CD4计数<200 cells/ul的艾滋病相关性痒疹患者的皮肤症状表现较重,皮肤生活质量指数积分较高,生存质量较低,中医证候积分较高。提示艾滋病相关性痒疹可能与免疫功能相关。4 PPE临床表现量表与中医证候积分量表、PPE临床表现量表与皮肤生活质量指数量表、皮肤生活质量指数量表与中医证候积分量表之间有弱正相关性。5每个证型相应的中药协定方对艾滋病相关性痒疹患者疗效显著,不仅可减轻患者皮疹及瘙痒带来的痛苦,而且能调整机体阴阳平衡,增强抗病能力,提高患者的生活质量,且安全性好。
【Abstract】 Currently there is still no TCM syndrome identification and treatment research about pruritic papular eruption. This research is based on the national "Eleventh Five" major projects, and the State Key Basic Research Program of special funding. This study, through theoretical research, analyzes correlation between pruritic papular eruption and the syndrome of Chinese Medicine, investigate the present situation and problems of pruritic papular eruption at home and abroad. Through clinical research, it analyzes epidemic information of pruritic papular eruption patients, studies their symptoms, signs, patterns as well as relations among various factors, so as to identify pattern rule of pruritic papular eruption patients. Through clinical treatment research it explores TCM treating methods for pruritic papular eruption. ObjectiveThrough theoretical research, this study explores the causes, pathogenesis, as well as common patterns and symptoms of pruritic papular eruption;through epidemiological survey, it tries to summarize the characteristics of the pattern;through clinical treatment, it observes the curative effect of corresponding Chinese medicine prescription of each pattern to pruritic papular eruption.Methods1 Theoretical ResearchBased on the itch rash literature and pruritic papular eruption relevant literature at home and abroad from January 1980 to December 2011 as well as survey of common clinical manifestations of pruritic papular eruption, this study explores the causes, pathogenesis, as well as common patterns and symptoms, providing help for pattern standardization, as well as formulation of TCM syndrome questionnaires and clinical treatment of pruritic papular eruption. 2 Clinical Research(1)Statistical analysis is carried out about the symptoms, signs, patterns and epidemiological data of 364 standard pruritic papular eruption patients from Henan, Beijing, Yunnan, Guangzhou, Hubei, Shenzhen, Guangxi, etc., and the characteristics of the pattern are summarized.(2)Through multi-center, randomized and controlled study,358 standard pruritic papular eruption patients are randomly divided into Chinese medicine treatment group and Western medicine control group. The treatment lasted for 4 weeks. We observed the curative effect of corresponding Chinese medicine prescription of each pattern to pruritic papular eruption. Results1 Theoretical ResearchThe skin symptoms of pruritic papular eruption patients are similar to those of the patients of prurigo nodularis, including skin itching, having extensive skin lesions, showing red spotted papule, nodules, blisters, even water seepage erosion. Red tongue, yellow, thick greasy moss, slippery, small, string pulse, etc. The syndrome differentiation of TCM are mainly blood deficiency, wind-heat, damp-heat or blood-heat patterns. The diseases are chiefly in the spleen and liver, the pathological factors are chiefly wind-evil, wet-evil, blood deficiency, etc. It is a vacuity-repletion complex pattern. The virtual mainly is the deficiency of both qi and blood, the repletion mainly are the wet poison implication, the wind, the wind and heat, blood stasis coalescence in the skin.2 Clinical Research(1)Clinical epidemiology and TCM syndrome researchAmong the 364 pruritic papular eruption patients, the youngest is 18 while the oldest is 65. Most of them are 30 to 49 years old. The ratio of male and female is 1.33:1.The possible infection approaches are mainly sexual contact, blood transmission and intravenous drug use. Skin itching in patients is mainly moderate, accounting for 47.8% of the total number. Pimple is mainly mild, accounting for 64.6% of the total number.Among all the enrolled patients, there are 23 whose CD4≥500 cells/ul,129 whose CD4 is between 200 and 499 cells/ul,209 whose CD4<200 cells/ul,and 3 without measurement.Among 364 pruritic papular eruption patients, there are 173 cases of blood heat engendering wind pattern,104 cases of blood deficiency with wind dryness pattern,84 cases of spleen deficiency with dampness trapping pattern, and 3 cases of other pattern.Common skin symptoms whose onset frequency is beyond 50% include itchy skin, pimples, scratches, pigmentation, nodules, skin lesions, lesions located in the upper limbs.Common complicated symptoms whose onset frequency is more than 30% include fatigue, dry throat, insomnia, abnormal body, vexation, poor appetite, weakness of waist and knees, and dizziness.Research has found that patients whose CD4 is less than 200 cells/ul are susceptible to pattern of spleen deficiency with damp encumbrance, while those with CD4 between 200 to 499 cells/ul are susceptible to pattern of blood deficiency and wind dryness.Patients with blood-transmitted pruritic papular eruption are susceptible to pattern of spleen deficiency with damp encumbrance, sexually transmitted patients are susceptible to pattern of blood heat engendering wind, and intravenous drug infected patients are susceptible to pattern of blood deficiency and wind dryness. pruritic papular eruption patients without itching and papule are more likely to be sexually transmitted infections, patients with mild itching and pimples are more likely to be intravenous drug users, and patients with moderate and severe itching and pimples are more likely to be blood transmitted infections.The male witness more sexual contact and intravenous drug infections, while the female see more blood infections. As for the age, patients below 40 are more likely to be sexual contact and intravenous drug infections, while those beyond 40 are more likely to be blood transmitted infections. As for symptoms, moderate and severe itching and pimples are more likely to be blood transmitted infections.Those more aged with lower CD4 count and more serious pimples have more serious itching.Patients with mild and moderate itching see more pattern of blood deficiency and wind dryness, while those with severe itching see more pattern of spleen deficiency with damp encumbrance. Patients with mild pimples see more pattern of blood deficiency and wind dryness, while those with moderate and severe pimples see more pattern of spleen deficiency with damp encumbrance.With the age increasing, scale scores of TCM syndrome and PPE clinical performance gradually increase.From high to low, scores of TCM syndrome are pattern of spleen deficiency with damp encumbrance, pattern of blood heat engendering wind, and pattern of blood deficiency and wind dryness. It indicates that the more complicated the pattern is, the more severe symptoms are.From high to low, scale scores of PPE clinical performance and TCM syndrome are blood transmitted patients, sexual contact patients, and venous drug infected patients.There is a weak positive correlation between PPE clinical performance scale and Chinese Medicine syndromes scale, PPE clinical performance scale and skin life quality index scale, skin life quality index scale and Chinese Medicine syndromes scale. Patients with the more serious skin symptoms, as a whole.the more serious symptoms also are, the worse skin quality of life also are.(2)Clinical treatment research358 standardized patients with Pruritic papular eruption are selected and randomly divided into Chinese medicine treatment group and Western medicine control group. The treatment lasted for 4 weeks. We observed patients’CD4 count, TCM syndrome score, survival quality score, PPE clinical performance scale, skin life quality index scale, etc. The results show that Chinese medicine prescription of each pattern is safe and distinctly curative, not only relieving the rash and itching pain,but also adjusting the balance of yin and yang of the body, enhancing the resistance, and improving the quality of life of the patients.Conclusions1 Pruritic papular eruption patients are mainly young males. Infection are mainly through sexual contact, blood transmission and intravenous drug use. Most itches are moderate while pimples are mild. CD4 count is usually below 200 cells/ul.2 Pruritic papular eruption patients mainly suffer from three patterns, namely, pattern of blood heat engendering wind, blood deficiency and wind dryness, and spleen deficiency with damp encumbrance. There is different pattern distribution among different people.3 Pruritic papular eruption patients with CD4 count below 200 cells/ul have more severe skin symptoms, higher skin life quality index score, lower survival quality and higher TCM syndrome score. It indicates that Pruritic papular eruption may associated with immune function.4 There is a weak positive correlation between PPE clinical performance scale and Chinese Medicine syndromes scale, PPE clinical performance scale and skin life quality index scale, skin life quality index scale and Chinese Medicine syndromes scale.5 Chinese medicine prescription of each pattern is safe and distinctly curative, not only relieving the rash and itching pain, but also adjusting the balance of yin and yang of the body,enhancing the resistance, and improving the quality of life of the patients.