【作者】 赵庆利；

【导师】 蔡瑞康；

【作者基本信息】 中国人民解放军军医进修学院 ， 中西医结合临床， 2009， 博士

【摘要】 目的:总结归纳蔡瑞康教授诊治皮肤病的学术经验。对瘢痕疙瘩（Keloid,K）患者进行辨体、辨病、辨证分析。观察自制中药外治的临床疗效并探讨其作用机制。方法:应用《中医体质分类判定标准》对124例K患者进行中医体质类型研究。对154例K患者的总体及分型后临床资料进行分析。根据《血瘀证诊断标准》等对154例K患者进行血瘀证及兼证类型调查,测定43例K患者血液流变学指标,对5例K患者的不同分型皮损进行超声及皮肤镜检查。采用随机、对照临床试验方法观察自制中药软膏、酊剂外用治疗K疗效。对自制中药作用后的体外培养K成纤维细胞的形态、增殖活性、Ⅰ型胶原蛋白、基质金属蛋白酶1（MMP-1）及血管内皮细胞生长因子（VEGF）的表达及细胞毒性进行检测。结果:①与正常人比较,K患者属湿热质、瘀血质、痰湿质、阴虚质、特禀质、气虚质的百分比增加;男性、女性、17～45岁患者属湿热质的百分比增加;男性、36～45岁患者属瘀血质、痰湿质、阴虚质、特禀质的百分比增加;17～25岁患者属痰湿质、阴虚质的百分比增加;与痤疮患者比较,与痤疮相关K患者属阴虚质的百分比增加（p＜0.05）。②K发病年龄11～30岁占81.17%,有家族史者占25.97%,皮损累及部位依次为胸、背、下颌、四肢、腹腰臀,主要诱因为痤疮（48.70%）、毛囊炎（35.71%）。87.50%胸背下颌多发型K由痤疮诱发,54.90%、23.53%胸部单发型K由毛囊炎、搔抓诱发,四肢多发型、混合型K与瘢痕体质有关,手术居胸外单发型K发病诱因的首位。③99.35%K患者属血瘀证,兼证类型依次为湿热证（61.44%）、气滞证（34.64%）、痰湿证（26.80%）、气虚证（1.31%）。与正常人比较,K患者中切变率30^-S、5^-S全血粘度值、全血低切还原粘度、红细胞聚集指数增高的病例数增加（p＜0.05）。K皮损内呈缺血或缺动脉血状态,浅部血管数目、分布及形态异常,依皮损分型不同而血流状态及浅部血管表现亦不同。④与积雪苷比较,自制中药软膏外用治疗K12周后,从靶皮损疗效评估、严重程度总评分、分级三种方式判定均差异有统计学意义（p＜0.05）。⑤在一定浓度下,自制中药提取物作用后K成纤维细胞形态发生改变,增殖活性降低,Ⅰ型胶原蛋白表达减低,MMP-1表达增高,VEGF表达呈双向性改变,乳酸脱氢酶（LDH）活性增高。结论:运用中医学及中西医结合理论与方法诊治皮肤病是蔡教授的学术特色。K发生与某些中医体质类型有关。K临床类型不同其发病原因亦不同。K存在着血行瘀滞以及血液流变性异常、皮损处微循环障碍。自制中药软膏治疗K疗效满意,该药从多方面影响着K成纤维细胞的生物性状。更多还原

【Abstract】 Objective:To summrize the academic experience of prof.Cai Ruikang in diagnosing and treating dermatosis,analyze the patients with keloids by differentiating individual,disease and syndrome,observe the clinical effect of topical therapy of self-made traditional Chinese drug and explore its functional mechanism.Methods:124 patients’ body constitution types were researched according to＜TCM Classification Standards of Health＞.154 patients’overall and classified clinical data were analyzed. 154 patients were investigated whether they corresponded to＜Diagnostic Standards for Blood Stasis Syndrome＞or not and about accompanied syndromes.43 patients’ hemorheological indexes were detected.5 patients’ different types of lesions were evaluated with sonography and demoscopy equipments.Clinical curative effects on keloids with self-made drug were observed by randomized and controlled clinical trial. The drug action on the biological activity of keloid-derived fibroblasts were evaluated with regard to their appearance,proliferation,cytotoxicity and the expressions of typeⅠcollagen,matrix metalloproteinasel(MMP-1)and VEGF.Results:①Compared with the normal group,the percentage of wet-heat,blood-stasis,phlegm-wetness,yin-deficiency, special diathesis and qi-deficiency types increased in the patients with keloids.The percentage of wet-heat type increased in male and female patients,at the 17-45 years of age.The percentage of blood-stasis,phlegm-wetness,yin-deficiency and special diathesis types increased in male patients,at the 36-45 years of age.The percentage of phlegm-wetness and yin-deficiency types increased in the patients at the 17-25 years of age.Compared with the patients with acne,the percentage of yin-deficiency type increased in the patients with acne associated keloids(p＜0.05).②81.17%of the patients had their disease started between the ages of 11 and 30 years,and 25.97%had the positive family history of keloid.Chest,back and submaxilla area were the most common sites for scarring.The major initiating factors of scarring were acne(48.70%) and folliculitis(35.71%).Multiple keloids on the chest,back and submaxilla related to acne(87.50%),solitary keloid on the chest to folliculitis(54.90%)and scratching (23.50%),multiple keloids on the limbs and mixed type to scar physique,solitary keloid on any part except chest to surgery.③99.35%of the patients with blood-stasis syndrome and 61.44%,34.64%,26.80%,1.31%with wet-heat,qi-stagnancy, phlegm-wetness,qi-deficiency syndrome were successively observed.Compared with normal group,the number of the patients being detected four elevating hemorheological indexes increased(p＜0.05).Blood or arterial blood shortage was presented in the lesions of keloids.The number,distribution and shape of superficial blood vessel were abnormal.The status of blood flow and the manifestation of superficial blood vessel were different in the light of different types of lesions.④Compared with asiaticoside group,after having been treated with self-made drug unguent for 12 weeks,the differences determined by general assessment,score and grade on the basis of the severity of target lesion were statistically significant(p＜0.05).⑤Within certain concentration,after the extractant from self-made drug taking action,the fibroblast appearance was altered,the cellular proliferating activity was decreased,the LDH activity was increased and the expression of collagenⅠwas suppressed,the expression of MMP-1 was enhanced while the expression of VEQF was increased or decreased.Conclusion:Appling TCM and combination of TCM with Western to diagnoses and treatment of dermatosis is prof.Cai’s academic characteristics.The occurance of keloid relate to some body constitution types,blood stasis,systemic and topical dysaemia.The onset causes of different keloid types are different.The curative effect of self-made drug unguent is significant in treating keloids.The medicine may influent the biological mechanism of keloid fibroblasts in various aspects.更多还原