二步照射法对氨基酮戊酸光动力疗法治疗中重度痤疮患者疼痛及临床疗效的影响

Effect of two-step irradiance schedule on pain control during and clinical efficacy of aminolevulinic acid-based photodynamic therapy for moderate-to-severe acne

目的探讨二步照射法对氨基酮戊酸光动力疗法(ALA-PDT)治疗中重度痤疮患者疼痛及临床疗效的影响。方法选择2018年1月至2019年3月在恩施州中心医院皮肤科行ALA-PDT治疗的中重度痤疮患者60例,按照治疗的先后顺序平均分为观察组和对照组。对照组采用常规的治疗方法照射,光输出强度65 mW/cm2、20 min;观察组给予起始光输出强度40 mW/cm2、8 min,照射至20 J/cm2,继以光输出强度65 mW/cm2、15 min,使光照总能量达78 J/cm2,根据患者反应适当调整光照强度,每2周照射1次,连续3次。记录并比较两组患者开始出现疼痛时间和照光开始后5、10、15、20、25、30、50 min时的疼痛评分;治疗结束后1个月评估临床疗效;治疗过程中及治疗结束后随访3个月,记录其他不良反应。结果观察组疼痛开始时间为(10.40 ± 1.13)min,对照组为(3.95 ± 0.77)min,两组差异有统计学意义(t = 25.919,P < 0.05)。治疗过程中,观察组和对照组的疼痛评分均随着照光时间点的变化出现显著波动(F = 323.631,P < 0.01),但观察组与对照组疼痛评分的波动趋势差异有统计学意义(F = 89.338,P < 0.01),时间点和分组的交互作用有统计学意义(F = 24.059,P < 0.01)。在照光开始后第5、10、15分钟时,观察组的疼痛评分低于对照组,两组差异有统计学意义(t值分别为21.714、28.407、28.286,均P < 0.05);在照光开始后第20分钟时,两组间疼痛评分差异无统计学意义(t = 1.505,P > 0.05);在照光开始后第25分钟(观察组照光结束2 min、对照组照光结束5 min)、30 min、50 min(冷敷结束时)时两组的疼痛评分差异亦无统计学意义(t值分别为0.606、1.038、0.344,均P > 0.05)。两组光照结束时(观察组照光开始后第23分钟,对照组光照开始后第20分钟)疼痛评分差异无统计学意义(t = 1.968,P = 0.149)。3次治疗结束后1个月,观察组有效率为90%(27/30),对照组有效率为83.3%(25/30),两组差异无统计学意义(χ2 = 0.577,P = 0.706)。两组患者水疱、红斑水肿、干燥脱屑、瘙痒、反应性痤疮及色素沉着发生率差异均无统计学意义(均P>0.05)。结论二步照射法能有效控制ALA-PDT治疗中重度痤疮过程中的相关疼痛,特别在治疗初始阶段,使患者可以顺利完成3次ALA-PDT治疗,并保证临床疗效。

Objective To evaluate the effect of two-step irradiance schedule on pain control during and clinical efficacy of aminolevulinic acid(ALA)-based photodynamic therapy(PDT)for moderate to severe acne.Methods Sixty patients with moderate to severe acne were enrolled from the Department of Dermatology,the Central Hospital of Enshi Tujia and Miao Autonomous Prefecture from January 2018 to March 2019,and equally divided into 2 groups according to the order of treatment:control group receiving conventional irradiation at a light output intensity of 65 mW/cm2 for 20 minutes,and observation group irradiated at an initial light output intensity of 40 mW/cm2 for 8 minutes until the irradiation energy reached 20 J/cm2,followed by irradiation at a light output intensity of 65 mW/cm2 for 15 minutes until the total irradiation energy reached 78 J/cm2.During the treatment,the irradiation intensity was appropriately adjusted according to the patients′response,and all the patients were treated once every 2 weeks for 3 consecutive sessions.The time to onset of pain and pain scores at 5,10,15,20,25,30 and50 minutes after the start of irradiation were recorded and compared between the two groups;clinical efficacy was evaluated 1 month after the end of the treatment;other adverse reactions were recorded during the treatment and 3-month follow-up after the end of treatment.Results The time to onset of pain was significantly different between the observation group(10.40±1.13 minutes)and the control group(3.95±0.77 minutes;t=25.919,P<0.05).During the treatment,the pain score significantly changed over time(F=323.631,P<0.01),and significantly differed between the observation group and control group(F=89.338,P<0.01).Additionally,there was a significant interaction between the treatment duration and treatment methods(F=24.059,P<0.01).At 5,10 and 15 minutes after the start of irradiation,the pain score was significantly lower in the observation group than in the control group(t=21.714,28.407,28.286 respectively,all P<0.05);at 20 minutes,there was no significant difference in the pain score between the two groups(t=1.505,P>0.05);at 25 minutes(that is,2 and 5 minutes after the end of irradiation in the observation group and control group respectively),30 minutes,50 minutes(that is,the end of the cold compress),there was also no significant difference in the pain score between the two groups(t=0.606,1.038,0.344 respectively,all P>0.05);at the end of irradiation(that is,23 and 20 minutes after the start of irradiation in the observation group and control group respectively),there was still no significant difference in the pain score between the two groups(t=1.968,P=0.149).One month after the 3 sessions of treatment,there was no significant difference in the response rate between the observation group(90%,27/30)and control group(83.3%,25/30;χ2=0.577,P=0.706).Moreover,there was no significant difference in the incidence of blisters,erythema,edema,skin dryness,desquamation,pruritus,reactive acne or pigmentation between the two groups(all P>0.05).Conclusion The two-step irradiance schedule can effectively control related pain during the treatment of moderate to severe acne with ALA-PDT,especially in the initial stage of treatment,making patients successfully complete 3 sessions of ALA-PDT treatment and ensuring the clinical efficacy.