系统糖皮质激素治疗进展期白癜风的疗效及相关因素研究

Efficacy of systemic glucocorticoid treatment and its related factors in patients with progressive vitiligo

目的探讨系统糖皮质激素(简称激素)治疗白癜风疾病活动度评分(VIDA)≥2分的进展期患者的疗效及相关因素。方法2018年6月至2019年6月于杭州市第三人民医院皮肤科,收集未经系统性激素治疗、VIDA≥2分、皮损面积<1%的进展期白癜风患者272例,分析皮损面积和型别、VIDA评分、是否具有诱发因素及特殊临床标记(三色白癜风、纸屑样白斑、同形反应及炎症性白癜风)。采用随机数字表法将患者随机分为外用激素组(62例),口服泼尼松+外用激素组(76例)和注射复方倍他米松+外用激素组(134例),后两组又称为系统+外用激素组。外用激素组采用卤米松乳膏或0.05%丙酸氯倍他索乳膏治疗,每日1次;口服泼尼松治疗时,每7天调整1次剂量,按30、20、15、10、5 mg/d剂量递减,疗程共35 d;采用复方倍他米松注射液治疗时,每20天肌内注射1次,每次1 ml,共2次。观察治疗3个月后各组皮损稳定率,随访1年后白癜风型别变化。统计分析采用Kruskal-Wallis H检验、χ^2检验和Fisher确切概率法。结果治疗3个月后,3组白癜风患者皮损面积扩大率差异有统计学意义(H=12.468,P<0.001),口服泼尼松+外用激素组和注射复方倍他米松+外用激素组均显著低于外用激素组(P<0.001、=0.005,α=0.0167);缓慢进展期患者中,系统+外用激素病情稳定率均显著高于外用激素组(χ^2=23.973、11.877,均P<0.001);不同VIDA评分的系统+外用激素治疗患者病情稳定率不同(χ^2=17.122,P<0.001)。伴诱发因素或特殊临床标记的患者系统激素治疗3个月后病情稳定率[47.3%(35/74),41.2%(47/114)]均显著低于无明显诱发因素或特殊临床标记的患者[70.6%(96/136),87.5%(84/96);χ^2=11.098、47.548,均P<0.001]。随访1年后,外用激素组白癜风型别由局限型转为非局限型的比例(41.9%,26/62)显著高于系统+外用激素组(21.9%,46/210;χ^2=10.328,P=0.006),伴诱发因素组和有特殊临床标记组高于无诱发因素组和无特殊临床标记组(均P<0.01)。结论高VIDA评分、伴诱发因素和特殊临床标记的进展期白癜风患者应尽早介入系统激素治疗。

Objective To investigate the efficacy of systemic glucocorticoid treatment and its related factors in progressive vitiligo patients with vitiligo disease activity(VIDA)scores≥2 points.Methods A total of 272 progressive vitiligo patients with VIDA scores≥2 points and skin lesion area<1%of body surface area,who received no systemic glucocorticoid treatment,were collected from Department of Dermatology,the Third People′s Hospital of Hangzhou from June 2018 to June 2019.The area and type of skin lesions,VIDA scores,predisposing factors and special clinical markers(trichrome vitiligo,confetti-like depigmentation,Koebner phenomenon and inflammatory vitiligo)were analyzed.These patients were randomly divided into 3 groups by a random number table:topical glucocorticoid group(62 cases),oral prednisone+topical glucocorticoid group(76 cases)and compound betamethasone injection+topical glucocorticoid group(134 cases),and the latter two groups were also called as the systemic and topical glucocorticoid group.The patients in the topical glucocorticoid group were treated with halometasone cream or 0.05%clobetasol propionate cream once a day;during the oral prednisone treatment,the dose was adjusted once every 7 days,and gradually reduced from 30 mg/d to 20,15,10 and 5 mg/d,and the treatment lasted 35 days;during the treatment with compound betamethasone injection,intramuscular injection was performed once every 20 days at a dose of 1 ml for 2 sessions.The stable disease rate(defined as the proportion of patients experiencing no progression during the study among the analyzed patients)was calculated in these groups after 3 months of treatment,and changes in vitiligo types were evaluated after 1 year of follow-up.Statistical analysis was carried out by using Kruskal-Wallis H test,χ^2 test and Fisher′s exact test.Results After 3-month treatment,there was a significant difference in the expansion rate of skin lesion area among the 3 groups(H=12.468,P<0.001),and the expansion rate of skin lesion area was significantly lower in the oral prednisone+topical glucocorticoid group and compound betamethasone injection+topical glucocorticoid group than in the topical glucocorticoid group(P<0.001,=0.005,respectively,α=0.0167);among the patients with slowly progressive vitiligo(VIDA scores=2 or 3 points),the stable disease rate was significantly higher in the systemic and topical glucocorticoid group than in the topical glucocorticoid group(χ^2=23.973,11.877,respectively,both P<0.001);the stable disease rate also significantly differed among the patients with different VIDA scores(VIDA scores=2,3 or 4 points)in the systemic and topical glucocorticoid group(χ^2=17.122,P<0.001).After 3-month treatment,the patients with predisposing factors or special clinical markers showed significantly decreased stable disease rate(47.3%[35/74],41.2%[47/114],respectively)compared with those without predisposing factors or special clinical markers(70.6%[96/136],87.5%[84/96];χ^2=11.098,47.548,respectively,both P<0.001).After 1 year of follow-up,the proportion of patients with localized vitiligo converted into non-localized vitiligo was significantly higher in the topical glucocorticoid group(41.9%,26/62)than in the systemic and topical glucocorticoid group(21.9%,46/210;χ^2=10.328,P=0.006),and higher in the group with predisposing factors or special clinical markers than in that without predisposing factors or special clinical markers respectively(both P<0.01).Conclusions Early systemic glucocorticoid treatment should be performed in the progressive vitiligo patients with high VIDA scores,predisposing factors and special clinical markers.