反射式共聚焦显微镜联合光学相干断层成像在黄褐斑微观辨证中的作用

The Role of Reflectance Confocal Microscopy and Optical Coherence Tomography in Microscopic Differentiation in Patients With Melasma

目的探讨不同中医证型女性黄褐斑皮损的微观差异。方法收集2023年1月—2023年12月在华中科技大学同济医学院附属武汉中西医结合医院皮肤科门诊确诊的113例女性黄褐斑患者,在判断其符合纳入标准并征得患者知情同意后,收集整理患者资料并对其进行中医分型,将黄褐斑分为肝郁血瘀型、脾虚型、肾阳虚型及肝肾阴虚型。同时对各型患者行反射式共聚焦显微镜(RCM)、光学相干断层成像(OCT)检查,观察和分析女性黄褐斑各中医证型皮肤组织形态学特征。结果113例女性黄褐斑患者中,中医辨证分型包括肝郁血瘀型51例(45.13%),脾虚型34例(30.09%),肾阳虚型16例(14.16%),肝肾阴虚证12例(10.62%)。入选对象皮损处RCM下表皮色素数量分布均见增加,以patternⅡ、patternⅢ模式占比居多;均有显著的黑素细胞活跃现象,主要以patternⅠ、patternⅡ模式占比居多,四种主要证型间无显著差异。肝肾阴虚型RCM下以混合型改变为主,表皮黑素颗粒分布明显增多,黑素细胞明显活跃,黑素细胞悬垂及真皮层噬黑素细胞浸润均显著;脾虚型RCM下以表皮型改变为主,真皮内噬黑素细胞浸润出现比例较低;OCT观察发现黄褐斑皮损毛细血管网深度,平均分布在皮下54.57±14.19μm之间,四种主要证型间无统计学差异。肝郁血瘀型黄褐斑皮损中,血管扩张改变较其他三型显著。结论不同中医证型黄褐斑皮损,其组织学改变具有一定差异性和规律性,皮肤影像学指标可为中医辨证,个体精准化治疗提供必要的客观参考依据。

Objective Using skin imaging techniques,to investigate microscopic morphological characteristies,analyze the difference of different dialectical types of Chinese medicine for female patients with melasma,and provide histology evidence for Chinese Medicine System of syndrome differentiation.Methods Selecting the female patients diagnosed with melasma,from January to December in 2023,in the outpatient department of Dermatology,Traditional Chinese and Western Medicine Hospital of Wuhan,Tongji Medical college,Huazhong University of Science and Technology.All met the diagnostic criteria and inclusion criteria and with their informed consent,collecting the data information,classifying them by traditional Chinese medicine dialectical classification.According to dialectical types of Chinese medicine of melasma,categorize melasma into liver-weak and breath-stagnat type,spleen-deficiency type,kidney-positive-deficiency type and kidney-liver-negative-deficiency type.Reflectance confocal microscopy(RCM)and optical coherence tomography(OCT)examinations were conducted on target lesion,collected the information of patients,subclinical morphological changes were observed.Results Depending on traditional chinese medicine dialectical classification,113 female patients with melasma were subdivided into 51 cases liver-weak and breath-stagnat type(45.13%),34 cases spleen-deficiency type(30.09%),16 cases kidney-positive-deficiency type(14.16%),12 cases kidney-liver-negative-deficiency type(10.62%).Increased quantity of melanin and activation of melasma were observed in all the 113 patients on RCM observation,patternⅡ/Ⅲand patternⅠ/Ⅱaccounted for a higher proportion respectively.However,there were no siginificant differences in dialectical types of Chinese medicine.In patients with syndrome of kidney-liver-negative-deficiency type,the mixed RCM type were responsible for the largest proportion of cases,revealed presence of elevated degree of pigment at the level of the epidermis,activated melanocytes located at all the different levels of the skin,pendulous melanocytes at DEJ and upper dermis,dermal melanophages on RCM observation.In patients with syndrome of spleen deficiency,the epidermal RCM type were responsible for the largest proportion of cases,the percentage of dermal melanophages was lower compared with the other three groups.D-OCT findings that dermal blood vessels depth in melasma was 54.57±14.19μm,vessel density and vessel diameter are increased in liver-weak and breath-stagnat type compared with the other three groups.Conclusion The microscopic morphological characteristies presented magnificant difference regularity,and the regularity coincides with differentiation of symptoms and signs of different dialectical types of Chinese medicine for melasma.Skin imaging technology provide objective basis for the dialectical of Chinese medicne,individual treatment and precision approach.