对1049例寻常型银屑病患者病程证候、证素演变规律的回顾性研究

A retrospective study on the evolution of TCM syndrome and TCM syndrome elements in the course of disease in 1,049 patients with psoriasis vulgaris

目的探讨寻常型银屑病慢性病程不同阶段的中医证候及证素演变规律。方法基于2019年7月—2024年3月1049例寻常型银屑病患者的电子病历数据建立数据库。使用桑基图和网络关联图分析患者初诊,进行期(第2、3周),进行期(第4、5周),皮损改善期(第6、7周)及缓解期的证候及证素演变规律。通过社区检测算法构建证素网络,并以热图形式展示局部皮损辨证与整体辨证的关联规则。结果①初诊:局部皮损辨证,以血热证最多(79.79%);病位证素中,肝最多(35.62%);病性证素中,火(热)最多(75.48%)。②进行期(第2、3周):局部皮损辨证,仍以血热证最多(73.13%);病位证素中,肝最多(31.71%);病性证素中,仍是火(热)最多(82.11%),湿(22.26%)及气滞(8.39%)开始增加。③进行期(第4、5周):局部皮损辨证,以血热证(45.91%)及血燥证(37.19%)为主;病位证素中,里最多(15.25%);病性证素中,火(热)最多(50.66%),阴虚增加(34.26%)。④皮损改善期(第6、7周):局部皮损辨证,血燥证(49.44%)及血瘀证(33.33%)均增多;经络(13.44%)及血瘀(28.20%)分别为病位证素及病性证素中增加最明显并成为占比最多者。⑤缓解期:局部皮损辨证,血瘀证成为主要皮损辨证类型(55.69%),血燥证数量减少(21.16%);经络(25.71%)及血瘀(62.34%)仍是病位证素及病性证素中最主要的证素。结论寻常型银屑病的证候整体呈现由实到虚的演变规律,初诊至进行期(第2、3周)证素、证候类型以热证为主,进行期(第4、5周)证素、证候类型以热证兼有湿证或阴虚证为主,皮损改善期证素网络的变化最为显著,此时血瘀表现逐渐增多,至缓解期达到峰值。血瘀、湿、气滞证贯穿疾病全程;气滞、血瘀可能是导致寻常型银屑病进行期患者病情进一步恶化、病程迁延不愈的主要因素。

Objective The study aimed to elucidate the evolution of the syndromes in Traditional Chinese Medicine(TCM)and TCM syndrome elements in different chronic stages of psoriasis vulgaris.Methods A database was constructed using electronic medical records collected from July 2019 to March 2024 from 1,049 patients with psoriasis vulgaris.The study used Sankey diagrams and network association graphs to analyze the evolution of TCM syndromes and their elements in patients at the different stages:initial diagnosis,progressive stage(Week 2-3),progressive stage(Week 4-5),skin lesion improvement stage(Week 6-7),and remission stage.The syndrome elements network was constructed using community detection algorithms,and the association rules between local skin lesion syndrome differentiation and overall syndrome differentiation were displayed using heatmaps.Results(ⅰ)Initial diagnosis.In the syndrome differentiation of local skin lesions,blood heat syndrome was the most common(79.79%);among the disease location of TCM syndrome elements(called“disease location”),liver was the most prevalent(35.62%);and among the pathological factors of TCM syndrome elements(called“pathological factors”),fire(heat)was the most common(75.48%).(ⅱ)Active stage(Week 2-3).In the syndrome differentiation of local skin lesions,blood heat syndrome remained the most prevalent(73.13%);among the disease location,liver was still the most prevalent(31.71%);and among the pathological factors,fire(heat)continued to be the most common(82.11%),while dampness(22.26%)and qi stagnation(8.39%)began to increase.(ⅲ)Active stage(Week 4-5).The syndrome differentiation of local skin lesions was dominated by blood heat syndrome(45.91%)and blood dryness syndrome(37.19%);among disease location,the interior was the most prevalent(15.25%);and among the pathological factors,fire(heat)remained the most common(50.66%),with an increase in yin deficiency(34.26%).(ⅳ)Skin lesion improvement stage(Week 6-7).In the syndrome differentiation of local skin lesions,both blood dryness syndrome(49.44%)and blood stasis syndrome(33.33%)increased;among the disease location,meridians increased most significantly and became the most prevalent(13.44%);and among the pathological factors,blood stasis increased most significantly and became the most prevalent(28.20%).(ⅴ)Remission stage.In the syndrome differentiation of local skin lesions,blood stasis syndrome became the primary(55.69%),while the percentage of blood dryness syndrome decreased(21.16%);meridians(25.71%)and blood stasis(62.34%)remained the most predominant syndrome elements related to disease location or pathological factors.Conclusion The overall pattern of TCM syndromes in psoriasis vulgaris evolved from excess to deficiency.From the initial diagnosis to the active phase(Week 2-3),heat syndrome dominated;during the active phase(Week 4-5),heat syndrome coexisted with damp syndrome or yin deficiency syndrome;changes in the syndrome element network were the most significant during the lesion improvement phase,with blood stasis gradually increasing and peaking during the remission phase.Blood stasis,dampness,and qi stagnation were pervasive throughout psoriasis vulgaris;qi stagnation and blood stasis may be the main elements causing further deterioration and prolonged course of the disease during the active phase in patients.