敏感性皮膚與黃褐斑治療選擇

敏感性皮膚與黃褐斑治療選擇

長(zhǎng)沙美萊美容醫(yī)院深圳美萊美容醫(yī)院

麥躍楊鵬

黃褐斑診斷含義狹義黃褐斑原發(fā)性黃褐斑廣義黃褐斑繼發(fā)性黃褐斑+PIH+膚色暗沉

合并癥褐青色痣雀斑光老化斑

臨床表現(xiàn)為“花、暗”Melasma-likehyperpigmentationinducedbyintensepulsedlighttreatmentinChineseindividuals(MLH)

LinFang(中國),MichaelH.Goldetal.

JournalofCosmeticandLaserTherapy,PostedonlineonSeptember4,2014Background:Symmetricmelasma-likehyperpigmentation(MLH)hasbeenidentifiedinseveralpatientsfollowingintensepulsedlaser(IPL)treatmentsessions.ThesepatientsexhibitednotypicalsignsofmelasmapriortoIPLtherapy.

Objectives:ToinvestigatetheincidenceofMLHinChinesepatientsreceivingIPLtreatmentandtodiscusspotentialcausativefactorsforthisconditionandpotentialpreventivemeasures.

Methods:675patientswithskintypesIII–IVwhoweretreatedwithIPLwereretrospectivelystudied.

Results:MLHwasnotedin20cases(20/675,2.96%)within3monthsfollowingIPLtreatmentsession.AllthepatientshadapigmentarydisorderpriortotheirIPLtreatments,themostcommonbeingphotoagingorthepresenceoffreckles.Thelesionsseenin14ofthe20cases(14/20,70%)weremultiplepigmentedlesionsalongawidedistributionoftheskinwithundefinedborders.Sixofthecaseshadastrongpost-treatmentlocalreactionwhichalsomayhavecontributedtotheMLH.In2cases,theoriginalskinconcernbecameworsefollowingtheIPLtherapyandmayhavebeenareasonfortheformationofMLH.In6cases,wenotedthattheseindividualswerenotregularusersofsunscreenpost-therapy,despiteourrecommendations,whichalsomayhavecontributedtotheformationoftheirMLH.

Conclusions:TheadverseeventandformationofIPL-inducedMLHseeninChineseindividualsdoeshavearelationshiptoaprimarypigmentarylesion(s)andtrendtowardmelasmapriortotheIPLtherapy.TheIPLparameterschosenshouldbesuitablefortheskinconditionbeingtreatedandshouldfollowtherecommendationsofthemanufacturer'sdefaultsettingspriortoundertakingthetreatments.Post-therapyskincareandtheuseofappropriatesunprotectionarealsoimportantfactorsinpreventingMLH.

黃褐斑的顏色分析

黃----含鐵血黃素胡羅卜素皮膚代謝產(chǎn)物

氧和血紅蛋白下降

皮膚水潤度不足

褐----黑色素

治療原則----掃“黃”打“褐”

但在臨床治療上往往注重打“褐”而忽視“掃黃”

敏感性皮膚伴色素、含鐵血黃素沉著1、黃褐斑體質(zhì)：決定是否患黃褐斑2、加重因素：1）紫外線（現(xiàn)認(rèn)為可見光、紅外線均可加重）

2）精神壓力、睡眠不足（間接影響內(nèi)分泌、肝臟代謝）

3）皮膚屏障功能障礙（刺激性化妝品、清潔過度、摩擦刺激）這類黃褐斑又稱為慢性刺激性炎癥性色素沉著癥

4）不良護(hù)膚品

5）不良護(hù)膚治療

6）內(nèi)分泌

7）避孕藥黃褐斑發(fā)生的影響因素InflammatoryfeaturesofmelasmalesionsinAsianskin

TaiKyungNoh(韓國)

etal.

TheJournalofDermatology,Articlefirstpublishedonline:11AUG2014

DOI:10.1111/1346-8138.12573Thesecasesweredividedinto“non-inflammatory”and“inflammatory”groups.SkinbiopsiesandimmunostainingforCD68,CD117,andleukocytecommonantigen(LCA)wereperformedinthelesionalandperi-lesionalskinoftencasesinthenon-inflammatorygroupandninecasesintheinflammatorygroup.Amongthe197subjects(meanage,41.5years;meanageofmelasmaonset,33.8years),50patients(25.4%)werecategorizedintotheinflammatorygroup.Thisgroupcomprisedcasesthathadinflammatorysymptomsandeventsthattriggeredthemelasmalesions.ThelesionaldermiscontainedmoreCD68+melanophages,CD117+mastcells,andLCA+leukocytesintheinflammatorygroupthaninthenon-inflammatorygroup.InflammatoryclinicalfeaturesandanincreasednumberofinflammatorycellsinthelesionmaybeinvolvedinthedevelopmentofmelasmainAsianskin.近期報(bào)道黃褐斑病理特性AmJDermatopathol.2011May;33(3):291-5.doi:10.1097/DAD.0b013e3181ef2d45.Histochemicalandimmunohistochemicalstudyinmelasma:evidenceofdamageinthebasalmembrane.Torres-álvarezB1,Mesa-GarzaIG,Castanedo-CázaresJP,Fuentes-AhumadaC,Oros-OvalleC,Navarrete-SolisJ,MoncadaB.Authorinformation1DepartmentofDermatology,HospitalCentralDr.IgnacioMoronesPrieto,UniversidadAutónomadeSanLuisPotosí,S.L.P.,(UASLP),México.torresmab@.mxAbstractThepathogenesisofmelasmahasnotbeenclearlyelucidated.UsingFontanaMasson;diastase-resistantperiodicacid-Schiffstains;andimmunohistochemistrytostemcellfactor(SCF),itsreceptorc-kit,anti-mastcelltryptase,andanti-collagentypeIVantibody,weevaluatedmelasmalesionsandcomparedthemwithperilesionalskinandphotoprotectedskin.Samplesweretakenfromlesionalandphotoprotectednonlesionalskinin24patients.Inother24patients,wetookbiopsiesoflesionalandperilesionalskin.WithFontanaMasson,weobservedmanypigmentedbasalcellsprotrudingintothedermisofthemelasmaskin.Periodicacid-Schiffstainandanti-collagentypeIVshoweddamageonthebasalmembranein95.5%and83%,respectively,inmelasmalesion.TheimmunoreactivityofSCFandtheprevalenceofmastcellswereincreasedinthedermisofmelasmacomparedwithperilesionaldermis.Theexpressionofc-kitwassignificantlyincreasedatlesionalepidermis;afrequentprotrusionofc-kit-positivebasalcellsintothedermiswasevidentin70%versusthatin29%ofperilesionalskin.Theexpressionofc-kitwasincreasedatlesionaldermisofmelasmacomparedwithperilesionalskin.Wefoundalowcorrelationbetweenc-kitexpressionandprevalenceofmastcells;thesewereincreasedinmelasmaskin.TheresultsmaysuggestaroleofSCF,c-kit,andmastcellsinthepathogenesisofmelasma.Weweresurprisedbytheunexpectedevidenceofdamagetobasalmembrane(BM),whichcouldfacilitatethefallorthemigrationofactivemelanocytesandmelaninintothedermisallowingtheconstanthyperpigmentationinmelasma.文獻(xiàn)解讀黃褐斑非炎癥性----原發(fā)性黃褐斑炎癥性-------繼發(fā)性黃褐斑（與皮膚屏障受損有關(guān)）病理基礎(chǔ)不同，治療選擇各異Surveyofpracticingdermatologistsontheprevalenceofsensitiveskininmen

K.Vanoosthuyzeetal.

InternationalJournalofCosmeticScience,Articlefirstpublishedonline:6JUN2013Themajorityofdermatologistsinbothstudies(82.0%and58.3%,respectively)eitheragreedorstronglyagreedthattheyhavenoticedanincreaseinmalepatientsreportingsensitivefacialskinoverthepast5years.SomeregionaldifferenceswereapparentintheEuropeansurvey,withasignificantly(P≤0.05)higherproportionagreeinginCentral/EasternEurope(84.9%)andAsia(89.9%)comparedwithWesternEurope(75.1%).Generalfactorscitedthatcouldinfluencetheincidenceofperceivedskinsensitivityincludedenvironmentalfactors,stress,increasedacceptanceinsocietyandincreaseduseofproducts.WiththeexceptionofUVlightexposure,whichwascitedbyamajorityofdermatologistsinallgeographicalregions,exacerbatingenvironmentalfactorsdifferedinamannerthatmayhavebeenrelatedtodifferingclimatesintheregions.Inbothsurveys,over90%ofrespondersagreedthattheselectionofshavingproductswasimportantformenwithsensitiveskin.PollutionandSkin:Fromepidemiologicalandmechanisticstudiestoclinicalimplications

JeanKrutmannetal.

JournalofDermatologicalScience,PublishedOnline:September13,2014中歐專家綜述：空氣污染與皮膚Highlights?Pollution-inducedskindamageisaglobalproblemwithparticularrelevanceinChinaandIndia.?Ambientparticulatematterexposurecontributestoprematureskinaging.?Ozonedepletesantioxidantsfromskin.?Airpollutionexertsdetrimentaleffectsonhealthyanddiseasedskin.?Thearylhydrocarbonreceptoriskeyinmediatingairpollution-inducedskindamage.?Individualswithsensitiveskinmayrepresentasusceptiblesubgroup.?Specificcosmeticproductsarerequiredtoprotectskinfromairpollution-induceddamage.2014年初，由1名德國環(huán)境醫(yī)學(xué)專家和2名中國皮膚科醫(yī)生等7名專家組成國際專家組，通過對(duì)國際和中國相關(guān)最新文獻(xiàn)進(jìn)行綜述，總結(jié)了空氣污染對(duì)皮膚早衰影響的最新研究進(jìn)展、以及敏感皮膚與環(huán)境污染的關(guān)聯(lián)，并提出了針對(duì)污染的基礎(chǔ)性護(hù)膚建議：

1、使用洗凈（rinseoff）型產(chǎn)品，如洗發(fā)水、沐浴露等，清除皮膚污染物；

2、使用BB霜或粉底隔護(hù)皮膚；

3、使用防曬產(chǎn)品阻隔紫外線損傷，預(yù)防光敏成分產(chǎn)生光反應(yīng)；

4、使用潤膚產(chǎn)品修護(hù)皮膚屏障功能；

5、避免過度洗潔皮膚，以防損傷皮膚天然屏障。

此外，專家組認(rèn)為，有可能、也很有必要開發(fā)出抗污染損傷類護(hù)膚品。Worldwideairpollutionisamajorhealthconcern.Thereisaccumulatingscientificevidencethatairpollutionplaysanimportantroleinextrinsicaging.Thisarticleinvitesthereadertoconsiderpollutionasapossibleemergingetiologicagentforthedevelopmentofmelasma.Pollutionmaybeariskfactorformelasmaandotherfacialpigmentarydyschromias.Airpollutionintheformofairborneparticulatematter(PM)andPolycyclicaromatichydrocarbons(PAHs)entertheskinviananoparticlesandgeneratequinones,whichareredox-cyclingchemicalsthatproducereactiveoxygenspecies(ROS).ThePMincreasestheamountofROSthattriggerstheincreaseofmetalloproteinasesthatleadstoextrinsicaging,whichincludesskinpigmentation.Theincidenceofdisordersoffacialhyperpigmentationspecifically,melasma,isincreasedinpersonsofskintypeIII-VIlivinginIndiaandSouthEastAsia.Interestingly,thesearealsogeographicregionswithveryheavypollution.India,SouthEastAsia,China,andUnitedStatesleadtheworldinairpollution.JDrugsDermatol.2015;14(4):337-341.PollutionasaRiskFactorfortheDevelopmentofMelasmaandOtherSkinDisordersofFacialHyperpigmentation?IsThereaCasetoBeMade?WendyE.RobertsMDFAADRanchoMirage,CA空氣污染對(duì)黃褐斑及其他面部色素沉著性皮膚問題的影響皮膚新常態(tài)：敏感性皮膚爆發(fā)性增多

維持皮膚屏障功能完整的重要性1、屏障功能受損，如過度換膚、剝脫性治療、頻繁外用皮質(zhì)激素及重金屬，黃褐斑發(fā)生率增高2、屏障受損，皮膚天然防曬功能下降，紫外線作用增強(qiáng)，刺激色素合成增強(qiáng)3、屏障受損，皮膚內(nèi)環(huán)境紊亂，外源性刺激導(dǎo)致皮膚炎性反應(yīng)持續(xù)，刺激色素合成

色素動(dòng)態(tài)平衡色素合成

代謝降解

黃褐斑色素就屬于典型的色素合成與色素代謝失平衡

thereisincreasedmelaninintheepidermisand/oranincreasednumberofmelanosomesinthedermis,withanormalnumberofhighlymelanizedanddendriticmelanocytes.

色素合成調(diào)控

主要依靠色素合成酶三酶一素

酪氨酸酶多巴色素異構(gòu)酶DHICA氧化酶內(nèi)皮素信號(hào)途徑MSH/cAMPsignalingpathwayKITsignalingpathwayWntsignalingpathway

目前臨床上抑制色素合成效果還不盡如人意黑色素的轉(zhuǎn)運(yùn)和降解

黑色素細(xì)胞合成黑素體→成熟后分泌轉(zhuǎn)運(yùn)→角朊細(xì)胞，角朊細(xì)胞吸收黑素體→黑素體在表皮角朊細(xì)胞內(nèi)被內(nèi)溶酶體降解，另有部分黑色素移向真皮淺層，或被吞噬細(xì)胞所吞噬降解，或被運(yùn)至血液循環(huán)中分解排出。

治療黃褐斑綜合思路

一、打“褐”1．抑制色素合成能力

1）抑制黑色素細(xì)胞活性：激光類

2）抑制酪氨酸活性：外用藥、口服、靜脈

3）增加還原劑：維C、維E、還原型谷胱甘肽

4）降低皮膚敏感性，減少刺激因素，減少局部炎性反應(yīng)：

防曬、增強(qiáng)皮膚抗氧化能力、修復(fù)（保濕、生長(zhǎng)因子）2．促進(jìn)色素代謝能力

1）促進(jìn)色素顆粒破壞：光電類

2）進(jìn)行角質(zhì)更新：光電類、化學(xué)剝脫劑

3）增強(qiáng)吞噬細(xì)胞功能：低能量射頻、弱激光

4）促進(jìn)色素顆粒轉(zhuǎn)運(yùn)：射頻光熱效應(yīng)設(shè)備5）恢復(fù)皮膚正常生理結(jié)構(gòu)

二、掃“黃”1、含鐵血黃素：減少皮膚過敏，增強(qiáng)皮膚厚度2、胡羅卜素：食物、藥物攝入過多3、皮膚代謝產(chǎn)物：角質(zhì)層堆積(卡斑)、脂褐素、蛋白質(zhì)的末端糖基化產(chǎn)物、

膽紅素4、氧和血紅蛋白下降：慢性疾病、亞健康狀態(tài)5、肝臟代謝功能下降：熬夜、睡眠不足、疲勞6、皮膚水潤度不足：水光注射、微針補(bǔ)水7、重金屬沉積：微針三、黃褐斑維持治療：減少復(fù)發(fā)，維持療效黃褐斑治療提倡綜合治療，根據(jù)不同情況搭配形成‘‘雞尾酒式”治療方案相對(duì)于祛除黑色素而言，抑制黑色素的產(chǎn)生才是更重要的黃褐斑治療方法學(xué)1、光電類

Q-開關(guān)激光：點(diǎn)陣紅寶石694nm

1064nm（包括點(diǎn)陣型）

IPL：OPT560、590、615、640nm

非剝脫點(diǎn)陣激光：1540、1550、1565、1927nm….剝脫性點(diǎn)陣激光（CO2點(diǎn)陣激光和2940nm鉺點(diǎn)陣激光）長(zhǎng)脈寬1064nm：CUTERA

VBeam595nm:用于伴發(fā)毛細(xì)血管擴(kuò)張（可減輕燒灼感）射頻類：低能量，用于色素吸收排除碳粉（黑臉娃娃）：促進(jìn)表皮色素及代謝產(chǎn)物清除楊鵬

麥躍李娟孫林潮1540nm非剝脫點(diǎn)陣鉺玻璃激光治療黃褐斑的療效觀察中國美容醫(yī)學(xué)2011,20(12):1929楊鵬

麥躍李娟孫林潮

長(zhǎng)脈寬1064nmNd：YAG激光治療黃褐斑療效觀察中國美容醫(yī)學(xué)2011,20(07):1118-麥躍周敏彭雙發(fā)Q-開關(guān)1064nm激光治療黃褐斑臨床療效觀察實(shí)用皮膚病學(xué)雜志2008,1(4):2342、化學(xué)剝脫：苦杏仁酸、果酸…（促進(jìn)表皮色素及代謝產(chǎn)物清除）3、美塑療法：微針、氨甲環(huán)酸皮下注射（抑黑、促色素代謝、重金屬排除）4、外用藥：氫醌、熊果苷、果酸、lumixyl5、系統(tǒng)用藥：抑制酪氨酸酶活性、抗氧化，促進(jìn)肝臟代謝功能（美白針）6、增強(qiáng)藥物作用：透皮系統(tǒng)（巴布貼、離子導(dǎo)入面膜iontophoresismask

）

7、增加皮膚水潤度：水光注射、自體脂肪、PRP8、提高氧和血紅蛋白：活血化瘀藥物、氧療9、改善皮膚屏障功能、減少炎性反應(yīng)（減少含鐵血黃素及色素沉積）：

LED（紅光、黃光）、修復(fù)產(chǎn)品、甘草酸苷full-faceiontophoresismaskvitaminCtherapySuccessfulShort-TermandLong-TermTreatmentofMelasmaandPostin!ammatoryHyperpigmentationUsingVitaminCWithaFull-FaceIontophoresisMaskandaMandelic/MalicAcidSkinCareRegimenJDrugsDermatol.2013;12(1):45-50.

治療方案組合原則抑制色素合成+促進(jìn)色素代謝+輔助治療+日常護(hù)理口服藥、靜脈藥美塑療法屏障修復(fù)防曬外用藥IPL抑制炎性反應(yīng)修復(fù)Q-開關(guān)激光水光注射保濕非剝脫性點(diǎn)陣正確潔面果酸

Treatmentofmelasmawithmixedparametersof1,064-nmQ-switchedNd:YAGlasertoningandanenhancedeffectofultrasonicapplicationofvitaminC:asplit-facestudy

Mei-ChingLee(中國臺(tái)灣)etal.LasersinMedicalScience,July2014DOI10.1007/s10103-014-1608-2四次治療（間隔一個(gè)月），每次使用三套不同參數(shù)：1、8-mmspotsize,2.0J/cm2（全臉一遍（）；2、6-mmspotsize,3.5J/cm2（全臉一遍）；3、4-mmspotsize,3.2J/cm2（全臉一遍，色素皮損處多遍，直至出現(xiàn)治療終點(diǎn)）治療終點(diǎn)：輕微紅腫，避免瘀斑。

治療方法學(xué)的選擇1、Q-開關(guān)激光適用于原發(fā)性黃褐斑、混合型黃褐斑因敏感性皮膚導(dǎo)致黃褐斑增多，目前在黃褐斑治療中的重要性在下降

2、強(qiáng)脈沖光表皮性黃褐斑、混合型黃褐斑低能量短脈寬強(qiáng)脈沖光治療黃褐斑JCosmetLaserTher.2015Apr6:1-4.Effectivenessoflow-fluenceandshort-pulseintensepulsedlightinthetreatmentofmelasma:Arandomizedstudy.BaeMI1,ParkJM,JeongKH,LeeMH,ShinMK.Authorinformation1DepartmentofDermatology,CollegeofMedicine,KyungHeeUniversity,Seoul,Korea.Abstr