火针干预结合辨证取穴针刺治疗慢性瘙痒性皮肤病病例系列研究

发布时间：2018-05-26 18:21

本文选题：火针 + 辨证取穴针刺　；参考：《中国中医科学院》2017年硕士论文

【摘要】：研究背景瘙痒是许多皮肤病和全身性疾病的常见症状,是一种能够引起搔抓欲望的感觉,是机体对有害刺激的多维度的感受反应。瘙痒发病率高,可显著影响患者的生活质量,严重者可出现自杀倾向。瘙痒作为一种难以忍受的症状长期困扰着人们的生活。中医认为,瘙痒属于“痒症”的范畴,乃风、湿、热、虫、毒侵犯人体肌表,加上先天禀赋不耐,使皮肤气血不和所致。目前瘙痒的治疗以镇静止痒为主,并将全身治疗和局部治疗相结合。中医中药以辨证论治为特点,同病异治、异病同治,为瘙痒的治疗提供了新的思路。由于瘙痒的发病原因比较复杂,病情常常反复,因此难以达到理想的治疗效果,新的治疗方法仍将是未来的研究热点。针灸作为祖国医学的瑰宝之一,具有广阔前景及现实意义。火针结合辨证针刺治疗作为一种非药物疗法,对于慢性瘙痒性皮肤病的疗效颇佳。火针具有散寒除湿、行气散毒、温经活血的作用。我们通过临床实践发现,火针可应用于皮肤科疾病的治疗,其热效应可以改善皮损区域的微循环,加快炎症和代谢物质的吸收。火针着眼于疾病的局部征象,而辨证针刺则重视疾病的整体状态,审症求因,根据疾病的不同证候分别予祛风散寒、清热凉血、滋阴润燥、祛湿解毒、养血疏肝。两者结合可起到标本兼治的效果。火针配合辨证针刺可用于慢性瘙痒性皮肤病的治疗,并且具有一定的基础理论和临床实践的证据。然而火针配合针刺干预对于慢性瘙痒性皮肤病的疗效、效应时间点等,都需要进一步循证医学方法的验证。本研究采用前瞻性病例系列研究的方法,将火针配合辨证针刺作为干预措施,以验证火针配合辨证针刺治疗对于改善慢性瘙痒性皮肤病患者症状与体征、焦虑及抑郁状态、生活质量等方面的有效性,探索火针配合辨证针刺对于慢性瘙痒性皮肤病的最佳有效干预疗程,评价火针配合辨证针刺治疗慢性瘙痒的安全性,为该病的临床诊疗提供新的思路和依据。研究目的通过观察火针配合辨证取穴针刺对慢性瘙痒性皮肤病患者症状、体征的影响以及对不同原因诱发瘙痒程度的影响及其之间的比较,对慢性瘙痒性皮肤病患者病损局部红外热像及散斑血流的影响,对理化指标的影响,生活质量以及焦虑、抑郁状态的影响,探讨火针结合辨证取穴针刺对慢性瘙痒性皮肤病的临床疗效,为今后火针配合辨证取穴针刺的临床应用和推广提供试验参考,为火针配合辨证取穴针刺治疗慢性瘙痒性皮肤病进一步的机制研究提供临床依据。研究方法本研究根据纳入排除标准共选取来自针灸医院门诊2015年3月至2017年3月的81例慢性瘙痒性皮肤病患者。治疗采用火针和体针相结合的综合疗法,主穴为瘙痒较重、皮肤表面有明显的丘疹、皮肤干燥或增厚等改变的部位,使用火针点刺,配穴根据证候分类进行辨证取穴针刺。每周治疗2次,共治疗16次(8周)。采用症状积分分级法、视觉模拟评分法(Visual Analogue Scale,VAS)、红外热像及散斑血流检测、理化指标检测(包括嗜酸性粒细胞计数和血清总IgE)、汉密顿焦虑量表(Hamilton Anxiety Scale,HAMA)、汉密顿抑郁量表(Hamilton Depression Scale,HAMD)和皮肤病生活质量指数(Dermatology Life Quality Index,DLQI)为疗效指标,分别在治疗前、治疗后、治疗结束4周后随访时记录各项评分,统计分析评分的变化,进行疗效评定。研究结果(1)与0周(治疗前)相比,4周(治疗8次)和8周(治疗16次)后,患者癌痒程度明显减轻,而治疗8周后的疗效明显优于治疗4周后,且12周(随访)时疗效基本维持不变。(2)火针配合辨证取穴针刺对以上四种不同类型的瘙痒性皮肤病均有突出的疗效,但效应的时间点不同。湿疹患者对火针配合辨证针刺的敏感度不高,当次治疗后瘙痒缓解的幅度较小,但存在一定的延迟效应,每次治疗前较上一次治疗前相比均有明显减轻;神经性皮炎患者敏感度较高,每次治疗后与治疗前相比缓解都特别明显,然而每次治疗前相比,总体呈缓慢下降趋势;特应性皮炎患者初时每次治疗后瘙痒缓解明显,第五次治疗开始瘙痒程度评分反复无常,对治疗的敏感度时高时低,但总体表现为下降趋势;荨麻疹患者对火针配合辨证取穴针刺敏感度高,效应也持久,在前三次治疗后瘙痒己经明显缓解,此后每次治疗前瘙痒程度不高,但治疗后仍有减轻。(3)治疗前皮损处红外热像值、散斑血流值明显高于无皮损处,治疗后伴随皮损的逐渐恢复,高红外热像值减小,面积逐渐缩小,散斑血流的变化趋势与红外热像相同。(4)24例慢性瘙痒性皮肤病患者进行了治疗前、后外周血嗜酸性粒细胞及血清总IgE进行了检测。从外周血嗜酸性粒细胞计数观察,所有患者治疗前、后检测值均在正常范围内(正常值为0.02-0.5x109/L)。从血清总IgE含量观察,有9例患者(包括湿疹4例、神经性皮炎1例、特应性皮炎2例、荨麻疹2例)治疗前检测值较正常值增高(正常值为1OOIU/ml),15例在正常范围内,治疗后伴随瘙痒症状的改善,治疗前血清总IgE含量较正常值增高的无明显变化趋势。(5)治疗后,患者HAMA及HAMD评分较治疗前均有显著下降。在治疗前,有28人(34.57%)轻度焦虑,27人(33.33%)中度焦虑,13人(16.05%)重度焦虑,1人(1.23%)极重度焦虑,仅有12人(14.82%)无焦虑,治疗后患者群中焦虑状态整体改善,无焦虑人数增加至40人(49.38%),轻度焦虑人数为26人(32.2%),中度焦虑人数为14人(17.28%),重度焦虑人数为1人(1.2%),无极重度焦虑患者。治疗前,有21人(25.93%)轻度抑郁,18人(22.22%)中度抑郁,2人(2.47%)重度抑郁,仅有40人(49.38%)无抑郁,治疗后患者群中抑郁状态整体改善,无抑郁人数增加至55人(67.9%),轻度抑郁人数为16人(19.75%),中度抑郁人数为10人(12.35%),重度抑郁人数为0。治疗后无焦虑人数比治疗前明显增加,中度、重度及极重度焦虑人数明显减少,说明火针配合辨证取穴针刺后,患者瘙痒情况的缓解可以整体改善其焦虑状态。治疗后无抑郁人数较治疗前也明显增加,中度及重度抑郁人数减少,说明治疗后,患者瘙痒情况的缓解亦可整体改善其抑郁状态。(6)治疗前,81例慢性瘙痒性皮肤病患者皮肤病生活质量量表(DLQI)评分平均18.41 ±3.24分。合计各条目平均得分从高到低依次为瘙痒或疼痛、皮肤护理、着装、学习工作、尴尬或自卑、运动、性生活、购物或做家务、社交娱乐、亲朋关系。治疗前后DLQI评分显著下降,平均8.94±4.52分。说明火针结合辨证取穴针刺可以通过解决患者的瘙痒困扰来提高他们的生活质量。(7)81例瘙痒性皮肤病患者在8周(16次治疗)有42例达Ⅰ级改善标准(占51.85%),24例达Ⅱ级改善标准(占29.63%),15例为Ⅲ级改善(占18.52%);12周(随访时)疗效基本保持,有44例达Ⅰ级改善标准(占54.32%),21例达Ⅱ级改善标准(占25.93%),16例为Ⅲ级改善(占17.95%)。(8)81位接受火针治疗的患者中,有42人(52%)认为火针治疗很舒服,乐于接受;有22人(27%)认为火针治疗不痛也不痒;有15人(19%)认为火针治疗有些疼痛,但可以接受;仅有2人(2%)认为火针治疗难以接受。所有受试者未出现过晕针、断针、血肿;治疗后及随访时未发现感染等不良情况。除有1例患者因个人体质导致瘢痕消退时间较长外,未发现因使用火针结合辨证取穴针刺而产生的任何不良反应及毒副作用。研究结论(1)火针结合辨证取穴针刺能够有效改善慢性瘙痒性皮肤病患者的瘙痒程度、瘙痒面积及瘙痒频率,本研究中的最佳有效干预疗程是8周;(2)火针配合辨证取穴针刺对四种不同类型的慢性瘙痒性皮肤病(包括湿疹、神经性皮炎、特应性皮炎、荨麻疹)的效应时间点不同;(3)火针结合辨证取穴针刺可以调节慢性瘙痒性皮肤病患者皮损处的红外热像及散斑血流情况,可以明显改善患者的生活质量、焦虑、抑郁状态;(4)治疗前、后慢性瘙痒性皮肤病患者的理化指标(包括外周血嗜酸性粒细胞计数和血清总IgE含量)没有明显改变;(5)火针结合辨证取穴针刺虽然是一种微创疗法,但只要操作规范,护理得当,治疗具有安全性。
[Abstract]:Background pruritus is a common symptom of many skin diseases and systemic diseases. It is a feeling that can cause Scratch and desire. It is the multidimensional response of the body to harmful stimuli. The incidence of pruritus is high, which can significantly affect the quality of life of the patient, and the serious person can have suicide tendency. Itching is a long-term symptom. Traditional Chinese medicine believes that itching belongs to the category of "itching", which is caused by wind, wet, hot, insect, toxic invasion of the human body surface and innate inability to make the skin and blood disharmony. The treatment of itching is based on the static itching of the town and combines the whole body treatment with the local treatment. Treatment and treatment with different diseases provide new ideas for the treatment of pruritus. Because the cause of itching is complicated and the condition is often repeated, it is difficult to achieve the ideal treatment effect. The new treatment method will still be the research hotspot in the future. As one of the treasures of the motherland medicine, the acupuncture and moxibustion have broad prospects and practical significance. As a non drug therapy, acupuncture therapy has a good effect on chronic pruritus dermatosis. The fire needle has the effect of dispersing cold and dehumidification, dispersing gas and warming through blood circulation. Through clinical practice, we find that the fire needle can be used in the treatment of diseases in the Department of dermatology. The heat effect can improve the microcirculation in the area of skin damage and accelerate the inflammation and metabolic substances. Absorption. The fire needle focuses on the local signs of the disease, while the syndrome differentiation acupuncture attaches great importance to the whole state of the disease, and tries to seek the cause of the disease. According to the different syndromes of the disease, it is given to dispel the wind and cold, cool the heat, cool the blood, nourish the Yin and moisten the dryness, remove the dampness and detoxify, raise the blood and remove the liver. The combination of the acupuncture and the acupuncture can be used for the chronic itching skin. The treatment of skin disease has a certain basic theory and evidence of clinical practice. However, the efficacy and time points of the acupuncture intervention for chronic itchy dermatosis should be verified by further evidence-based medical methods. To verify the efficacy of fire needle combined with syndrome differentiation acupuncture in improving symptoms and signs, anxiety, depression and life quality of patients with chronic itchy skin diseases, and to explore the best effective intervention treatment for chronic pruritus with acupuncture and syndrome differentiation acupuncture, and to evaluate the treatment of chronic itching with acupuncture and syndrome differentiation acupuncture. The purpose of this study is to provide new ideas and basis for the clinical diagnosis and treatment of the disease. The purpose of this study is to observe the effect of the acupuncture on the symptoms and signs of the patients with chronic itchy dermatosis and the effect of the pruritus on different causes, and to compare the local infrared heat of the patients with chronic itchy dermatosis. The effect of image and speckle blood flow, the influence of physical and chemical indexes, quality of life, anxiety and depression, the clinical effect of acupuncture combined with acupuncture point acupuncture on chronic pruritus dermatosis, the clinical application and extension of acupuncture in the future with acupuncture and syndrome differentiation are discussed. A total of 81 patients with chronic itchy dermatosis from March 2015 to March 2017 were selected from the outpatient department of acupuncture and moxibustion at the treatment of acupuncture and moxibustion. The combination of fire needle and body acupuncture was used to treat patients with chronic itchy skin diseases. The main point was the heavy itching and the skin surface. There were obvious papules, dry skin or thickening of the skin, using fire needle pricking and acupuncture points according to the syndrome classification. 2 times a week for 16 times (8 weeks). The symptom integral classification, visual analog score (Visual Analogue Scale, VAS), infrared thermal image and speckle blood flow detection, physical and chemical index detection (package) Including eosinophil count and serum total IgE), the Hamilton Anxiety Scale (Hamilton Anxiety Scale, HAMA), the Hamilton Depression Scale (Hamilton Depression Scale, HAMD) and the quality of life index of the dermatosis (Dermatology Life Quality) were the therapeutic targets, respectively, before the treatment, after the treatment, 4 weeks after the end of the treatment, the records were recorded. Results (1) compared with 0 weeks (before treatment), 4 weeks (8 times) and 8 weeks (treatment 16), the patient's cancer itching was significantly reduced, and the curative effect of 8 weeks after the treatment was obviously better than that of the treatment for 4 weeks, and the curative effect was basically maintained at 12 weeks (2). (2) acupuncture combined with acupuncture points with acupuncture points with syndrome differentiation. The four different types of itchy skin diseases have prominent curative effect, but the time points of the effect are different. The patients with eczema have little sensitivity to the acupuncture combined with acupuncture, and the amplitude of the pruritus is smaller after the treatment, but there is a certain delay effect, and the neuronature before each treatment is significantly lower than that before the previous treatment. The patients with dermatitis had a high sensitivity, and the remission of the patients was very obvious after each treatment. However, compared with the treatment before each treatment, the overall decrease trend was slow. The itching of the patients with atopic dermatitis was obviously relieved at the beginning of the treatment. The initial pruritus score of the fifth treatment was repeated infrequent, and the sensitivity to the treatment was low, but the overall table was low. The patients with urticaria have high sensitivity and lasting effect on acupuncture combined with syndrome differentiation, and the pruritus has been alleviated after the first three treatments, and the itching degree is not high before each treatment. (3) the infrared thermal image of the lesions before treatment, the value of the speckle blood flow is obviously higher than that of the non skin lesion, and the treatment is accompanied by the treatment. The skin lesion gradually recovered, the high infrared thermal image decreased, the area gradually reduced, and the trend of the speckle blood flow was the same as that of the infrared thermography. (4) before treatment, 24 cases of chronic itchy skin diseases were detected in the peripheral blood eosinophils and serum total IgE. All patients were treated by eosinophil count from peripheral blood. The post detection values were in the normal range (normal value 0.02-0.5x109/L). From the total serum IgE content, 9 patients (including 4 eczema, 1 cases of neurodermatitis, 2 cases of atopic dermatitis, 2 urticaria) were compared with normal values (normal value 1OOIU/ml), 15 cases were in the normal range, and the treatment accompanied with the improvement of pruritus. There was no obvious trend in the increase of serum total IgE content before treatment. (5) after treatment, the patients' HAMA and HAMD scores were significantly lower than before treatment. Before treatment, there were 28 (34.57%) mild anxiety, 27 (33.33%) moderate anxiety, 13 (16.05%) severe anxiety, 1 (1.23%) extremely severe anxiety, only 12 (14.82%) without anxiety, after treatment. The overall anxiety state of the group was improved, the number of non anxiety increased to 40 (49.38%), the number of mild anxiety was 26 (32.2%), the number of moderate anxiety was 14 (17.28%), the number of severe anxiety was 1 (1.2%), and there were no extreme severe anxiety patients. Before treatment, there were 21 (25.93%) mild depression, 18 (22.22%) moderate depression, 2 (2.47%) severe depression and only serious depression before treatment. 38%) no depression, the overall improvement of depression in the group of patients after treatment, the number of non depression increased to 55 (67.9%), the number of mild depression was 16 (19.75%), the number of moderate depression was 10 (12.35%), and the number of severe depression was 0. after treatment, and the number of moderate, severe and severe anxiety decreased obviously, indicating that the number of moderate, severe and extreme severe anxiety was significantly reduced. After acupuncture combined with syndrome differentiation, the relieving of pruritus could improve the anxiety state as a whole. The number of non depression after treatment was significantly increased and the number of moderate and severe depression decreased. After treatment, the relieving of itching can also be improved as a whole. (6) 81 cases of chronic pruritus dermatosis before treatment. The average score of the patient's dermatology quality of life scale (DLQI) score was 18.41 + 3.24 points. The average score of the total items from high to low was pruritus or pain, skin care, dress, learning, embarrassment or inferiority, exercise, sex life, shopping or doing housework, social entertainment, relatives and friends. The score of DLQI decreased significantly before and after treatment, with an average of 8.94 + 4.52 points. (7) there were 42 cases of itchy dermatosis in 8 weeks (16 times), 42 cases (51.85%), 24 cases (29.63%), 15 cases (18.52%), and 15 (18.52%), and 81 weeks (follow up) curative effect basic. There were 44 cases of improvement of grade I (54.32%), 21 cases of grade II improvement (25.93%), 16 cases of grade III (17.95%). (8) among 81 patients receiving fire needle therapy, 42 (52%) considered fire needle treatment very comfortable and willing to accept; 22 (27%) thought fire needle treatment was not painful nor itching; there were 15 people (19%) think fire needle therapy has some pain. Pain, but it was acceptable; only 2 (2%) thought fire needle therapy was difficult to accept. All the subjects did not have a needle sickness, broken needle, hematoma, and did not find any bad conditions after treatment and follow-up. Except for 1 patients, the time of scar withdrawal caused by personal physique was longer, no one was found to be caused by the use of acupuncture combined with acupuncture point acupuncture. Research conclusions (1) acupuncture combined with acupuncture point acupuncture can effectively improve the itching degree, pruritus area and pruritus frequency of patients with chronic pruritus, and the best effective intervention course in this study is 8 weeks. (2) four different types of chronic itchy dermatosis (including acupuncture acupuncture combined with acupuncture point needle puncture). The effect time points of eczema, neurodermatitis, atopic dermatitis, urticaria are different. (3) acupuncture combined with acupuncture point acupuncture can adjust the infrared thermal image and speckle flow of the skin lesions of patients with chronic itchy skin diseases, and can obviously improve the quality of life, anxiety and depression of the patients; (4) the patients with chronic itchy skin disease before treatment. There was no obvious change in physical and chemical indexes (including eosinophil count in peripheral blood and total IgE content in serum). (5) acupuncture combined with acupuncture and acupuncture is a minimally invasive therapy, but it is safe to treat with proper operation and proper nursing.
【学位授予单位】：中国中医科学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R246.7

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