新型分数双波长皮秒激光联合新型全息分束器治疗痤疮瘢痕疗效及安全性分析

2021-09-27 13:58刘春保赵彧关吉利孔珍珍
中国美容医学 2021年8期
关键词:安全性疗效

刘春保 赵彧 关吉利 孔珍珍

[摘要]目的:探討新型Nd:YAG分数双波长皮秒激光联合新型全息分束器治疗面部痤疮瘢痕的有效性和安全性。方法:收集2018年1月-2019年9月笔者医院治疗的62例面部痤疮瘢痕患者为研究对象。采用自体对照的方式,左面颊为对照组,右面颊为观察组。对照组给予点阵CO2激光治疗,观察组给予新型Nd:YAG分数双波长皮秒激光联合新型全息分束器治疗。两组均每月治疗1次,共4次。治疗结束12周,评估临床疗效及患者治疗满意度。记录治疗及随访期间的治疗相关不良事件发生情况,对所有数据进行统计学分析。结果:两组临床疗效整体分级间差异具有统计学意义(P<0.05)。观察组总有效率与极有效率均高于对照组(P<0.05)。观察组无效率及弱效率均低于对照组(P<0.05)。观察组治疗满意度评分高于对照组(P<0.05)。观察组红斑、水疱、瘙痒、疼痛、脱屑、色素沉着及色素减退等治疗相关不良事件发生率均低于对照组(均P<0.05)。结论:新型分数双波长皮秒激光联合新型全息分束器治疗面部痤疮瘢痕有效、安全,患者治疗满意度高。

[关键词]皮秒激光;全息分束器;痤疮瘢痕;疗效;安全性

[中图分类号]R619+.6    [文献标志码]A    [文章编号]1008-6455(2021)08-0083-04

Clinical Efficacy and Safety Analysis of a Novel Fractional Dual-Wavelength Picosecond Laser Combined with A Novel Holographic Beam Splitter in the Treatment of Acne Scars

LIU Chun-bao1, ZHAO Yu2, GUAN Ji-li1, KONG Zhen-zhen1

(1. Department of Dermatology;2.Department of Plastic Surgery,Sanya Hospital of Traditional Chinese Medicine,Sanya 572000,Hainan,China)

Abstract:Objective To learn the clinical efficacy and safety analysis of a new Nd:YAG fractional dual-wavelength picosecond laser combined with a new holographic beam splitter in the treatment of atrophy facial acne scars. Methods 62 patients with facial acne scars, treated in our hospital from January 2018 to September 2019, were collected. The autologous control method was adopted. left cheek was taken as control group, while the right cheek was taken as observation group. The control group was given fractional CO2 laser treatment, the observation group was given a new Nd:YAG fractional dual-wavelength picosecond laser combined with a new holographic beam splitter. Both groups were treated once a month for 4 times. Clinical efficacy and patient satisfaction were assessed at 12 weeks after treatment. Record the treatment-related adverse events during treatment and follow-up. Statistical analysis was performed. Results There was a significant difference between two groups in overall clinical efficacy (P<0.05). The total effective rate and extremely effective rate in observation group were higher than those in control group (P<0.05). The ineffective rate and weak effective rate in observation group were lower than those in control group (P<0.05). Patients treatment satisfaction in observation group was higher than that in control group (P<0.05). The incidence of treatment-related adverse events such as erythema, blistering, itching, pain, desquamation, hyperpigmentation, and hypopigmentation in observation group were lower than those in control group (P<0.05). Conclusion The novel fractional dual-wavelength picosecond laser combined with a new holographic beam splitter is effective and safe for treating atrophy facial acne scars, with high patient's treatment satisfaction.

Key words: picosecond laser; holographic beam splitter; acne scars; efficacy; safety

激光诱导的组织光击穿作用(Laser-induced optical breakdown,LIOB)最初被用于眼科治疗[1]。近来利用LIOB的皮秒激光已被用于嫩肤、痤疮瘢痕治疗及去除文身等[2-3]。Habbema等[4]研究发现LIOB通过紧密聚焦的皮秒域1 064nm脉冲靶向作用于真皮乳头。基于Habbema的研究,已开发出一种新的技术,该技术使用具有755纳秒域激光的微透镜阵列,将激光束分成许多强度更高的激光能量聚焦区域以改善面部痤疮瘢痕及嫩肤[5]。随后,使用不同波长开发了其他提供聚焦皮秒级脉冲小束的激光器,包括结合了磷酸钛氧钾(KTP)倍频晶体的1 064nm和532nm钕:钇铝石榴石(Nd:YAG)激光器等。分数激光由于具有创建微热处理区的能力,而可用于改善光损伤和痤疮瘢痕,从而导致皮肤炎症反应和随后的重塑[6-7]。多项研究证实点阵CO2激光治疗痤疮瘢痕安全、有效[8]。本研究比較点阵CO2激光与新型Nd:YAG分数双波长皮秒激光经全息分束器将全部激光能量重组并分布至方形栅格的聚焦光子束治疗面部痤疮瘢痕的疗效与安全性。

1  资料和方法

1.1 一般资料:收集2018年1月-2019年9月笔者医院诊治的62例面部痤疮瘢痕患者为研究对象,其中男26例,女36例,年龄17~35岁,平均年龄为(26.27±3.63)岁;病程3~31个月,平均病程(18.36±5.72)月;Fitzpatrick皮肤分型:Ⅲ型12例,Ⅳ型28例,Ⅴ型22例;有吸烟史者6例,合并多囊卵巢综合征者1例。

1.2 纳入标准:①符合《中国痤疮治疗指南(2014修订版)》诊断标准[9];②双侧面颊受累;③轻度至重度萎缩性瘢痕;④患者了解本研究并签署知情同意书。排除标准:①妊娠或哺乳期女性;②合并系统性红斑狼疮、卟啉病等光敏感性疾病;③合并过敏性皮炎、湿疹、鳞癌及黑素瘤等面部皮肤病者;④瘢痕体质者;⑤12个月内有异维A酸系统应用史;⑥6个月内有维A酸类药物外用史;⑦3个月内有积雪苷霜应用史。本研究符合2013年修订的《赫尔辛基宣言》要求,符合伦理学要求。伦理学批准文号:2018LL0129。

1.3 治疗仪器及药物:生理氯化钠溶液(规格:500ml;4.5g;国药准字:H20066533,石家庄四药有限公司生产);复方利多卡因乳膏(规格:5克/支;国药准字:H20063466,北京紫光制药有限公司);JZ-2型超脉冲点阵CO2激光治疗仪(成都国雄光电技术有限公司);皮秒Nd:YAG激光器倍频系统(PicoWay1,Syneron-Candela Corporation);全息分束光学器件(PicoWay Resolve1,Syneron-Candela Corporation)。

1.4 治疗方法:本研究采用自体对照。左面颊为对照组,右面颊为观察组。对照组:给予点阵CO2激光治疗,治疗前用生理盐水清洁皮损部位,采用复方利多卡因乳膏涂于患处,1h后进行点阵CO2激光治疗(能量10~160mJ,波长10 600nm,光斑直径≤0.5mm,输出功率1~3W,扫描面积max=15mm×15mm),光斑尺寸及光斑能量均依据皮疹情况而定,治疗间隔1个月,共治疗4次。治疗后随访至第12周;观察组:给予新型分数双波长皮秒激光联合新型全息分束器治疗,即采用全息分束光学器件将新型Nd:YAG分数双波长皮秒激光的激光能量聚焦成直径150μm的微光束阵列,微光束阵列再依次排列在6mm×6mm处理区域内。激光以1 064nm波长在每微束1.3~2.9mJ下以450ps的脉冲持续时间发出,而532nm的波长在每微束0.16~1.5mJ下以375ps的脉冲持续时间发出,激光以6Hz的重复频率进行治疗。治疗前,用生理盐水清洁皮损,采用复方利多卡因乳膏涂于患处1h后。依次以彼此成直角、垂直和水平的一排成行地进行2次激光扫描,通过以绘画模式传递脉冲来处理受影响的区域。治疗能量依据皮疹情况而定,治疗终点为红斑或轻度瘀斑。治疗间隔1个月,共治疗4次。治疗后随访至第12周。

1.5 疗效评估:分别于首次治疗前及治疗结束12周随访时采用单反相机在光线充足的环境中距离面颊30cm处拍摄面部皮损照片,由两位高年资皮肤科医师根据两次皮损照片对患者面部萎缩性瘢痕改善情况进行评估,意见不一致者由第3位高年资皮肤科医师进行判定。疗效评估标准[10]:极有效:皮损改善≥75%;显效:皮损改善50%~75%;弱效:皮损改善25%~50%;无效:皮损改善<25%。总有效率=极有效率+显效率。

1.6 患者满意度评估:治疗结束12周后,由患者对治疗满意度进行评分,评分范围0~10分,评分与患者治疗满意度间正相关。

1.7 治疗相关不良事件:记录治疗开始至随访结束期间,红斑、水疱、瘙痒、疼痛、脱屑、色素减退、色素沉着等治疗相关不良事件。

1.8 统计学分析:采用SPSS 26.0对数据进行统计学分析。计数资料采用率(%)表示,配对资料间比较采用McNemar检验;有序配对资料间比较采用秩和检验;当0

2  结果

2.1 两组临床疗效比较:两组临床疗效整体分级间差异具有统计学意义(均P<0.05)。观察组总有效率与极有效率高于对照组,差异具有统计学意义(P<0.05)。观察组无效率及弱效率均低于对照组,差异具有统计学意义(P<0.05)。两组显效率间差异无统计学意义(均P>0.05)。见表1。

2.2 两组治疗满意度比较:观察组治疗满意度评分高于对照组,差异具有统计学意义(P<0.05)。见表2。

2.3 两组治疗不良反应情况比较:观察组红斑、水疱、瘙痒、疼痛、脱屑、色素沉着及色素减退等治疗相关不良事件发生率均低于对照组,差异均具有统计学意义(P<0.05)。见表3。

3  讨论

痤疮瘢痕是一种常见损容性皮肤病,会对患者生活质量产生严重负面影响,微针、激光、化学剥脱及真皮填充等均被尝试用于治疗且均可不同程度的改善皮损[10]。CO2 激光能量的中红外波长为10 600nm,可很好地被皮肤中水分子吸收,局部热效应可有助于痤疮瘢痕修复及光子嫩肤等,点阵CO2激光是目前公认的治疗痤疮瘢痕的有效方法,副作用发生率很低,主要可导致瘢痕加重、炎症后色素沉着和感染等[11]。第一代非点阵CO2激光对于改善皱纹及痤疮瘢痕有效性好,但却较点阵CO2激光的副作用更多,较非消融性点阵CO2激光安全性更高[12-13]。分数CO2激光治疗光损伤时效稍差,但可减少长期及短期副作用的发生率[14]。Elsaie等[15]研究发现消融性点阵CO2激光与非消融性点阵CO2激光都是治疗痤疮瘢痕的有效方法,安全性好且患者满意度高,其中消融性点阵CO2激光疗效更好,但非消融性点阵CO2激光痛苦更少且停机时间更短。近年来,点阵CO2激光与多种治疗方式的联用有效性的发现更是进一步巩固了点阵CO2激光在痤疮瘢痕治疗中的重要作用。Chang等[16]研究发现自体富血小板血浆联合消融性CO2激光对痤疮瘢痕治疗具有协同作用,且可加速激光损伤皮肤的恢复。Zhou等[17]研究发现脂肪干细胞培养基与点阵CO2激光联用可提高萎缩性痤疮瘢痕患者的治疗满意度、皮肤弹性与水分,减少经皮水分丢失、皮肤粗糙度及黑色素指数等,组织学分析发现脂肪干细胞培养基增加了皮肤胶原蛋白、弹性蛋白的密度及有序排列。非消融性1 550nm、1 440nm和1 320nm分级激光器是最早用于治疗光损伤与痤疮瘢痕的非消融性设备[13,18]。经验丰富的医生采用1 550nm激光治疗I~IV型皮肤者通常不会引起治疗后色素沉着[19]。但Er:YAG 1 550nm光纤激光器治疗共识中称,因色素沉着的高风险性仅最有经验的激光外科医师才能将其用于VI型皮肤患者的治疗[18]。Mahmoud等[20]亦报道了使用Er:YAG 1 550nm光纤激光器治疗IV~VI型皮肤时较高的色素沉着发生率。

皮秒激光已被证实可有效治疗去除文身、良性色素沉着性病变、痤疮瘢痕及光老化等[21]。Yang等[22]采用532nm和1 064 nm分数双波长皮秒激光对20例Ⅲ~Ⅳ型患者的痤疮瘢痕进行治疗后显示出良好的疗效及安全性,认为与色基依赖性皮秒激光脉冲热释放热离子相关。Dai等[23]发现消融性1 064nm皮秒激光治疗亚洲人痤疮瘢痕安全有效,并认为与1 064nm皮秒激光的选择性光损伤及表皮消融作用有关。多项研究发现1 064nm及532nm Nd:YAG分数皮秒激光所承载的高能量被表皮局部的黑素颗粒所吸收,并以一种非热效应的形式诱导LIOB效应,继而在治疗后即刻开始促进真皮胶原纤维、弹性纤维、黏蛋白等的形成,从而有效改善萎缩性痤疮瘢痕及皮肤光损伤等[23-24]。另外,皮秒激光所致表皮内空泡形成、通过作用于氧合血红蛋白及去氧血红蛋白所致的真皮血管损伤等亦被认为与真皮重塑相关[25-26]。

本研究采用1 064nm和532nm双波长分数皮秒激光对痤疮瘢痕进行治疗,1 064nm和532nm激光的最大能量分别为每微束2.9mJ、1.5mJ,与达到1 064nm的临床终点相比,在532nm处需要更低的能量,而这或许与532nm处的黑色素吸收强度比1 064nm更高有关。极高的峰值功率和极小的150μm的微束直径可将兩种波长的激光能量最大程度的限制在表皮及真皮的极小区域及层次内,且随着光束直径的差异,其穿透深度存在显著差异,因此,如何才能发挥两种波长激光的协同作用以最大限度地发挥其治疗作用成为研究的主要难点。

此前,曾有研究采用分度微透镜阵列处理755nm的皮秒激光用于治疗面部痤疮瘢痕与皱纹[5],为本研究提供了很好的参考。最终本研究选定新型全息分束器对分数双波长皮秒激光进行处理,该系统可将分数双波长皮秒激光的能量集中在一个极小的激光阵列中而最大限度发挥治疗作用。本研究发现,观察组总有效率与极有效率高于对照组(P<0.05),观察组无效率及弱效率均低于对照组(P<0.05),观察组患者治疗满意度评分高于对照组(P<0.05),且观察组红斑、水疱、瘙痒、疼痛、脱屑、色素沉着及色素减退等治疗相关不良事件发生率均低于对照组(均P<0.05),提示相比于点阵CO2激光,经全息分束器处理的分数双波长皮秒激光可更有效地改善面部痤疮瘢痕,且患者治疗满意度更高,治疗相关不良事件发生率降低,提示其临床应用具有较高的安全性。

综上,新型分数双波长皮秒激光联合新型全息分束器治疗萎缩性面部痤疮瘢痕有效、安全,患者治疗满意度高。

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[收稿日期]2020-06-15

本文引用格式: 劉春保,赵彧,关吉利,等.新型分数双波长皮秒激光联合新型全息分束器治疗痤疮瘢痕临床疗效及安全性分析[J].中国美容医学,2021,30(8):83-86.

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