敏感性皮膚與黃褐斑治療選擇

長沙美萊美容醫院深圳美萊美容醫院

麥躍楊鵬

黃褐斑診斷含義狹義黃褐斑原發性黃褐斑廣義黃褐斑繼發性黃褐斑+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：決定是否患黃褐斑2、加重因素：1）紫外線（現認為可見光、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）不良護膚品

5）不良護膚治療

6）內分泌

7）避孕藥黃褐斑發生的影響因素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.文獻解讀黃褐斑非炎癥性----原發性黃褐斑炎癥性-------繼發性黃褐斑（與皮膚屏障受損有關）病理基礎不同，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名德國環境醫學專家和2名中國皮膚科醫生等7名專家組成國際專家組，通過對國際和中國相關最新文獻進行綜述，總結了空氣污染對皮膚早衰影響的最新研究進展、以及敏感皮膚與環境污染的關聯，并提出了針對污染的基礎性護膚建議：

1、使用洗凈（rinseoff）型產品，如洗發水、沐浴露等，清除皮膚污染物；

2、使用BB霜或粉底隔護皮膚；

3、使用防曬產品阻隔紫外線損傷，預防光敏成分產生光反應；

4、使用潤膚產品修護皮膚屏障功能；

5、避免過度洗潔皮膚，以防損傷皮膚天然屏障。

此外，專家組認為，有可能、也很有必要開發出抗污染損傷類護膚品。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：敏感性皮膚爆發性增多

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、頻繁外用皮質激素及重金屬，黃褐斑發生率增高2、屏障受損，皮膚天然防曬功能下降，紫外線作用增強，刺激色素合成增強3、屏障受損，皮膚內環境紊亂，外源性刺激導致皮膚炎性反應持續，刺激色素合成

色素動態平衡色素合成

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.

色素合成調控

主要依靠色素合成酶三酶一素

酪氨酸酶多巴色素異構酶DHICA氧化酶內皮素信號途徑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運和降解

黑色素細胞合成黑素體→成熟后分泌轉運→角朊細胞，角朊細胞吸收黑素體→黑素體在表皮角朊細胞內被內溶酶體降解，另有部分黑色素移向真皮淺層，或被吞噬細胞所吞噬降解，或被運至血液循環中分解排出。

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：

防曬、增強皮膚抗氧化能力、修復（保濕、生長因子）2．促進色素代謝能力

1）促進色素顆粒破壞：光電類

2）進行角質更新：光電類、化學剝脫劑

3）增強吞噬細胞功能：低能量射頻、弱激光

4）促進色素顆粒轉運：射頻光熱效應設備5）恢復皮膚正常生理結構

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

膽紅素4、氧和血紅蛋白下降：慢性疾病、亞健康狀態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、微針補水7、重金屬沉積：微針三、黃褐斑維持治療：減少復發，維持療效黃褐斑治療提倡綜合治療，根據不同情況搭配形成‘‘雞尾酒式”治療方案相對于祛除黑色素而言，抑制黑色素的產生才是更重要的黃褐斑治療方法學1、光電類

Q-開關激光：點陣紅寶石694nm

1064nm（包括點陣型）

IPL：OPT560、590、615、640nm

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

VBeam595nm:用于伴發毛細血管擴張（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）：促進表皮色素及代謝產物清除楊鵬

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

麥躍李娟孫林潮

長脈寬1064nmNd：YAG激光治療黃褐斑療效觀察中國美容醫學2011,20(07):1118-麥躍周敏彭雙發Q-開關1064nm激光治療黃褐斑臨床療效觀察實用皮膚病學雜志2008,1(4):2342、化學剝脫：苦杏仁酸、果酸…（促進表皮色素及代謝產物清除）3、美塑療法：微針、氨甲環酸皮下注射（抑黑、促色素代謝、重金屬排除）4、外用藥：氫醌、熊果苷、果酸、lumixyl5、系統用藥：抑制酪氨酸酶活性、抗氧化，促進肝臟代謝功能（美白針）6、增強藥物作用：透皮系統（巴布貼、離子導入面膜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（減少含鐵血黃素及色素沉積）：

LED（紅光、黃光）、修復產品、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+促進色素代謝+輔助治療+日常護理口服藥、靜脈藥美塑療法屏障修復防曬外用藥IPL抑制炎性反應修復Q-開關激光水光注射保濕非剝脫性點陣正確潔面果酸

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

Mei-ChingLee(中國臺灣)etal.LasersinMedicalScience,July2014DOI10.1007/s10103-014-1608-2四次治療（間隔一個月），每次使用三套不同參數：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，直至出現治療終點）治療終點：輕微紅腫，避免瘀斑。

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

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