刘龙灿 鲜华 敖贤 许丹 安娟 王春梅

本文来源：《中华整形外科杂志》2023年12月 第39卷 第12期

DOI:10. 3760 / cma.j.cn114453-20230301-00044

作者单位：南方医科大学皮肤病医院整形美容外科， 广州510091

通信作者：王春梅，Email：1944134044@qq.com

【摘要】 

目的 探讨环钻切除术加浅层X线照射联合局部药物注射治疗胸部多发性瘢痕疙瘩的可行性和临床效果。

方法 选取2020年3月至2021年6月于南方医科大学皮肤病医院治疗的胸部多发性瘢痕疙瘩患者，采用随机数字表法分成观察组和对照组。观察组先进行环钻切除术，术后24 h内照射1次浅层X线，之后每周照射1次，共照射4次，放疗结束1周后予局部药物注射治疗(1 ml醋酸曲安奈德注射液＋0.6 ml氟尿嘧啶注射液＋3.4 ml 2%盐酸利多卡因注射液制备成5 ml混合液)，每月1次，共4次，单次注射终点反应为瘢痕疙瘩变白；对照组不接受环钻切除术，其他治疗与观察组相同。于治疗前和治疗后3、6、12个月进行温哥华瘢痕量表(VSS)评分和治疗有效性评价(治愈、显效、好转、无效)，记录治疗前后瘢痕疙瘩总体积、局部注射药物总量和不良反应情况。采用SPSS 26.0软件进行数据分析，计量资料数据用x±s表示，2组间比较采用独立样本 t检验，同组治疗前后比较采用重复测量数据的方差分析；计数资料用百分数表示，组间比较采用 χ 2检验。P<0.05为差异有统计学意义。

结果 共纳入58例患者，每组各29例，其中男性36例，女性22例；年龄18～59岁，平均29岁；每例患者胸部瘢痕疙瘩数量为5～12个。治疗前，观察组与对照组VSS评分差异无统计学意义[(13.21±1.24)分vs.(12.90±1.21)分， t＝0.97， P＝0.337]。治疗结束后随访3、6、12个月，观察组VSS评分分别为(4.21±1.26)、(4.34±1.40)、(4.55±1.33)分，对照组VSS评分分别为(5.66±1.32)、(6.07±1.44)、(6.62±1.40)分，2组间比较差异有统计学意义( t＝－4.27、－4.63、－5.78， P均<0.001)；组内比较显示，观察组患者治疗后3、6、12个月VSS评分差异无统计学意义( F＝2.50， P＝0.111)，对照组患者治疗后3、6、12个月VSS评分呈逐渐升高趋势，差异有统计学意义( F＝30.75， P<0.001)。观察组显效22例，好转7例，显效率为75.86%(22/29)；对照组显效6例，好转23例，显效率为20.69%(6/29)，2组显效率差异有统计学意义( χ 2＝17.68， P<0.001)。治疗前观察组与对照组瘢痕疙瘩总体积差异无统计学意义[(7.76±1.71) cm 3 vs.(8.27±1.26) cm 3， t＝－1.28， P＝0.207]；治疗后随访12个月，观察组瘢痕疙瘩总体积[(2.57±0.59) cm 3]明显小于对照组[(5.51±1.39) cm 3]，差异有统计学意义( t＝－10.47, P<0.001)。观察组局部注射药物总量[(6.45±1.25) ml]明显少于对照组[(11.00±1.73) ml]，差异有统计学意义( t＝－11.48， P<0.001)。2组患者均在进行浅层X线照射后3～5 d出现照射区域一过性色素沉着，6个月内自然消退。除此之外，观察组出现5例不良反应，分别为部分创面延迟愈合2例，毛细血管扩张2例，月经周期异常1例；对照组出现13例不良反应，包括毛细血管扩张7例，月经周期异常2例，皮肤萎缩凹陷4例。观察组不良反应发生率明显低于对照组，差异有统计学意义[17.24%(5/29) vs. 44.83%(13/29)， χ 2＝5.16， P<0.001]。

结论 环钻切除术加浅层X线照射联合局部药物注射治疗胸部多发性瘢痕疙瘩，具有操作简便、治疗效果好、不良反应少的优点。

Clinical application of punch excision in the treatment of chest multiple keloids 

Liu  Longcan, Xian  Hua, Ao  Xian, Xu  Dan, An  Juan, Wang  Chunmei

Department of Plastic & Cosmetic Surgery, Dermatology Hospital of Southern Medical University, Guangzhou 510091, China

Corresponding author: Wang Chunmei, Email: 1944134044@qq.com

  【Abstract】

Objective To explore the feasibility and clinical outcomes of punch excision combined with superficial X-ray and intralesional drug injection in the treatment of chest multiple keloids.

Methods Patients with chest multiple keloids in Dermatology Hospital of Southern Medical University from March 2020 to June 2021 were selected and randomly divided into observation group and control group according to random number table. In the observation group, punch excision was performed first, superficial X-ray was irradiated once within 24 h after surgery, and then once a week, for a total of 4 sessions. One week after radiotherapy, intralesional injection was performed with 5 ml mixture of 1 ml triamcinolone acetate injection, 0.6 ml fluorouracil injection and 3.4 ml 2% lidocaine hydrochloride injection, once a month, for a total of 4 times. Single injection endpoint reaction was keloid whiteness. The control group did not receive punch excision, and other treatments were the same as those in the observation group. Vancouver scar scale (VSS) score and efficacy evaluation (cure, excellent, improvement, ineffective) were performed before treatment and 3, 6, 12 months after treatment. Total keloids volume, intralesional injection volume and adverse reactions before and after treatment were recorded. SPSS 26.0 software was used for data analysis, and the measurement data were expressed as Mean±SD. Independent sample t-test was used for comparison between two groups, and repeated measurement data analysis of variance was used for comparison before and after treatment in the same group. Statistical data were expressed as % and χ 2 test was used for comparison between groups. P<0.05 was considered statistically significant.

Results A total of 58 patients were included, 29 in each group. There were 36 males and 22 females. The age ranged from 18 to 59 years old, with an average age of 29. The number of chest keloids in each patient was 5-12. Before treatment, the VSS scores of observation group and control group was 13.21±1.24 and 12.90±1.21 respectively. There was no significant difference in VSS scores between the two groups before treatment ( t=0.97, P=0.337). After 3, 6 and 12 months of follow-up, the VSS scores of the observation group were 4.21±1.26, 4.34±1.40 and 4.55±1.33 respectively, while those of the control group were 5.66±1.32, 6.07±1.44 and 6.62±1.40 respectively. The differences between the two groups were statistically significant ( t=-4.27, -4.63, -5.78, all P<0.001). Intra-group comparison showed that there were no statistically significant differences in VSS scores at 3, 6 and 12 months after treatment in the observation group ( F=2.50, P=0.111), while VSS scores at 3, 6 and 12 months after treatment in the control group showed a gradually increasing trend, with statistically significant difference ( F=30.75, P<0.001). In the observation group, 22 cases showed excellent effect, 7 cases improved, and the excellent rate was 75.86%(22/29). In the control group, there were 6 cases of excellent effect and 23 cases of improvement, the excellent rate was 20.69%(6/29), and the difference between the two groups was statistically significant ( χ 2=17.68, P<0.001). Before treatment, the total keloids volume of the observation group was (7.76±1.71) cm 3, which was (8.27±1.26) cm 3 of the control group, and there was no significant difference between the two groups before treatment ( t=-1.28, P=0.207). In the follow-up of 12 months after treatment, the total keloids volume of the observation group[(2.57±0.59) cm 3] was significantly smaller than that of the control group[(5.51±1.39) cm 3], and the difference was statistically significant ( t=-10.47, P<0.001). The total amount of intralesional injection in the observation group[(6.45±1.25) ml] was less than that in the control group[(11.00±1.73) ml], and the difference was statistically significant ( t=-11.48, P<0.001). Transient hyperpigmentation appeared in the irradiation area 3-5 days after superficial X-ray, which subsided naturally within 6 months in both groups. In addition, there were 5 adverse reactions in the observation group, including delayed healing (2 cases), telangiectasia (2 cases) and abnormal menstrual cycle (1 case). There were 13 cases of adverse reactions in the control group, including telangiectasia (7 cases), abnormal menstrual cycle (2 cases), and atrophic and sunken skin (4 cases). The incidence of adverse reactions in the observation group was significantly lower than that in the control group, and the difference was statistically significant [17.24%(5/29) vs. 44.83%(13/29), χ 2=5.16, P<0.001].

Conclusion Punch excision combined with superficial X-ray and intralesional drug injection for the treatment of chest multiple keloids has the advantages of simple operation, good therapeutic effect and less adverse reactions.

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: Ethical approval was given by the Medical Ethics Committee of Dermatology Hospital of Southern Medical University (2021003).