中國(guó)特應(yīng)性皮炎診療指南（2020版）

郝醫(yī)生

<section data-tools="135編輯器" data-id="91500" style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><section data-width="100%" style="max-width: 100%; width: 368px; text-align: center; overflow-wrap: break-word !important;"><section data-brushtype="text" style="padding-left: 45px; max-width: 100%; display: inline-block; background-image: url("https://mmbiz.qpic.cn/mmbiz_jpg/fgnkxfGnnkTmY2nSxFDmicLibRyLocyicnPWLIv76fFAKW5Fcd9YvjuNyG63tNFMqk6n7RpzS4vO33Andq4dzB6MQ/640?wx_fmt=jpeg"); height: 40px; background-repeat: no-repeat; background-size: auto 40px; border-bottom: 2px solid rgb(124, 204, 214); line-height: 50px; color: rgb(124, 204, 214); font-size: 18px; overflow-wrap: break-word !important;">一、病因及發(fā)病機(jī)制</section></section></section><p style="max-width: 100%; clear: both; min-height: 1em; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><br style="max-width: 100%; overflow-wrap: break-word !important;"></h3><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">AD的發(fā)病與遺傳和環(huán)境等因素關(guān)系密切［8］。父母親等家族成員有過(guò)敏性疾病史是本病的最強(qiáng)風(fēng)險(xiǎn)因素［6］，遺傳因素主要影響皮膚屏障功能與免疫平衡。本病患者往往有多種免疫學(xué)異常，其中Th2細(xì)胞活化為重要特征，還可有皮膚屏障功能減弱或破壞如表皮中聚絲蛋白（filaggrin）減少或缺失。環(huán)境因素包括氣候變化、生活方式改變、不正確的洗浴、感染原和變應(yīng)原刺激等?，F(xiàn)代生活方式（過(guò)于衛(wèi)生、西式飲食等）及環(huán)境暴露（環(huán)境污染、被動(dòng)吸煙等）等可能通過(guò)表觀遺傳修飾引起免疫系統(tǒng)與皮膚屏障異常，參與AD的發(fā)病［9-10］。此外，心理因素（如精神緊張、焦慮、抑郁等）也在AD的發(fā)病中發(fā)揮一定作用［8，11］。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">雖然AD的確切發(fā)病機(jī)制尚不清楚，但目前研究認(rèn)為，免疫異常、皮膚屏障功能障礙、皮膚菌群紊亂等因素是本病發(fā)病的重要環(huán)節(jié)。Th2型炎癥是AD的基本特征，IL-4和IL-13是介導(dǎo)AD發(fā)病的重要細(xì)胞因子［12］，主要由Th2細(xì)胞、嗜堿性粒細(xì)胞和2型固有淋巴樣細(xì)胞（innate lymphoid cells）等產(chǎn)生。在AD的慢性期，皮損中還可見(jiàn)Th1、Th17和Th22的混合炎癥浸潤(rùn)［13］。Filaggrin等基因突變導(dǎo)致的皮膚屏障功能障礙使外界環(huán)境物質(zhì)（如微生物和過(guò)敏原）易于侵入表皮而啟動(dòng)Th2型炎癥［14］，朗格漢斯細(xì)胞和皮膚樹(shù)突細(xì)胞通過(guò)對(duì)變應(yīng)原的提呈參與了這一過(guò)程［15-17］。Th2型炎癥因子可以抑制角質(zhì)形成細(xì)胞屏障相關(guān)蛋白的表達(dá)，進(jìn)一步破壞皮膚屏障功能［18］。AD皮損和外觀正常皮膚常伴有以金黃色葡萄球菌定植增加和菌群多樣性下降為主要表現(xiàn)的皮膚菌群紊亂［19］，以及所導(dǎo)致的代謝等功能異常［20］，促進(jìn)了皮膚炎癥的進(jìn)展。反復(fù)搔抓是導(dǎo)致皮膚炎癥加重和持續(xù)的重要原因，搔抓促使角質(zhì)形成細(xì)胞產(chǎn)生炎癥介質(zhì)，也會(huì)導(dǎo)致自身抗原釋放，產(chǎn)生針對(duì)自身抗原的IgE［21］。非免疫性因素如神經(jīng)-內(nèi)分泌因素也可參與皮膚炎癥的發(fā)生和發(fā)展［8，11，22］。</span></section> <section data-tools="135編輯器" data-id="91500" style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><section data-width="100%" style="max-width: 100%; width: 368px; text-align: center; overflow-wrap: break-word !important;"><section data-brushtype="text" style="padding-left: 45px; max-width: 100%; display: inline-block; background-image: url("https://mmbiz.qpic.cn/mmbiz_jpg/fgnkxfGnnkTmY2nSxFDmicLibRyLocyicnPWLIv76fFAKW5Fcd9YvjuNyG63tNFMqk6n7RpzS4vO33Andq4dzB6MQ/640?wx_fmt=jpeg"); height: 40px; background-repeat: no-repeat; background-size: auto 40px; border-bottom: 2px solid rgb(124, 204, 214); line-height: 50px; color: rgb(124, 204, 214); font-size: 18px; overflow-wrap: break-word !important;">二、臨床表現(xiàn)</section></section></section><p style="max-width: 100%; clear: both; min-height: 1em; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><br style="max-width: 100%; overflow-wrap: break-word !important;"></h3><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">本病通常初發(fā)于嬰兒期，1歲前發(fā)病者約占全部患者的50%，但近來(lái)發(fā)現(xiàn)，晚發(fā)患者并不少見(jiàn)。該病呈慢性經(jīng)過(guò)，臨床表現(xiàn)多種多樣，最基本的特征是皮膚干燥、慢性濕疹樣皮損和明顯瘙癢。我國(guó)兒童AD患者病情嚴(yán)重度大多為輕度（74.6%），其次為中度（23.96%），重度較少（1.44%）［6］。根據(jù)在不同年齡段的表現(xiàn)，分為嬰兒期（出生至2歲）、兒童期（> 2 ~ 12歲）、青少年與成人期（> 12 ~ 60歲）和老年期（> 60歲）四個(gè)階段。嬰兒期：皮損多分布于兩頰、額部和頭皮，皮疹以急性濕疹表現(xiàn)為主，后逐漸蔓延至四肢伸側(cè)；兒童期：多由嬰兒期演變而來(lái)，也可不經(jīng)過(guò)嬰兒期而發(fā)生，多發(fā)生于面頸、肘窩、腘窩和小腿伸側(cè)，以亞急性和慢性皮損為主要表現(xiàn)，皮疹往往干燥肥厚，有明顯苔蘚樣變；青少年與成人期：皮損與兒童期類(lèi)似，也以亞急性和慢性皮炎為主，主要發(fā)生在肘窩、腘窩、頸前等部位，也可發(fā)生于軀干、四肢、面部、手部，大部分呈干燥、肥厚性皮炎損害，部分患者也可表現(xiàn)為癢疹樣；老年期是近幾年來(lái)逐漸被重視的一個(gè)特殊類(lèi)型，男性多于女性，皮疹通常嚴(yán)重而泛發(fā)，甚至出現(xiàn)紅皮?。?3］。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">根據(jù)實(shí)驗(yàn)室檢查特征和皮膚炎癥模式，可將AD分為若干類(lèi)型：①根據(jù)總IgE水平和是否有特異性IgE，分為內(nèi)源型和外源型，內(nèi)源型指血清總IgE水平正常（＜200 KU/L），無(wú)特應(yīng)性疾病史，缺乏過(guò)敏原特異性IgE；外源型指以高水平IgE為特征，有個(gè)人或家族性的特應(yīng)性疾病史及食物和/或吸入性過(guò)敏原特異性IgE水平增高［24］；②根據(jù)皮膚炎癥模式，分為以Th2、Th22、Th17和Th1為主，或者幾種混合的炎癥模式，如兒童期AD以Th2型炎癥為主，而成人期AD則以Th2/Th22型混合炎癥為主，亞裔以Th2/Th17混合炎癥為主［25］。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">AD患者有一些有助于疾病診斷的特征性表現(xiàn)，包括皮膚干燥、魚(yú)鱗病、毛周角化、掌紋癥、手足部皮炎/濕疹、眼瞼濕疹、乳頭濕疹、唇炎、復(fù)發(fā)性結(jié)膜炎、眶下褶痕、鼻下和耳根皺褶處濕疹、眶周黑暈、白色糠疹、出汗時(shí)瘙癢、對(duì)羊毛敏感、過(guò)度蟲(chóng)咬反應(yīng)、白色劃痕等。部分患者可同時(shí)有其他過(guò)敏性疾病，如過(guò)敏性哮喘、過(guò)敏性鼻結(jié)膜炎等。我國(guó)研究數(shù)據(jù)顯示，16.7%的AD患者同時(shí)患有哮喘，33.7%同時(shí)患有過(guò)敏性鼻結(jié)膜炎，這些皮膚以外過(guò)敏性疾病的發(fā)病率隨著年齡的增長(zhǎng)而增長(zhǎng)［26］。此外，由于長(zhǎng)期慢性炎癥反應(yīng)，慢性病程患者合并發(fā)生精神神經(jīng)系統(tǒng)疾病、炎性腸病、類(lèi)風(fēng)濕性關(guān)節(jié)炎、心血管疾病和淋巴瘤風(fēng)險(xiǎn)明顯增高［27-29］。</span></section> <section data-tools="135編輯器" data-id="91500" style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><section data-width="100%" style="max-width: 100%; width: 368px; text-align: center; overflow-wrap: break-word !important;"><section data-brushtype="text" style="padding-left: 45px; max-width: 100%; display: inline-block; background-image: url("https://mmbiz.qpic.cn/mmbiz_jpg/fgnkxfGnnkTmY2nSxFDmicLibRyLocyicnPWLIv76fFAKW5Fcd9YvjuNyG63tNFMqk6n7RpzS4vO33Andq4dzB6MQ/640?wx_fmt=jpeg"); height: 40px; background-repeat: no-repeat; background-size: auto 40px; border-bottom: 2px solid rgb(124, 204, 214); line-height: 50px; color: rgb(124, 204, 214); font-size: 18px; overflow-wrap: break-word !important;">三、AD的診斷</section></section></section><p style="max-width: 100%; clear: both; min-height: 1em; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><br style="max-width: 100%; overflow-wrap: break-word !important;"></h3><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">如果患者表現(xiàn)為濕疹樣皮損，應(yīng)當(dāng)懷疑有AD的可能，需詳細(xì)詢(xún)問(wèn)病史、家族史，結(jié)合臨床表現(xiàn)和全面體檢進(jìn)行診斷。必要時(shí)進(jìn)行外周血嗜酸性粒細(xì)胞計(jì)數(shù)、血清總IgE、過(guò)敏原特異性IgE、嗜酸性粒細(xì)胞陽(yáng)離子蛋白及斑貼試驗(yàn)等檢測(cè)。AD是一種異質(zhì)性疾病，表現(xiàn)多種多樣，診斷需要一定標(biāo)準(zhǔn)。目前國(guó)外常用的診斷標(biāo)準(zhǔn)包括Hanifin-Rajka標(biāo)準(zhǔn)［30］和Williams標(biāo)準(zhǔn)（主要標(biāo)準(zhǔn)：皮膚瘙癢；次要標(biāo)準(zhǔn)：① 屈側(cè)受累史，包括肘窩、腘窩、踝前、頸部（10歲以下兒童包括頰部皮疹）；② 哮喘或過(guò)敏性鼻炎史（或在4歲以下兒童的一級(jí)親屬中有特應(yīng)性疾病史）；③ 近年來(lái)全身皮膚干燥史；④ 有屈側(cè)濕疹（4歲以下兒童面頰部/前額和四肢伸側(cè)濕疹）；⑤2歲前發(fā)?。ㄟm用于 > 4歲患者）。確定診斷：主要標(biāo)準(zhǔn) + 3條或3條以上次要標(biāo)準(zhǔn)）［31］。我國(guó)學(xué)者康克非［32］、張建中等［33］和姚志榮等［7，34］也提出了診斷標(biāo)準(zhǔn)。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">張建中等［33］提出的中國(guó)AD診斷標(biāo)準(zhǔn)：①病程超過(guò)6個(gè)月的對(duì)稱(chēng)性濕疹；②特應(yīng)性個(gè)人史和/或家族史（包括濕疹、過(guò)敏性鼻炎、哮喘、過(guò)敏性結(jié)膜炎等）；③血清總IgE升高和/或外周血嗜酸性粒細(xì)胞升高和/或過(guò)敏原特異性IgE陽(yáng)性（過(guò)敏原特異性IgE檢測(cè)2級(jí)或2級(jí)以上陽(yáng)性）。符合第1條，另外加第2條或第3條中的任何1條即可診斷AD。此標(biāo)準(zhǔn)在診斷青少年和成人AD方面敏感性高于Hanifin-Rajka標(biāo)準(zhǔn)和Williams標(biāo)準(zhǔn)。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">姚志榮等［34］提出的中國(guó)兒童AD臨床診斷標(biāo)準(zhǔn)：①瘙癢；②典型的形態(tài)和部位（屈側(cè)皮炎）或不典型的形態(tài)和部位同時(shí)伴發(fā)干皮癥；③慢性或慢性復(fù)發(fā)性病程。同時(shí)具備以上3條即可診斷AD。典型的形態(tài)和部位（屈側(cè)皮炎）包括兒童面部和肢端受累；非典型的形態(tài)和部位包括：①典型的濕疹樣皮疹，發(fā)生在非屈側(cè)部位（頭皮皮炎、眼瞼濕疹、乳頭濕疹、外陰濕疹、錢(qián)幣狀濕疹、指尖濕疹、非特異性手部或足部皮炎/特應(yīng)性冬季足、甲或甲周濕疹和身體其他部位的濕疹樣皮疹）；②非典型濕疹樣皮疹，單純糠疹、唇炎、耳下和耳后/鼻下裂隙、癢疹、汗皰疹、丘疹性苔蘚樣變異。此標(biāo)準(zhǔn)的敏感性也高于Hanifin-Rajka標(biāo)準(zhǔn)和Williams標(biāo)準(zhǔn)。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">Williams標(biāo)準(zhǔn)在過(guò)去數(shù)年中應(yīng)用較廣。張氏標(biāo)準(zhǔn)推薦用于成人/青少年AD的診斷，姚氏標(biāo)準(zhǔn)推薦用于兒童AD的診斷。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">AD有典型表現(xiàn)者診斷并不困難，但臨床上有部分患者臨床表現(xiàn)不典型，勿輕易排除AD的診斷，應(yīng)當(dāng)仔細(xì)檢查和問(wèn)診，必要時(shí)進(jìn)行長(zhǎng)期隨訪。  </span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">AD的鑒別診斷包括脂溢性皮炎、接觸性皮炎、銀屑病、魚(yú)鱗病、疥瘡、副銀屑病、嗜酸性粒細(xì)胞增多性皮炎、皮膚T細(xì)胞淋巴瘤、Netherton綜合征、高IgE綜合征、朗格漢斯細(xì)胞組織細(xì)胞增生癥、Wiskott-Aldrick綜合征、AD樣移植物抗宿主?。℅VHD）等。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">AD嚴(yán)重度的評(píng)價(jià)方法較多，常用的有AD評(píng)分（SCORAD）、濕疹面積和嚴(yán)重程度指數(shù)評(píng)分（EASI）、研究者整體評(píng)分法（IGA）、瘙癢程度視覺(jué)模擬尺評(píng)分（VAS）等。根據(jù)SCORAD評(píng)分，將病情分為輕度（SCORAD：0 ~ 24分）、中度（SCORAD：25 ~ 50分）、重度（SCORAD：> 50分）。疾病嚴(yán)重度評(píng)估可作為制定治療方案的依據(jù)。</span></section><h3><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;"><br></span></h3> <section data-tools="135編輯器" data-id="91500" style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><section data-width="100%" style="max-width: 100%; width: 368px; text-align: center; overflow-wrap: break-word !important;"><section data-brushtype="text" style="padding-left: 45px; max-width: 100%; display: inline-block; background-image: url("https://mmbiz.qpic.cn/mmbiz_jpg/fgnkxfGnnkTmY2nSxFDmicLibRyLocyicnPWLIv76fFAKW5Fcd9YvjuNyG63tNFMqk6n7RpzS4vO33Andq4dzB6MQ/640?wx_fmt=jpeg"); height: 40px; background-repeat: no-repeat; background-size: auto 40px; border-bottom: 2px solid rgb(124, 204, 214); line-height: 50px; color: rgb(124, 204, 214); font-size: 18px; overflow-wrap: break-word !important;">四、治療與管理</section></section></section><p style="max-width: 100%; clear: both; min-height: 1em; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><br style="max-width: 100%; overflow-wrap: break-word !important;"></h3><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">治療的目的是緩解或消除臨床癥狀，消除誘發(fā)和/或加重因素，減少和預(yù)防復(fù)發(fā)，減少或減輕合并癥，提高患者的生活質(zhì)量。正規(guī)和良好的治療及疾病管理可使AD癥狀完全消退或顯著改善，患者可享受正常生活。</span></section><section data-tools="135編輯器" data-id="90150" style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><section style="margin: 10px auto; max-width: 100%; display: inline-block; overflow-wrap: break-word !important;"><section data-width="100%" style="padding-right: 5px; padding-left: 5px; max-width: 100%; display: inline-block; width: 230.531px; border-width: 0px 0px 1px 10px; border-style: solid; border-bottom-color: rgb(197, 36, 36); border-left-color: rgb(197, 36, 36); border-right-color: rgb(197, 36, 36); overflow-wrap: break-word !important;"><p data-brushtype="text" style="max-width: 100%; clear: both; min-height: 1em; overflow-wrap: break-word !important;">（一）疾病管理與患者教育</h3></section></section></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">由于本病是慢性復(fù)發(fā)性疾病，需要長(zhǎng)期治療，應(yīng)建立起良好的醫(yī)患關(guān)系，通過(guò)對(duì)疾病全程管理獲得最佳療效。患者教育十分重要，醫(yī)生應(yīng)向患者和家屬說(shuō)明本病的性質(zhì)、臨床特點(diǎn)和注意事項(xiàng)。同時(shí)應(yīng)與患者及家屬詳細(xì)分析尋找其發(fā)病病因和誘發(fā)加重因素（包括非特異性誘發(fā)因素，以及特異性過(guò)敏原誘發(fā)因素等），告知其回避策略。應(yīng)對(duì)患者的病史、病程、皮損面積和嚴(yán)重程度等進(jìn)行綜合評(píng)估，確定治療方案，力爭(zhēng)在短期內(nèi)控制疾病。醫(yī)生還應(yīng)向患者解釋藥物使用的方法，可期望療效和可能的不良反應(yīng)等。在隨訪過(guò)程中，醫(yī)生應(yīng)當(dāng)仔細(xì)觀察患者的病情變化，及時(shí)調(diào)整治療方案，并通過(guò)維持治療，盡可能長(zhǎng)期控制癥狀，減少?gòu)?fù)發(fā)［35］。</span></section><section data-tools="135編輯器" data-id="90150" style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><section style="margin: 10px auto; max-width: 100%; display: inline-block; overflow-wrap: break-word !important;"><section data-width="100%" style="padding-right: 5px; padding-left: 5px; max-width: 100%; display: inline-block; width: 142.812px; border-width: 0px 0px 1px 10px; border-style: solid; border-bottom-color: rgb(197, 36, 36); border-left-color: rgb(197, 36, 36); border-right-color: rgb(197, 36, 36); overflow-wrap: break-word !important;"><p data-brushtype="text" style="max-width: 100%; clear: both; min-height: 1em; overflow-wrap: break-word !important;">（二）基礎(chǔ)治療</h3></section></section></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; color: rgb(0, 122, 170); overflow-wrap: break-word !important;"><strong style="max-width: 100%; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">1. 洗?。?lt;/span></strong></span><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">合理的洗浴不僅可以去除皮膚表面污穢痂皮，還可以降低皮膚表面金黃色葡萄球菌定植數(shù)量。建議洗浴溫度在32 ℃ ~ 37 ℃，洗浴時(shí)間5 ~ 10 min。推薦使用低敏無(wú)刺激的潔膚用品，其pH值最好接近正常表皮pH值（約為6）［36］。如皮損有感染傾向，可在盆浴時(shí)加入次氯酸鈉（0.005%漂白粉?。┮砸种萍?xì)菌活性，有助于病情緩解［37］。洗浴頻度以每日或隔日1次為宜。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; color: rgb(0, 122, 170); overflow-wrap: break-word !important;"><strong style="max-width: 100%; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">2. 恢復(fù)和保持皮膚屏障功能：</span></strong></span><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">外用保濕潤(rùn)膚劑是AD的基礎(chǔ)治療，有助于恢復(fù)皮膚屏障功能［38-40］。保濕潤(rùn)膚劑不僅能阻止水分丟失，還能修復(fù)受損的皮膚屏障，減弱外源性不良因素的刺激，從而減少疾病的發(fā)作次數(shù)和嚴(yán)重度［41］。建議患者選用合適自己的保濕潤(rùn)膚劑［42］，建議足量多次使用，沐浴后應(yīng)該立即使用。冬季根據(jù)皮膚干燥情況可選用富含脂類(lèi)的潤(rùn)膚劑。建議兒童每周用量至少100 g，成人每周用量250 g［43］。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; color: rgb(0, 122, 170); overflow-wrap: break-word !important;"><strong style="max-width: 100%; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">3. 改善環(huán)境：</span></strong></span><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">避免各種機(jī)械、化學(xué)物質(zhì)刺激，如搔抓、摩擦，毛織物、酸性物質(zhì)、漂白劑等刺激，及時(shí)清除汗液對(duì)皮膚的刺激；避免飲酒和辛辣食物；避免過(guò)度干燥和高溫等刺激，適宜居住溫度為18 ℃ ~ 22 ℃；控制環(huán)境中致敏物，如塵螨、動(dòng)物皮屑、花粉等。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; color: rgb(0, 122, 170); overflow-wrap: break-word !important;"><strong style="max-width: 100%; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">4. 食物干預(yù)：</span></strong></span><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">據(jù)研究，5歲以下兒童常見(jiàn)食物過(guò)敏原為牛奶、雞蛋、小麥、花生和大豆；5歲以上兒童常見(jiàn)食物過(guò)敏原為堅(jiān)果、貝殼類(lèi)和魚(yú)；青少年和成人食物過(guò)敏少見(jiàn)，個(gè)別人有花粉相關(guān)食物過(guò)敏，如樺樹(shù)花粉相關(guān)的食物如蘋(píng)果、芹菜、胡蘿卜和榛果。如果食物和皮疹間的因果關(guān)系明確，建議避食4 ~ 6周，觀察皮疹改善情況［44］，如患者既往無(wú)嚴(yán)重過(guò)敏反應(yīng)史，必要時(shí)進(jìn)行食物激發(fā)試驗(yàn)。除非明確食物和發(fā)疹之間的因果關(guān)系，否則不推薦盲目避食，過(guò)度避食可導(dǎo)致?tīng)I(yíng)養(yǎng)不良。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; color: rgb(0, 122, 170); overflow-wrap: break-word !important;"><strong style="max-width: 100%; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">5. 避免接觸過(guò)敏：</span></strong></span><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">變態(tài)反應(yīng)性接觸性過(guò)敏反應(yīng)在AD患者中常見(jiàn)，發(fā)生率約6% ~ 60%，常見(jiàn)的接觸致敏物為鎳、新霉素、香料、甲醛、防腐劑、羊毛脂和橡膠等。建議AD患者盡可能避免接觸上述致敏物［45］。</span></section><section data-tools="135編輯器" data-id="90150" style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; overflow-wrap: break-word !important;"><section style="margin: 10px auto; max-width: 100%; display: inline-block; overflow-wrap: break-word !important;"><section data-width="100%" style="padding-right: 5px; padding-left: 5px; max-width: 100%; display: inline-block; width: 177.906px; border-width: 0px 0px 1px 10px; border-style: solid; border-bottom-color: rgb(197, 36, 36); border-left-color: rgb(197, 36, 36); border-right-color: rgb(197, 36, 36); overflow-wrap: break-word !important;"><p data-brushtype="text" style="max-width: 100%; clear: both; min-height: 1em; overflow-wrap: break-word !important;">（三）外用藥物治療</h3></section></section></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; color: rgb(0, 122, 170); overflow-wrap: break-word !important;"><strong style="max-width: 100%; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">1. 外用糖皮質(zhì)激素（topical corticosteroids，TCS）：</span></strong></span><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">TCS是AD的一線療法。根據(jù)患者的年齡、皮損性質(zhì)、部位及病情程度選擇不同劑型和強(qiáng)度的糖皮質(zhì)激素制劑，以快速有效控制炎癥，減輕癥狀。TCS強(qiáng)度一般可分為四級(jí)（超強(qiáng)效：0.1%氟輕松乳膏、0.05%氯倍他索乳膏；強(qiáng)效：0.05%鹵米松乳膏、0.05%二丙酸倍他米松乳膏、0.1%戊酸倍他米松乳膏、0.25%去羥米松軟膏劑及乳膏；中效：0.05%丙酸氟替卡松乳膏、0.1%糠酸莫米松乳膏、0.1%丁酸氫化可的松乳膏、0.1%曲安奈德乳膏；弱效：氫化可的松乳膏、0.05%地奈德乳膏/軟膏）［46］，初治時(shí)應(yīng)選用足夠強(qiáng)度的制劑，以求在數(shù)天內(nèi)迅速控制炎癥，炎癥控制后逐漸過(guò)渡到中弱效TCS或鈣調(diào)神經(jīng)磷酸酶抑制劑（topical calcineurin inhibitors，TCI）。面頸部及皺褶部位推薦短期使用中弱效TCS。肥厚性皮損可選用封包療法［47］。急性期泛發(fā)性嚴(yán)重或者頑固皮損推薦短期（通常3 d，時(shí)間不超過(guò)14 d）濕包治療，可快速有效控制癥狀，該療法特別適用于不宜系統(tǒng)用藥的兒童患者［48-49］，但要注意長(zhǎng)期大面積使用TCS可能導(dǎo)致皮膚和系統(tǒng)不良反應(yīng)。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">中重度或易復(fù)發(fā)AD患者皮損控制后，應(yīng)過(guò)渡到長(zhǎng)期“主動(dòng)維持治療”（proactive treatment），即在易復(fù)發(fā)的原有皮損區(qū)每周2次外用TCS或TCI，配合全身外用保濕潤(rùn)膚劑，能有效減少?gòu)?fù)發(fā)，減少外用糖皮質(zhì)激素用量［50-51］。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">有不少患者過(guò)于擔(dān)心外用糖皮質(zhì)激素的不良反應(yīng)，常常心存顧慮，甚至拒絕使用，醫(yī)生要耐心解釋正規(guī)使用藥物的安全性、用藥量、用藥方法、用藥頻度、療程、如何調(diào)整藥物等，消除患者顧慮，提高治療的依從性。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; color: rgb(0, 122, 170); overflow-wrap: break-word !important;"><strong style="max-width: 100%; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">2. 外用TCI：</span></strong></span><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">此類(lèi)藥物是治療AD重要的抗炎藥物，推薦用于面頸部、褶皺部位以及乳房、肛門(mén)外生殖器部位控制炎癥與瘙癢癥狀或用于主動(dòng)維持治療減少?gòu)?fù)發(fā)［52］。1%吡美莫司乳膏多用于輕中度AD［53］，0.03%（兒童用）與0.1%（成人用）他克莫司軟膏用于中重度AD。TCI長(zhǎng)期使用不會(huì)引起皮膚屏障破壞、皮膚萎縮等不良反應(yīng)。不良反應(yīng)主要為局部燒灼和刺激感，大部分患者可隨用藥時(shí)間延長(zhǎng)而逐步消失；部分患者（特別是急性期時(shí)）不能耐受藥物刺激反應(yīng)，建議先用TCS控制急性癥狀后，轉(zhuǎn)換為T(mén)CI維持治療［54］。</span></section><section style="max-width: 100%; color: rgb(51, 51, 51); font-family: -apple-system-font, BlinkMacSystemFont, "Helvetica Neue", "PingFang SC", "Hiragino Sans GB", "Microsoft YaHei UI", "Microsoft YaHei", Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; text-indent: 2em; overflow-wrap: break-word !important;"><span style="max-width: 100%; color: rgb(0, 122, 170); overflow-wrap: break-word !important;"><strong style="max-width: 100%; overflow-wrap: break-word !important;"><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">3. 其他外用藥：</span></strong></span><span style="max-width: 100%; font-size: 15px; overflow-wrap: break-word !important;">氧化鋅油（糊）劑、黑豆餾油軟膏等對(duì)AD也有效；生理氯化鈉溶液及其他濕敷藥物對(duì)于AD急性期的滲出有較好療效；外用磷酸二酯酶4（PDE-4）抑制劑軟膏已在美國(guó)獲批治療2歲及以上輕度至中度AD［55］。</span></section> <h3><span style="color: rgb(68, 68, 68); font-family: 微軟雅黑; font-size: 14px; text-align: justify; white-space: normal;">引用本文】中華醫(yī)學(xué)會(huì)皮膚性病學(xué)分會(huì)免疫學(xué)組  特應(yīng)性皮炎協(xié)作研究中心. 中國(guó)特應(yīng)性皮炎診療指南（2020版）[J]．中華皮膚科雜志，2020, 53（2）:81-88. doi：10.35541/cjd.20191000</span><br></h3> <h1><b style=""> 珀芙研官方商城</b></h1>