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病例漫谈 2:多发性毛发上皮瘤 [复制链接]

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    休斯敦激光美容外科中心的Melissa A. Bogle博士及其团队最近报道了一例新的治疗多发性毛发上皮瘤的病例。原文及译稿如下:
INITIAL PRESENTATIONA
49-year-old white female presented with multiple facial nodules, which first appeared when she was a teenager. Numerous family members had similar lesions and carried a diagnosis of familial trichoepitheliomas. The patient had no other medical problems.Physical examination revealed numerous pink, 2- to 8-mm papules predominantly in a midface distribution (forehead, cheeks, chin, nose, and cutaneous upper lip). Larger nodules measuring 12 to 18 mm were present on her nose and chin. (Figure 1A, B).
首发症状
     一名49岁白种女性患者,面部患有多处结节,十几岁时首发此病。其家族成员中很多都有类似的病变,诊断为家族性毛发上皮瘤。该患者无其它病史。
     体检报告显示,该患者的额头、脸颊、下巴、鼻子和上唇多处患有粉红丘疹,大小为2~8毫米。鼻子和下巴处可见12~18毫米大小的结节(图1A、图B)。
  


Figure 1A. Multiple trichoepitheliomas predominantly on the midface.


图1A 多发性毛发上皮瘤密集面中部





Figure 1B. Multiple trichoepitheliomas.


图B 多发性毛发上皮瘤



THERAPY
Surgical excision is the standard treatment for complete removal of single trichoepitheliomas. In this case, excision was impractical because of the large number of lesions and disfiguring scarring that would result. Because previous treatment with laser surgery had been helpful, an attempt was made to flatten out the lesions using the CO2 laser.The day before the procedure, the patient started prophylactic treatment with dicloxacillin 500 mg twice daily for one week and valacyclovir 500 mg twice daily for two weeks. Anesthesia was obtained with 1% lidocaine with epinephrine local infiltration and infraorbital and mental blocks. Metal eye shields were put in place. The first treatment session used the continuous wave (CW) CO2 laser at 15W with the 1-mm spot used at a defocused distance in order to make the beam diameter similar to that of the lesion. Smaller papules were treated with one to six passes until the lesions appeared to be flush with the skin. Larger papules and nodules were unroofed with electrosection, and a #15 blade was used to tease out the bulk of the lesions. The Ultrapulse CO2 laser (Coherent, Inc., Santa Clara, CA) was then used in the short pulsed mode to go over all treated areas at 400 mJ with the 3-mm spot. (Figure 2A, B) The patient tolerated the procedure well. (Figure 3)
治疗方法
    手术切除是根除单个毛发上皮瘤的标准疗法。该患者由于面部多处病变,手术切除会留下许多丑陋的疤痕。鉴于激光疗法已被证实对此病有效,我们尝试应用CO2激光疗法磨平患处丘疹。    术前一天,患者进行预防性治疗,给予500毫克双氯西林,一天2次,用药1周;500毫克伐昔洛韦,一天2次,用药2周。患者经1%利多卡因麻醉,肾上腺素局部浸润,眶下神经及脑部受阻。戴上金属眼罩。第一疗程,为保持光束直径与病变直径类似大小,15W CO2激光连续波的散焦距离应设为1毫米。小丘疹经1到6次处理后可较平整。大丘疹和结节要用电切除疗法,用15号刀片切掉大块病变。随后采用400MJ、3毫米散焦距离的超脉冲CO2激光(Coherent, Inc., Santa Clara, CA)短脉冲模式治疗所有患处(图2A、图B)。该患者手术耐受性较好(图3)。



Figure 2A. Immediately postprocedure with the CO2 laser and electrosection of larger nodules.


图2A 术后立即CO2激光并电切治疗较大结节





Figure 2B. Three days postprocedure.


图2B 术后三天





Figure 3. Three months postprocedure (Session 1) showing some remaining papules and nodules


图3 一个疗程3个月后可见几处残留丘疹和结节



A second treatment session four months later employed the continuous wave CO2 at 12W and three to four passes, followed by a single pass with the CO2 at 450 mJ, short pulse mode, with the 3-mm spot. (Figure 4). Energy from the CW CO2 was always found to be much more effective in flattening the lesions as compared to when used in the short pulse-resurfacing mode. The patient healed well and was pleased with her cosmetic improvement. (Figure 5)    
    四个月后进行第二疗程,采用15W的CO2激光连续波处理3到4次,再用450MJ、3毫米聚焦距离的CO2波短脉冲模式重复处理一次(图4)。我们发现,与短脉冲修复的效果相比较,CO2激光连续波治疗更有效,其产生的能量更利于病变处修复。患者预后良好,并对其面部修复效果非常满意(图5)。



Figure 4. Immediately postprocedure (Session 2) with the CO2 laser


图4 第二疗程立即CO2激光治疗





Figure 5. Moderately good cosmetic improvement after two sessions with CO2 laser surgery


图5 两个疗程CO2激光治疗后面部改观



FOLLOW UP
The patient has retained good clearance of the majority of the treated lesions at a three-year follow-up. She has continued to develop additional trichoepitheliomas, and a few of the previously treated lesions have returned. She plans to undergo a third treatment session using the above protocol in the future. (Figure 6)
随访
    患者随访三年,大部分患处清除效果良好,无病变复发症状。该患者其它部位偶见新增的毛发上皮瘤,但几处先前患处已有转归。患者计划将来继续进行第三个疗程(图6)。



Figure 6. The patient has retained good clearance of the treated lesions at three year follow-up


图6 三年随访无病变复发症状



病例来源:https://derm101.com/clincase/clincase.aspx?fileID=clincasestudy1_2

(编译:王凤霞 校对:王影影)
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