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【英国皮肤病协会关于皮肤疣诊疗指南】文献翻译

2015-9-13 18:42| 发布者: 管理员| 查看: 1721| 评论: 0

摘要: 在张学军教授要求下,我们每周从发达国家最新皮肤性病学诊疗指南中,选择一篇翻译成中文,以PPT的形式供大家学习交流,欢迎多提宝贵意见。希望这些指南对完善和改进我们的临床工作,以及对我国皮肤性病诊疗指南的修 ...

在张学军教授要求下,我们每周从发达国家最新皮肤性病学诊疗指南中,选择一篇翻译成中文,以PPT的形式供大家学习交流,欢迎多提宝贵意见。希望这些指南对完善和改进我们的临床工作,以及对我国皮肤性病诊疗指南的修订提供帮助。


British Association of Dermatologists’guidelines for the management of cutaneous warts 2014

英国皮肤病协会关于皮肤疣诊疗指南--2014年版

编译 杜鑫、王静,审校 杨春俊、张学军

文章转自: 安徽医科大学第二附属医院皮肤性病科

Background(背景)

Warts are caused by infection of keratinocytes by human papillomavirus (HPV). There are over 150 genotypically different types of HPV, with classification based on defined variation of the viral DNA. The majority of common warts are caused by HPV types 1, 2, 4, 27 or 57, and plane warts by HPV types 3 or 10. The HPV types originally identified in epidermodysplasia verruciformis (EV) and their closely related genotypes are also found on the skin, often as subclinical infections, but they can be associated with squamous cell cancer and premalignant dysplasias, especially in cases of immunosuppression.

疣是由HPV感染所致的皮肤病。根据病毒DNA的不同,有超过150个亚型。大多数寻常疣是由HPV1,2,4,27或57型导致,扁平疣是由HPV3或10型导致。皮肤HPV感染通常为亚临床感染,但它们可能与皮肤肿瘤的发病相关,特别是在免疫抑制的情况下。



Classification (疣的分类)

HPV-associated warts are subdivided on anatomical or morphological grounds into (i) common wart (Verruca vulgaris);

(ii) wart on the sole of the foot, plantar wart (Verruca plantaris);

(iii) flat wart or plane wart (Verruca plana)

(iv) genital wart (Condyloma accuminatum).

疣分类:寻常疣;跖疣;扁平疣;尖锐湿疣


common wart

plane wart

plantar wart

Epidemiology and course of infection(流行病学与感染)

HPV can spread from one individual to another by direct contact or via the environment. It is not known exactly how long the infectious virus can persist outside the body, but the related bovine papillomavirus is believed to retain infectivity for months or possibly years,and the same may be true for HPV.

HPV病毒可以通过直接接触或者环境传染给别人。目前并不清楚该病毒能在体外存活多久。但是牛RT瘤病毒可以在体外存活数月,HPV可能也类似。

Warts are a common skin disease worldwide. Infection is common in childhood, but can occur at any age. Small cohort observational studies have suggested that 5–30% of children and young adults have warts. Clearance in children can occur after only a few months, with half clear at 1 year and about two-thirds by 2 years.However, warts in adults can be much slower to clear, and persistence for 5–10 years is not uncommon.

疣可以发生于任何年龄,但是儿童更常见。约5-30%的儿童和青少年可发生疣。2年内有三分之二的儿童疣可以自发消失。而成人疣一般存在时间更长,可达5到10年。



Diagnosis(诊断)

Diagnosis of common hand and foot warts is usually not difficult. Warts need to be distinguished either clinically or histologically from other keratotic lesions on the hands or feet, such as actinic keratoses, knuckle pads or, more rarely, squamous cell carcinoma or focal palmoplantar keratoderma. On the feet, corns and calluses or callosities can be confused with warts, but paring and close inspection should allow them to be distinguished. On limbs, other hyperkeratotic lesions such as lichen planus or angiokeratoma may cause confusion, and plane warts may need to be distinguished from lichen planus or thin actinic or seborrhoeic keratoses.

疣的诊断一般不难。它需要与一些角化性皮肤病鉴别,如脂溢性角化,指节垫,日光性角化,局限型掌跖角化症等。跖疣和鸡眼或胼胝可通过“削皮试验”协助鉴别诊断。



Complications(并发症)

Impairment of the immune system, especially cell-mediated immunity, usually results in prolonged duration of warts. Warts may be the presenting feature of milder immunosuppressed states such as lymphoma, idiopathic CD4 lymphocytopenia or HIV infection,

so unusually severe or prolonged warts should prompt consideration of underlying immune deficit.

免疫系统特别是细胞免疫的损伤,会导致严重的长期的疣,临床上遇到这类患者,需注意是否有潜在的免疫损伤的可能。




Management


No therapy(观察)


Depending on their site and size, warts may be just a minor nuisance. If the affected individual is immunocompetent, then an expectant approach to management is entirely acceptable. Some warts can be uncomfortable or interfere with function, or may be a major cosmetic bother and embarrassment when numerous or on sites such as the face. Under these circumstances, a number of different treatments may be considered.

这主要取决于疣的部位及大小。若疣影响到美观或者功能,或者造成患者的不适,可以考虑其他的治疗方法。



Interventional treatment (干预)

There are numerous treatments for warts, and whether used singly or in combination they often have little evidence base for their use. Ideally treatment should not leave scars, although many patients may prefer a permanent scar to a persistent, unsightly and troublesome wart. There is no antiviral treatment that is specific for HPV, but some of the available therapies interfere with the viral life cycle. The most common approach to treatment is to damage or destroy the infected epithelium.

关于疣的治疗方法,不管是单用或者是联用各种治疗均没有强有力的证据基础。理想的治疗是不能留下疤痕。目前没有特效抗病毒药物治疗HPV,但是可以使用其它方法去阻止病毒。最常见的方法就是破坏及摧毁被感染的表皮。



Destructive treatments(破坏性治疗方法)

1.Salicylic acid(水杨酸)

2.Cryotherapy(冷冻)

3.Silver nitrate (硝酸银)

4.Phenol(苯酚)

5.Cantharidin(斑蝥素)

6.Glycolic acid 5% (5%乙醇酸)

7.Pyruvic acid(丙酮酸)

8.Citric acid 50%(柠檬酸)

9.Citric acid 50%(柠檬酸)

10.Formic acid(甲酸)

11.Trichloroacetic acid and monochloroacetic acid (三氯乙酸和一氯醋酸)

12.Hyperthermia(温热疗法)

13.Surgical interventions (外科手术治疗)

14.Photodynamic therapy (光动力疗法)



1.1 Salicylic acid(水杨酸)

Salicylic acid (SA) formulations are the most common preparation used in the treatment of viral warts. In 2011 a meta-analysis of five studies of 333 patients showed SA (all preparations) to be more effective than placebo. The most commonly used combination therapy is cryotherapy and SA. In an open study, a clearance rate of 86% (25/29) was reported in a retrospective analysis of cases treated with both cryotherapy and SA 70%.

水杨酸常用来治疗疣。

2011年一项针对333名患者的研究表明水杨酸比安慰剂更有效。水杨酸常与冷冻治疗联用,报道显示清除率可达到86%。



1.2 Cryotherapy(冷冻)

Liquid nitrogen, delivered by cryospray or cotton bud, is the most commonly used method in medical practice. Techniques differ between practitioners, with variations in freeze times, mode of application and intervals between. Paring before cryotherapy can improve results in plantar warts, but not hand warts.The reported cure rate of cryotherapy for warts at all sites from randomized trials is highly variable, ranging from 0% to 69% with a mean of 49%.

液氮冷冻是最常用的。疗效取决于治疗技术、冻结时间、治疗间隔等。跖疣治疗前“削皮”疗效更佳。冷冻的治疗有效率报道结果差异较大。从0到69%不等,平均为49%。



1.3 Silver nitrate (硝酸银)

A silver nitrate 10% solution was investigated in a placebo-controlled, doubleblinded study of hand and foot warts in 60 children and adults, and showed a clearance rate of 63% of patients after 6 weeks.

一项针对60例儿童和成年人手足疣的治疗报道,使用10%硝酸银溶液治疗6周后清除率可达到63%。



1.4 Phenol(苯酚)

Phenol is a caustic agent that has been compared with cryotherapy in a single-blinded, randomized study of 60 patients with hand warts. The cure rates of patients were 70% with cryotherapy and 83% with phenol.

苯酚是一种腐蚀性的液体。在一项和冷冻治疗对比的研究中,治愈率为83%,而冷冻为70%。



1.5 Cantharidin(斑蝥素)

This is a blistering agent that triggers acantholysis. The superficial nature of the injury reduces the risk of scarring. A study of 15 patients who were treated with a cantharidin 0.7% solution to treat plane facial warts showed clearance of warts in all 15 patients within 16 weeks with one to four treatments.

斑蝥素是一种起疱剂,它可以导致棘层松解,可以减少疤痕的产生。一项针对15例扁平疣患者的研究中,使用0.7%斑蝥素溶液治疗1到4次,16周内皮损完全清除。



1.6 Glycolic acid 5% (5%乙醇酸)

Glycolic acid is an a-hydroxy acid that acts as a peeling agent. In a case series of 15 children with facial plane warts it was well tolerated, cleared all of the cases and did not produce scarring.

在一项15例儿童扁平疣的治疗中,耐受性好,清除率高,并且不留下疤痕。



1.7 Pyruvic acid(丙酮酸)

Pyruvic acid is used as a peeling agent. In a case series investigating the response of common warts to pyruvic acid 70% alone or in combination with 5-FU 0.5%, 80% of patients showed improvement.

丙酮酸是一种剥离剂。在一项和5-FU联用治疗寻常疣的研究中,80%患者显示疗效。



1.8 Citric acid 50%(柠檬酸)


Citric acid was compared with tretinoin in a prospective randomized, doubleblinded study of 75 patients with plane warts on the body.After 6 weeks 64% of citric acid-treated lesions were cleared, vs. 54% of the tretinoin-treated lesions.

在一项和维甲酸治疗寻常疣的双盲研究中,柠檬酸治疗清除率为64%。



1.9 Formic acid(甲酸)

As an acid, it is stronger than SA but weaker than trichloroacetic acid. A number of studies have suggested its efficacy.

其疗效强于水杨酸,但弱于三氯醋酸



1.10 Trichloroacetic acid and monochloroacetic acid(三氯乙酸和一氯醋酸)

Trichloroacetic acid is used regularly to treat genital warts,and has been used without adequate trial evidence to treat common warts.

三氯乙酸常用来治疗生殖器疣,但是治疗寻常疣仍需要更多的证据。



1.11 Hyperthermia(温热疗法)

Two randomized trials have studied the effects of localized heat on warts. The more recent trial involved 60 patients with plantar warts randomized to hyperthermia with red light (up to 44 °C for 30 min on three consecutive days) or placebo red light alone. localized hyperthermia can be effective and is reasonably safe.

几项研究表明,温热疗法有效且安全。



1.12 Surgical interventions

There are no high-quality studies published on the effectiveness of surgical treatments such as curettage, cautery and laser, although these treatments are certainly widely used.

尽管刮除术、激光等广泛应用,但是没有高质量的研究表明其疗效。




1.3 Photodynamic therapy (光动力疗法)

There was a significant difference in wart clearance after 14 weeks in 45 patients with palmar and plantar lesions treated with 20% aminolaevulinic acid photodynamic therapy (ALA-PDT) compared with placebo-PDT. In total, 75% of plantar warts completely resolved in 6,7 ALA-PDT-treated patients compared with 23% in the placebo group.

一项研究表明,经过6到7次的ALA-PDT治疗,75%的疣体清除,而安慰剂只有23%的清除率。



2. Virucidal agents(杀病毒治疗)

Formaldehyde(甲醛)

Glutaraldehyde(戊二醛)



3.Antiproliferative agents(抗增殖治疗)

Vitamin D analogues(维生素D衍生物)

Dithranol(地蒽酚)

Podophyllin and podophyllotoxin (鬼臼毒素)

5-Fluorouracil

Bleomycin(博莱霉素)

Retinoids(维A酸)

Cidofovir(西多福韦)



4. Immunological therapy(免疫疗法)

Imiquimod(咪喹莫特)

Contact immunotherapy (接触性免疫疗法)

Intralesional immunotherapy(内部免疫疗法)

H2 receptor antagonists(H2受体拮抗剂)

Other systemic immunotherapy

Zinc oxide and zinc sulfate(氧化锌及硫酸锌)



5. Complementary and alternative treatments(补充和替代疗法)

Psychological treatments(心理疗法)

Herbal treatments(草药治疗)

Homeopathy(顺势疗法)

Acupuncture(针灸)





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