基于温哥华瘢痕量表评分的强脉冲光联合二氧化碳点阵激光序贯治疗深度烧伤后早期增生性瘢痕的效果

基于温哥华瘢痕量表评分的强脉冲光联合二氧化碳点阵激光序贯治疗深度烧伤后早期增生性瘢痕的效果

弓辰夏成德何素霞李永林

本文来源：《中华整形外科杂志》2023年8月第39卷第8期

DOI:10. 3760 / cma.j.cn114453-20230103-00001

作者单位：郑州市第一人民医院烧伤外科，郑州450000

通信作者：夏成德，Email：2273451508@qq.com

引用本文

弓辰,夏成德,何素霞,等. 基于温哥华瘢痕量表评分的强脉冲光联合二氧化碳点阵激光序贯治疗深度烧伤后早期增生性瘢痕的效果[J]. 中华整形外科杂志,2023,39(08)：823-829.DOI:10.3760/cma.j.cn114453-20230103-00001

【摘要】

目的探讨强脉冲光与二氧化碳点阵激光联合的序贯治疗深度烧伤后早期增生性瘢痕的效果。

方法采用回顾性队列研究，选择2019年5月至2021年1月郑州市第一人民医院收治的符合入选标准的深度烧伤后早期增生性瘢痕患者为研究对象。患者均在创面愈合后4~8周开始接受序贯治疗，根据每次治疗前温哥华瘢痕量表(VSS)评分选择治疗方式，若血管分布≥2分，厚度<2分，则给予强脉冲光治疗；若血管分布≥2分，厚度≥2分，则给予强脉冲光联合二氧化碳点阵激光治疗；若血管分布<2分，厚度≥2分，则给予二氧化碳点阵激光治疗；若血管分布<2分，厚度<2分，则治疗结束。强脉冲光治疗每个月1次，二氧化碳点阵激光治疗每3个月1次。患者治疗前、治疗结束后采用VSS、观察者瘢痕评估量表(OSAS)和患者瘢痕评估量表(PSAS)进行疗效评估，评分越高表明瘢痕越严重。记录患者治疗期间强脉冲光及二氧化碳点阵激光治疗次数，患者治疗结束时瘢痕形成时间及并发症发生情况。使用SPSS 22.0软件进行统计分析，计量资料数据采用x±s表示，采用配对样本t检验进行患者自身治疗前后的比较。

结果共纳入28例患者，男16例，女12例，年龄12~54岁。序贯治疗结束后患者VSS评分中色泽、厚度、血管分布、柔软度及总分均明显低于治疗前(t＝15.00、11.90、15.59、9.46、39.24，P均<0.001)；OSAS评分中血管分布、色泽、厚度、粗糙度、柔软度、表面积、总体评价及总分均明显低于治疗前(t＝14.89、10.82、9.54、7.23、16.97、8.60、16.42、25.08，P均<0.001)；PSAS评分中疼痛、瘙痒、颜色、硬度、厚度、不规则、总体评价及总分均明显低于治疗前(t＝26.40、24.53、16.54、12.18、12.25、21.04、22.00、29.38，P均<0.001)。患者治疗期间共进行强脉冲光治疗(4.00±1.22)次(2~6次)，二氧化碳点阵激光治疗(2.54±1.00)次(0~5次)，治疗结束时瘢痕形成时间为(13.82±2.98)个月(8~20个月)。治疗及随访过程中共发生并发症5例，包括皮肤水疱4例、感染1例，未出现即刻皮损、色素沉着、色素脱失、瘢痕加重等不良反应。

结论强脉冲光与二氧化碳点阵激光联合的序贯治疗可以明显改善深度烧伤后早期增生性瘢痕的外观及质地，减轻患者疼痛和瘙痒症状，安全性良好。

【关键词】瘢痕；烧伤；强脉冲光；二氧化碳激光；激光疗法

基金项目： 河南省医学科技攻关计划联合共建项目（LHGJ20210711）

Effect of intense pulsed light and carbon dioxide fractional laser sequential treatment of early hypertrophic scar after deep burn based on Vancouver scar scale

Gong Chen, Xia Chengde, He Suxia, Li Yonglin

Department of Burn Surgery, the First People’s Hospital of Zhengzhou, Zhengzhou 450000, China

Corresponding author: Xia Chengde, Email: 2273451508@qq.com

【Abstract】

Objective To explore the effects of intense pulsed light and carbon dioxide fractional laser sequential treatment of early hypertrophic scar after deep burn.

Methods A retrospective cohort study was used. The patients with early hypertrophic scar after deep burn who were admitted to the First People’s Hospital of Zhengzhou from May 2019 to January 2021 and met the inclusion criteria were selected as the study subjects. All patients began to receive sequential laser treatment 4-8 weeks after complete healing of wounds. The treatment method was selected according to the Vancouver scar scale (VSS) score before each treatment. If the blood vessel distribution ≥ 2 points and the thickness<2 points, they were treated with intense pulsed light. If the blood vessel distribution ≥2 points and the thickness ≥ 2 points, they were treated with intense pulsed light combined with carbon dioxide laser. If the blood vessel distribution <2 points and the thickness ≥ 2 points, they were treated with carbon dioxide laser. If the blood vessel distribution < 2 points and the thickness < 2 points, the treatment was ended. Intense pulsed light therapy was performed once a month, and carbon dioxide laser therapy was performed once every 3 months. Before and after treatment, patients were evaluated with VSS, observer scar assessment scale (OSAS) and patient scar assessment scale (PSAS), while higher scores indicated more severe scars. The number of intense pulsed light and carbon dioxide laser treatment during the treatment period, the time of scar formation and the occurrence of complications at the end of the treatment were recorded. SPSS 22.0 software was used for statistical analysis. Measurement data were expressed as Mean±SD, and paired sample t-test was used to compare patients before and after treatment.

Results A total of 28 patients were included, including 16 males and 12 females, aged 12-54 years. After the sequential treatment, the VSS scores of color, thickness, vascular distribution, softness and total score were significantly lower than those before the treatment (t=15.00, 11.90, 15.59, 9.46, 39.24, P<0.001); OSAS scores of vascular distribution, color, thickness, roughness, softness, surface area, overall evaluation and total score were significantly lower than those before treatment (t=14.89, 10.82, 9.54, 7.23, 16.97, 8.60, 16.42, 25.08, P<0.001); PSAS scores of pain, itching, color, hardness, thickness, irregularity, overall evaluation and total score were significantly lower than those before treatment (t=26.40, 24.53, 16.54, 12.18, 12.25, 21.04, 22.00, 29.38, P<0.001). During the treatment, the patients were treated with intense pulsed light for (4.00±1.22) times (2-6 times), carbon dioxide laser for (2.54±1.00) times (0-5 times). At the end of the treatment, the scar formation time was (13.82±2.98) months (8-20 months). Complications occurred in 5 cases during treatment and follow-up, including 4 cases of skin blisters and 1 case of infection. No immediate skin lesions, pigmentation, depigmentation, scar aggravation and other adverse reactions occurred.

Conclusion The combination of sequential therapy of intense pulsed light and carbon dioxide laser can significantly improve the appearance and texture of early hypertrophic scar after deep burn, which has good safety.

【Key words】Cicatrix; Burns; Intense pulsed light; Carbon dioxide laser; Laser therapy

Fund program: Scientific and Technological Research Projects in Henan Province (LHGJ20210711)

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 the First People’s Hospital of Zhengzhou (201905-01-1).

临床上深度烧伤后引起的增生性瘢痕非常常见，临床表现为充血明显、质地坚硬、高出皮肤表面，并伴有瘙痒感、疼痛感等不适，即便瘢痕成熟后仍可有色素和质地改变，更有甚者影响功能，容易给患者带来不同程度的外观影响以及功能障碍。因此，深度烧伤后增生性瘢痕的治疗一直是烧伤整形科临床工作的重点。近年来随着国内外多个指南及专家共识的发表[ 1 , 2 , 3 ]，烧伤后瘢痕早期行光电治疗的理念被越来越多的业内同行及患者所接受。根据烧伤后瘢痕的演变特点，即前期表现为瘢痕充血，后期表现为胶原沉积，光电设备和点阵激光的联合应用成为有效的治疗手段[ 4 , 5 , 6 ]。但两种方法联合治疗的模式、介入的时间仍存在争议，本研究根据每次治疗前患者温哥华瘢痕量表(Vancouver scar scale，VSS)[ 7 ]中血管分布及厚度的评分情况决定此次治疗是单一使用强脉冲光或二氧化碳点阵激光，亦或两者联合应用，并探讨此种序贯治疗模式的效果。

资料与方法

一、资料来源

采用回顾性队列研究，选择2019年5月至2021年1月就诊于郑州市第一人民医院的深度烧伤患者为研究对象。纳入标准：(1)深度烧伤创面未行手术治疗，愈合过程大于3周；(2)应用强脉冲光与二氧化碳点阵激光序贯治疗；(3)首次治疗时间为瘢痕形成后4~8周。排除标准：(1)妊娠、恶性肿瘤病史及放射治疗史；(2)研究期间瘢痕内药物注射史；(3)感染性或病毒性皮肤病；(4)免疫抑制药物史、长期全身应用皮质类固醇治疗史；(5)瘢痕疙瘩病史、家族史；(6)精神障碍病史。

本研究经郑州市第一人民医院伦理委员会批准[(2019)第05-01-1号]，所有患者治疗前均签署知情同意书。

二、治疗方法

治疗前与患者或家属充分沟通，告知治疗原理、过程及治疗后注意事项。每次治疗前先行VSS评分，若血管分布≥2分，厚度<2分，则给予强脉冲光治疗；若血管分布≥2分，厚度≥2分，则给予强脉冲光联合二氧化碳点阵激光治疗；若血管分布<2分，厚度≥2分，则给予二氧化碳点阵激光治疗；若血管分布<2分，厚度<2分，则治疗结束。

使用辉煌360激光光子工作站(以色列飞顿公司)在无麻醉下对红色瘢痕进行强脉冲光治疗，手具540 nm(波长540~1 200 nm)。患者治疗前均清洁术区后取合适体位，戴护目镜，外涂厚1~2 mm的专用冷凝胶，局部瘢痕做光斑测试，选择适当治疗参数(治疗终点反应为扩张的毛细血管颜色变浅)，然后以强脉冲光逐个光斑照射治疗。初始能量密度为15~18 J/cm2(根据瘢痕颜色、充血程度、耐受程度适当调整)，脉宽12或者15 ms，治疗能量密度每次递增或递减1~2 J/cm2。治疗结束后清洗皮肤，冷敷30 min，治疗后均要求患者防晒。每次治疗间隔1个月。

使用超脉冲二氧化碳点阵激光治疗仪(美国科医人医疗激光公司)进行点阵激光治疗，波长10 600 nm。对能够配合的患者采用表面麻醉，方法为瘢痕区涂抹复方利多卡因乳膏(每克含丙胺卡因25 mg与利多卡因25 mg，北京紫光制药有限公司)，保鲜膜包裹1 h；对无法配合表面麻醉的患者采用静脉麻醉。瘢痕区域以75%乙醇消毒后自然干燥，根据瘢痕厚度选择具体参数：瘢痕厚度<1 mm，应用Deep FX模式，能量密度为25~40 J/cm2，光斑密度5%；瘢痕厚度>1 mm，应用Scaar FX模式，能量密度60~120 J/cm2,光斑密度1%~3%；瘢痕厚度>4 mm,联合人工点阵模式，能量密度100 J/cm2，持续2~3 s。治疗后前3 d外用丙酸氟替卡松乳膏(湖北恒安芙林药业股份有限公司)，3 d后外用重组牛碱性成纤维细胞生长因子凝胶(珠海亿胜生物制药有限公司)，3~4 h涂抹1次，直至痂皮自然脱落。每次治疗间隔3个月。

所有患者治疗期间均同时使用压力治疗和外用硅酮类药物，直至治疗结束。

三、评估指标

患者治疗前、治疗结束后即刻拍照留档，并由2名医生采用VSS[ 7 ]和观察者瘢痕评估量表(observer scar assessment scale，OSAS)[ 8 ]进行评分，由患者本人进行患者瘢痕评估量表(patient scar assessment scale，PSAS)[ 8 ]评分。VSS项目包括瘢痕色泽(0~3分)、厚度(0~4分)、血管分布(0~3分)及柔软度(0~5分)，总分0~15分，评分越高表明瘢痕越严重。OSAS项目包括血管分布、色泽、厚度、粗糙度、柔软度、表面积及总体评价，每项1~10分，总分7~70分，评分越高表明瘢痕越严重。PSAS项目包括疼痛、瘙痒、颜色、硬度、厚度、不规则及总体评价，每项1~10分，总分7~70分，评分越高表明瘢痕越严重。记录患者治疗期间强脉冲光及二氧化碳点阵激光治疗次数、患者治疗结束时瘢痕形成时间及并发症情况。

四、统计学处理

所有数据使用SPSS 22.0软件进行统计分析。计量资料均符合正态分布，以x±s表示，自身前后对照行配对样本t检验。P<0.05为差异有统计学意义。

结果

一、瘢痕评估

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