白癜风治疗共识(2009版)
vitiligo surger 白癜风手术治疗指南
RecommendationsStandard guidelines of care for vitiligo surgeryDavinder Parsad, Somesh Gupta #Members, IADVL Dermatosurgery Task Force*, Department of Dermatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India, #Department of Dermatology & Venereology, All India Institute of Medical Sciences, New Delhi, IndiaAddress for correspondence:Address for correspondence: Dr Davinder Parsad, Department of Dermatology, Postgraduate Institute of Medical Education & Research, Chandigarh. Email: dprs@.inABSTRACTVitiligo surgery is an effective method of treatment for selected, resistant vitiligo patches in patients with vitiligo. Physician’s quali fi cations: The physician performing vitiligo surgery should have completed postgraduate training in dermatology which included training in vitiligo surgery. If the center for postgraduation does not provide education and training in cutaneous surgery, the training may be obtained at the surgical table (hands-on) under the supervision of an appropriately trained and experienced dermatosurgeon at a center that routinely performs the procedure. Training may also be obtained in dedicated workshops. In addition to the surgical techniques, training should include local anesthesia and emergency resuscitation and care. Facility: Vitiligo surgery can be performed safely in an outpatient day care dermatosurgical facility. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place, with which all nursing staff should be familiar. Vitiligo grafting for extensive areas may need general anesthesia and full operation theater facility in a hospital setting and the presence of an anesthetist is recommended in such cases. Indications for vitiligo surgery : Surgery is indicated for stable vitiligo that does not respond to medical treatment. While there is no consensus on de fi nitive parameters for stability, the Task Force suggests the absence of progression of disease for the past one year as a de fi nition of stability. Test grafting may be performed in doubtful cases to detect stability. Preoperative counseling and Informed consent: A detailed consent form elaborating the procedure and possible complications should be signed by the patient. The patient should be informed of the nature of the disease and that the determination of stability is only a vague guide. The consent form should speci fi cally state the limitations of the procedure, about the possible future progression of disease and whether more procedures will be needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures and one-to-one discussions. The need for concomitant medical therapy should be emphasized and the patient should understand that proper results take time (a few months to a year). Preoperative laboratory studies include hemogram including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time), and blood chemistry pro fi le. Screening for antibodies for hepatitis B surface antigen and HIV is recommended depending on individual requirements. Anesthesia: Lignocaine (2%) with or without adrenaline is generally used for anesthesia; in fi ltration and nerve block anesthesia are adequate in most cases. General anesthesia may be needed in patients with extensive lesions. Postoperative care: Proper postoperative immobilization and care are very important to obtain satisfactory results.Key Words: Vitiligo, Skin grafting, Punch grafting, Suction blister graftingHow to cite this article: Prasad D, Gupta S. Standard guidelines of care for vitiligo surgery. Indian J Dermatol Venereol Leprol 2008;74:S37-S45.Received: August, 2007. Accepted: May, 2008. Source of Support: Nil. Con fl ict of Interest: Nil.The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Dermatosurgery Task Force consisted of the following members: Dr. Venkataram Mysore (co-ordinator), Dr. Satish Savant, Dr. Niti Khunger, Dr. Narendra Patwardhan, Dr. Davinder Prasad, Dr. Rajesh Buddhadev, Lt. Col. Dr. Manas Chatterjee, Dr. Somesh Gupta, Dr. MK Shetty, Dr. Krupashankar DS, Dr. KHS Rao, Dr. Maya Vedamurthy, Ex of fi -cio members: Dr. Chetan Oberai, President IADVL (2007-2008), Dr. Koushik Lahiri, Secretary IADVL, Dr. Sachidanand S, President IADVL (2008-2009), and Dr. Suresh Joshipura, Immediate Past president IADVL (2007-2008).Evidence - Level A- Strong research-based evidence- Multiple relevant, high-quality scienti fi c studies with homogeneous results, Level B- Moderate research-based evidence- At least one relevant, high-quality study or multiple adequate studies, Level C- Limited research-based evidence- At least one adequate scienti fi c study, Level D- No research-based evidence- Based on expert panel evaluation of other informationFor Disclaimers and Disclosures, please refer to the table of contents page (page 1) of this supplement. The printing of this document was funded by the IADVL.INTRODUCTIONVitiligo is a common acquired depigmentation disorder of great cosmetic importance. The basic pathogenesis of vitiligo or for any of the putative subsets of vitiligo, still remains unknown. The medical treatment of vitiligo is dependent upon the presence of a melanocyte reservoir and is effective in only 60-70% of the patients. Certain types of vitiligo do not respond well to medical treatment and resistant lesions do persist even in those who respond. In light of these limitations of medical treatment, surgical treatment of vitiligo was first proposed in the 1960s. Over the years, the concept of surgical treatment has been expanded to include surgical “biotherapies” such as autologous, cultured melanocyte transplantation. The disease has a major impact on the quality of life of patients, particularly the Indian population, in which there is a severe stigma attached to the disease, affecting the social and psychological aspects of the patients. Due to these effects, there is a considerable need for active treatment of this disease, in contrast to fair-skinned patients in whom the disease is less apparent.RATIONALE AND SCOPEAs such, there are no uniformly acceptable measurement tools and indices for measurement of the efficacy of outcomes of the surgical modalities of vitiligo treatment. Assessment of quality of life and global assessment should be performed because the percentage of regimentation may not always be a good indicator of patient satisfaction. There is an urgent need for universally acceptable, objective, reproducible and easy-to-use measurements to evaluate the efficacy of surgical vitiligo studies. These guidelines provide minimal standards of care for various surgical methods of treatment of vitiligo, with a brief description of the procedures as well as their advantages and disadvantages.PHYSICIAN’S QUALIFICATIONSThe physician performing vitiligo surgery should have completed postgraduate training in dermatology; he/she should also have had adequate training in vitiligo surgery during postgraduation. Alternatively, training in vitiligo surgery may be obtained on the surgical table (hands-on) under the supervision of an appropriately trained and experienced dermatological surgeon. The training may also be obtained in dedicated workshops. In addition to the surgical technique, training should include techniques in local anesthesia and emergency resuscitation and care.FACILITYVitiligo surgery can be performed safely in an outpatient day care dermatosurgical facility under local anesthesia. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place with which all nursing staff should be familiar. Transplantation for extensive areas of vitiligo may need general anesthesia and in such cases, an operation theater facility in a hospital setting and the presence of an anesthetist are recommended. INDICATIONS FOR SURGERY AND PATIENT SELECTIONSurgery is indicated for all types of stable vitiligo including segmental, generalized and acrofacial types that do not respond to medical treatment. While there is no consensus on definitive parameters for stability, various recommendations suggest a period of disease inactivity ranging from six months to two years. The task force agrees on a year of disease inactivity as the cut-off period for defining stability (Level D). Test grafting may be performed in doubtful cases to detect stability. The choice of surgical intervention should be individualized according to the type of vitiligo, stability, localization of lesions and cost-effectiveness of the procedure. Patient counseling about the nature of the disease and about the fact that the determination of stability is only a rough guide is essential.EXPLANATION FOR STABILITYThe outcome of surgery is good in stable lesions whereas unstable lesions respond poorly. Thus, the stability status of vitiligo is the single, most important prerequisite in case selection. However, despite many studies, there is no consensus regarding the minimum required period of stability. The recommended period of stability in different studies has varied from four months to three years. Most authors have suggested that vitiligo can be classified as being stable when there is no progression of old lesions and/or development of new lesions during the past one year. A set of objective criteria-the Vitiligo disease activity score (VIDA), was suggested by Njoo et al.[7] in 1999 to follow the progress of the patient. It is a 6-point scale on which the activity of the disease is evaluated by the appearance of new vitiligo lesions or the enlargement of preexisting lesions gauged during a period ranging from < 6 weeks to one year [Table 1]. The task force recommends that surgeryParsad and Gupta: Guidelines of care for vitiligo surgeryfor vitiligo should be performed only in patients with VIDA scores of -1 or 0 (Level D).EVIDENCEDas SS, Pasricha JS. Punch grafting as a treatment of 1.residual lesions of vitiligo. Indian J Dermatol Venereol Leprol 1992;58:315-9.Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligo 2.vulgaris by autologous minigrafting: Results in nineteen patients. J Am Acad Dermatol 1995;33:990-5.Falabella R. Repigmentation of segmental vitiligo by 3.autologous minigrafting. J Am Acad Dermatol 1983;9:514-21.Falabella R. Grafting and transplantation of melanocytes for 4.repigmenting vitiligo and other types of leukoderma. Int J Dermatol 1989;28:363-9.Falabella R. Surgical treatment of vitiligo: Why, when and 5.how. J Eur Acad Dermatol Venereol 2003;17:518-20.Savant SS. Autologous miniature punch grafting in vitiligo.6.Indian J Dermatol Venereol Leprol 1992;58:310-4.Njoo MD, Das PK, Bos JD, Westerhof W. Association of the 7.Kobner phenomenon with disease activity and therapeutic responsiveness in vitiligo vulgaris. Arch Dermatol 1999;135:407-13.Falabella R. Surgical therapies for vitiligo and other 8.leukodermas, part 1: Minigrafting and suction epidermal grafting. Dermatol Ther 2001;14:7-14.In contrast, other authors have questioned the concept of stability and stated that existing parameters are arbitrary. EVIDENCE1. Malakar S, Dhar S. Treatment of stable and recalcitrant vitiligoby autologous miniature punch grafting: A prospective study of 1,000 patients. Dermatology 1999;198:133-9.2. Malakar S, Lahiri K. How unstable is the concept of stabilityin surgical repigmentation of vitiligo? Dermatology 2000;201:182-3.Considering the variety of opinions, it is preferable to take multiple factors during patient selection for vitiligo surgery into account.PARAMETERS FOR ESTABLISHING STABILITYOF VITILIGO1. History of progression: Absence of new lesions2. Extension of old lesions: No extension of old lesions3. Koebner phenomenon: Absence of Koebnerphenomenon either based on history or by checkingfor experimentally induced vitiligo4. Mini-grafting test or test-grafting: The original testwas proposed by Falabella et al.[1] to select patientswith stable vitiligo who may respond to melanocytetransplantation. The test was considered positive ifunequivocal repigmentation took place beyond 1mm from the border of the implanted graft over aperiod of three months. Although this test has beenconsidered as a gold standard for establishing thestability and success of repigmentation, doubts havebeen expressed over its utility. It has been seen thateven when the minigraft test is positive, the diseaseitself may be unstable.EVIDENCE1. Falabella R, Arrunategui A, Barona MI, Alzate A. Theminigrafting test for vitiligo: Detection of stable lesions formelanocyte transplantation. J Am Acad Dermatol 1995;32:228-32.CONSENSUS RECOMMENDATION OF THE TASKFORCE ON STABILITYThe available evidence is insufficient to recommend a single cut-off period to assess stability. To facilitate consensus on this issue, the task force attempts to provide a clear definition of stability-a patient reporting no new lesions, no progression of existing lesions, and absence of Koebner phenomenon during the past one year. Spontaneous repigmentation should be considered as a favorable sign for the transplantation procedure. A test graft may be considered whenever there is a doubt about the stability, or the patient is unable to give a clear history on stability. It needs to be stressed here that the treating physician should always consider each patient individually and exercise his/ her judgment (LEVEL D).2. The age of the patient for vitiligo surgery: As such, no uniformly accepted opinion exists concerning the minimum age for surgery. Vitiligo surgery is generally performed under local anesthesia, which would be difficultin children. General anesthesia for vitiligo surgery in aTable 1: VIDA 6-point scoreDisease activity VIDA scoreActive in past 6 weeks +4Active in past 3 months +3Active in past 6 months +2Active in past 1 year +1Stable for at least 1 year 0Stable for at least 1 year andspontaneous repigmentation -1Parsad and Gupta: Guidelines of care for vitiligo surgeryyoung child poses unacceptable risks and the progress of the disease is difficult to predict in children. Hence, many dermatologists feel that surgical procedures should not be performed in children. However, studies have suggested that results of transplantation procedures were better in younger individuals than in older ones. Thus, no consensus exists in this aspect and physicians should exercise their judgment after taking all aspects of the individual patient into consideration. (LEVEL C)EVIDENCE1. Gupta S, Kumar B. Epidermal grafting in vitiligo: Influence ofage, site of lesion, and type of disease on outcome. J Am Acad Dermatol 2003;49:99-104.2. Gupta S, Kumar B. Epidermal grafting for vitiligo in adolescents.Pediatr Dermatol 2002;19:159-62. PREOPERATIVE COUNSELING AND INFORMED CONSENTProper counseling is essential; the nature of the disease, procedure, expected outcome and possible complications should be clearly explained to the patient. The need for concomitant medical therapy should be emphasized. Patients should understand that proper results may take time to appear (few months to one year). The patient should be provided with adequate opportunity to seek information through brochures, computer presentations, and one-to-one discussions.A detailed consent form (see appendix 1) describing the procedure and possible complications should be signed by the patient. The consent form should specifically state the limitations of the procedure, possible future disease progression and whether more procedures will be needed for optimal outcome.ANESTHESIAThe recipient site is locally anesthetized by infiltration of 2% xylocaine, the pain of which can be reduced by prior application of EMLA® cream applied under occlusion for 1-2 hours. Adrenaline should not be used on the recipient site as it makes the judgment of adequacy of the denudation to the required depth difficult. Tumescent anesthesia and nerve blocks may be used in larger areas. If grafting is planned for extensive areas, general anesthesia may be needed in a hospital setting. (LEVEL D)METHODS OF SURGICAL MODALITIESMethods of surgical modalities for vitiligo include both tissue grafts and cellular grafts.TISSUE GRAFTS1. Punch grafting: In this procedure, punch grafts (of1.2-2.0 mm diameter) are taken from donor areasover the thighs, buttocks, postauricular areas/posterior earlobe or the medial aspect of the upperarm. These are grafted into recipient sites in stablevitiligo lesions, which are created by using punches1-2 mm in diameter. To ensure a better fit, recipientpunches are generally smaller by 0.5 mm than donorpunches. Smaller sized grafts may be used to yieldbetter cosmetic results.Sockets are created in the recipient area at a distance of5-10 mm and the harvested grafts are placed in thesesockets. This allows the perigraft spread of pigment tocover the surrounding depigmented skin, the extent ofwhich varies according to the skin color and site of thetreated patch (more on exposed sites). (LEVEL B)EVIDENCE1. Savant SS. Miniature punch grafting. In: Savant SS, editor.Association of scientific cosmetologists and dermatosurgeons textbook of dermatosurgery and cosmetology. 2nd ed.Mumbai: ASCAD; 2005. p. 359-69.2. Babu A, Thappa DM, Jaisankar TJ. Punch grafting versussuction blister epidermal grafting in the treatment of stable lip vitiligo. Dermatol Surg 2008;34:166-78.3. Das SS, Pasricha JS. Punch grafting as a treatment of residual lesionsof vitiligo. Indian J Dermatol Venereol Leprol 1992;58:315-9.4. Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligovulgaris by autologous minigrafting: Results in nineteen patients. J Am Acad Dermatol 1995;33:990-5.5. Falabella R. Repigmentation of segmental vitiligo byautologous minigrafting. J Am Acad Dermatol 1983;9:514-21.Dressings are postoperatively placed to ensure immobili- zation, and may be removed in 24 hours to check for the displacement of the grafts. Grafts are taken up in 7-10 days after which phototherapy or treatment with topical steroid is started to ensure even spread of perigraft pigment.EVIDENCE1. Barman KD, Khaitan BK, Verma KK. A comparative study ofpunch grafting followed by topical corticosteroid versusParsad and Gupta: Guidelines of care for vitiligo surgerypunch grafting followed by PUVA therapy in stable vitiligo.Dermatol Surg 2004;30:49-53.2. Lahiri K, Malakar S, Sarma N, Banerjee U. Inducingrepigmentation by regrafting and phototherapy (311 nm) in punch grafting failure cases of lip vitiligo: a pilot study. Indian J Dermatol Venereol Leprol 2004;70:156-8.Advantages: This is the easiest and least expensive method and may be used satisfactorily in all areas other than the nipples and the angle of the mouth, where involuntary muscle contraction may interfere with graft uptake. It is even suitable for ‘difficult-to-treat’ locations such as the fingers, toes, palms and soles, etc.Disadvantages and complications: This method is not suitable for large lesions as uniform pigmentation may not always be achieved. Other important complications include cobblestoning and a polka dot appearance.2. Suction blister epidermal grafting: This procedureconsists of obtaining very thin skin grafts consistingof only the epidermis. A physiological split is madeat the dermoepidermal junction by the applicationof prolonged suction at a negative pressure of -200to -500 mm of Hg to the donor site. The recipientsite is dermabraded by using either a manual or amotorized dermabrader, depending on the size and site of the lesion. Thin grafts are applied to the dermabraded recipient site. Alternatively, the recipient site may be denuded by an Erbium:YAGor carbon dioxide (CO2) Laser. Equipment neededincludes specially altered disposable syringes, suctioncups or glass funnels, suction apparatus and manual/motorized dermabraders. The graft may fall off in aperiod of a week to ten days. (LEVEL B)Advantages: It yields excellent cosmetic results as the graft is very thin. One of the major advantages of this procedure is that chances of scarring at the donor or recipient sites are minimal as the graft is purely epidermal.Disadvantages: The major disadvantage of this procedure is that it is time-consuming as donor site blistering requires a few hours. Large areas can not be treated by this method. EVIDENCE1. Falabella R. Surgical therapies for vitiligo and otherleukodermas, part 1: Minigrafting and suction epidermal grafting. Dermatol Ther 2001;14:7-14.2. Hasegawa T, Suga Y, Ikejima A, Muramatsu S, Mizuno Y,Tsuchihashi H, et al. Suction blister grafting with CO(2) Laserresurfacing of the graft recipient site for vitiligo. J Dermatol 2007;34:490-2.3. Pai GS, Vinod V, Joshi A. Efficacy of erbium: YAG Laser-assistedautologous epidermal grafting in vitiligo. J Eur Acad Dermatol Venereol 2002;16:604-6.3. Split-thickness grafting: Split-thickness skin graftinginvolves the free transfer of the epidermis along witha portion of the dermis from one site to another.The procedure is carried out under local anesthesia(for localized lesions) or general anesthesia (for extensive lesions). It consists of obtaining very thin, split thickness skin grafts, consisting of the epidermis and a part of the upper papillary dermis,and grafting them on the denuded (dermabraded or Laser-abraded) recipient site. The grafts are further secured with pressure and immobilization.Motorized dermatomes such as Padgett’s or Zimmer’sdermatomes, may be used to obtain ultra-thin, split-thickness grafts, which may give cosmetically superior results compared to those with manual dermatomes (Level B).Instruments include dermabraders, skin-grafting knives such as the Humby’s knife or any of its modifications, as well as other surgical instruments. Large areas can be grafted in a single sitting.Advantages: This method has the advantage of treating a relatively large area in a short period of time.Disadvantages: Taking split-thickness grafts of uniform thickness requires skill and experience. Other disadvantages include ‘stuck-on’ or ‘tire patch’ appearance, curling of the border with beaded appearance, color mismatch, milia, perigraft halo of depigmentation, and donor site scarring.EVIDENCE1. Achauer BM, Le Y, Vander Kam VM. Treatment of vitiligo withmelanocytic grafting.Ann Plast Surg 1994;33:644-6.2. Kahn AM, Cohen MJ. Repigmentation in vitiligo patients.Melanocyte transfer via ultra-thin grafts.Dermatol Surg 1998;24:365-7.3. Oz d emir M, Cetinkale O, Wolf R, Kotoğyan A, Mat C, Tüzün B,Tüzün Y. Comparison of two surgical approaches for treating vitiligo: a preliminary study. Int J Dermatol. 2002;41:135-8. 4. Agrawal K, Agrawal A. Vitiligo: repigmentation withdermabrasion and thin split-thickness skin graft. Dermatol Surg 1995;21:295-300.4. Other tissue grafting procedures: Several othermethods of tissue grafting have been performed Parsad and Gupta: Guidelines of care for vitiligo surgeryby different authors. These methods or their modifications may be used by the treating physiciandepending on individual expertise and experience.Hair follicle-grafting has been performed by a fewauthors for treating small patches in hair bearingareas and has been found useful in treating lesionswith leukotrichia. A small strip of hair-bearing scalpis taken from the occipital area; single hairs areseparated and transplanted into vitiligo patches 5-10mm apart. (LEVEL C)EVIDENCE1. Na GY, Seo SK, Choi SK. Single hair grafting for the treatmentof vitiligo. J Am Acad Dermatol 1998;38:580-4.2. Agrawal K, Agrawal A. Vitiligo: Surgical repigmentation ofleucotrichia. Dermatol Surg 1995;21:711-5.3. Laxmisha C, Kumari R, Thappa DM. Surgical repigmentationof leukotrichia in localized vitiligo. Dermatol Surg 2006;32:981-2.4. Malakar S, Dhar S. Repigmentation of vitiligo patchesby transplantation of hair follicles. Int J Dermatol 1999;38:237-8.In flip-top grafting, superficial, thinly shaved biopsies that are 2-4 mm in size, are taken using a razor blade, which are then sectioned into smaller 1-2 mm grafts. A 5-mm flap of epidermis with minimal dermis is raised with a razor blade at the recipient site, and the grafts are placed under this flap. The major advantage of this procedure is that there is rapid healing and no cobblestoning. (LEVEL C) EVIDENCE1. McGovern TW, Bolognia J, Leffell DJ. Flip-top pigmenttransplantation: A novel transplantation procedure for the treatment of depigmentation. Arch Dermatol 1999;135:1305-7.CELLULAR GRAFTSThese methods represent important recent advances and need specialized training and appropriate equipments. The following cellular grafting techniques have been advocated in the surgical management of vitiligo:1. Autologous, noncultured epidermal cell suspension2. Autologous, cultured melanocyte transplantation3. Autologous, cultured epithelial grafts1) Transplantation of autologous, epidermal cellsuspension (noncultured melanocyte grafting): Inthis procedure, a shave biopsy sample is taken witha dermatome. The skin sample is immersed in atrypsin solution, the epidermis separated from the dermis, and after some additional steps, a cellular suspension of keratinocytes and melanocytes is obtained, which is transplanted on the denuded recipient site. (LEVEL B)Advantages: In comparison with other surgical methods, the basal layer suspension method has the advantage that a fairly large area can be treated with the donor-to-recipient expansion ratio ranging from 5-10 fold. (LEVEL B)Disadvantages: Taking split-thickness grafts requires skill and experience. This technique requires a properly equipped laboratory and trained personnel.EVIDENCE1. Olsson MJ, Juhlin L. Long-term follow-up of leucodermapatients treated with transplants of autologous cultured melanocytes, ultrathin epidermal sheets and basal cell layer suspension.Br J Dermatol 2002;147:893-904.2. van Geel N, Ongenae K, De Mil M, Haeghen YV, Vervaet C,Naeyaert JM. Double-blind placebo-controlled study of autologous transplanted epidermal cell suspensions for repigmenting vitiligo.Arch Dermatol 2004;140:1203-8.3. Mulekar SV. Melanocyte-keratinocyte cell transplantation forstable vitiligo.Int J Dermatol 2003;42:132-6.4. Olsson MJ, Juhlin L. Leucoderma treated by transplantationof a basal cell layer enriched suspension.Br J Dermatol 1998;138:644-8.2) Transplantation of cultured autologous melanocytes:Melanocytes are cultured in vitro for 15-30 days bythe addition of media and growth factors. Once sufficient numbers are present, melanocytes are detached from the culture plates and suspension istransplanted onto the denuded recipient area in a density of 1000-2000 melanocytes/mm2. The recipientarea can be denuded by dermabrasion, CO2,or an Erbium:YAG Laser. (LEVEL B)Advantages:The major advantage is that the procedure can treat unlimited areas; however, it is recommended that vitiligo involving > 30% of the body surface area should not be treated surgically as chances of success are minimal in such cases. (LEVEL D)Disadvantages: There have been some safety concerns about the use of cultured autografts in vitiligo. 12-tetradecanoylphorbol 13-acetate (TPA) used in the culture medium is a tumor promoter, making its long-term safety aParsad and Gupta: Guidelines of care for vitiligo surgery。
中国白癜风诊疗共识(2014版)
白癜风诊疗共识（2014版）中国中西医结合学会皮肤性病专业委员会色素病学组本指南以中国中西医结合学会皮肤性病专业委员会色素病学组制订的白癜风治疗共识(2009版)为基础，经色素病学组、中华医学会皮肤科分会白癜风研究中心部分专家及国内相关专家讨论制定。
参加起草及讨论的成员(按姓氏汉语拼音排序)：傅雯雯、高天文、何黎、贾虹、李恒进、李铁男、李珊山、卢忠、鲁严、李春英、李强、刘清、马东来、乔树芳、秦万章、宋智琦、孙越、宋秀祖、涂彩霞、温海、王玮蓁、许爱娥、项蕾红、张学军、张建中、郑志忠、赵广、朱光斗。
白癜风治疗目的是控制皮损发展，促进白斑复色。
一、选择治疗方法时主要考虑因素：1．病期：分进展期和稳定期。
进展期判定参考白癜风疾病活动度评分(VIDA)积分、同形反应、Wood灯。
①VIDA积分：近6周内出现新皮损或原皮损扩大(+4分)，近3个月出现新皮损或原皮损扩大(+3分)，近6个月出现新皮损或原皮损扩大(+2分)；近1年出现新皮损或原皮损扩大(+1分)；至少稳定1年(0分)；至少稳定1年且有自发色素再生(-1分)。
总分＞1分即为进展期，≥4分为快速进展期；②同形反应：皮肤损伤1年内局部出现白斑。
损伤包括物理性(创伤、切割伤、抓伤)、机械性摩擦、化学性/热灼伤、过敏性(接触性皮炎)或刺激性反应(接种疫苗、纹身等)、慢性压力、炎症性皮肤病、治疗性(放射治疗、光疗)。
白斑发生于持续的压力或摩擦部位，或者是衣物，饰品的慢性摩擦部位，形状特殊，明显由损伤诱发；③Wood灯：皮损颜色呈灰白色，边界欠清，wood灯下皮损面积大于目测面积，提示是进展期。
皮损颜色是白色，边界清，wood灯下皮损面积≤目测面积，提示是稳定期。
以上3条符合任何一条即可考虑病情进展；④可同时参考激光共聚焦扫描显微镜(简称皮肤CT)和皮肤镜的图像改变，辅以诊断。
2．白斑面积(手掌面积约为体表面积1％)：1级为轻度，＜l％；2级为中度，l％～5％；3级为中重度，6％～50％；4级为重度，＞50％。
白癜风诊疗专家共识
患者应积极配合医生的治疗方案，按时服药、定期复诊。同时，注意 个人卫生和环境卫生，避免感染等诱发因素。
总结：提高白癜风诊疗水平， 06 改善患者生活质量
加强专业培训和学术交流活动组织
定期组织பைடு நூலகம்业培训课程
针对皮肤科医生、全科医生等开展白癜风诊疗技术培训课程，提 高其诊断和治疗水平。
避免药物相互作用
注意药物间的相互作用，避免使用可能加重白癜 风或其他皮肤问题的药物。
加强皮肤护理
加强皮肤护理，保持皮肤清洁干燥，避免感染等 并发症的发生。
05 并发症预防与处理措施
心理干预和辅导工作部署
建立心理支持体系
为患者提供心理咨询服务，帮助患者调整心态，增强治疗信心。
开展心理健康教育
向患者普及白癜风相关知识，提高患者对疾病的认知水平，减少恐 慌和焦虑情绪。
04 特殊人群白癜风处理建议
儿童青少年患者管理策略
心理干预
关注儿童青少年心理健康 ，提供心理支持和辅导， 减轻因白癜风造成的心理 压力。
个体化治疗方案
根据患儿年龄、病情严重 程度及部位，制定个体化 治疗方案，避免过度治疗 。
定期随访
定期监测病情变化，及时 调整治疗方案，确保治疗 效果。
妊娠期女性患者处理措施
3
辅助治疗提高疗效
在抗感染治疗的同时，可以采取一些辅助治疗措 施，如局部清洁、消毒等，以提高治疗效果。
避免诱发因素，降低复发率
避免过度暴晒和外伤
紫外线过度照射和外伤是白癜风的常见诱发因素之一，患者应避免 长时间暴露在强烈阳光下或受到外伤。
保持健康生活方式
良好的生活习惯和饮食习惯有助于降低复发率。患者应保持充足的 睡眠，均衡饮食，适当锻炼以增强免疫力。
白癜风治疗方案
白癜风治疗方案第1篇白癜风治疗方案一、背景概述白癜风，又称白驳风，是一种常见的后天性局限性或泛发性皮肤色素脱失病，表现为皮肤白斑。
本病对患者生活质量造成较大影响，需采取综合措施进行治疗。
本方案旨在为白癜风患者提供一套合法合规的治疗方案，以期达到缓解症状、提高生活质量的目的。
二、治疗原则1. 综合治疗：结合病情、病因、患者个体差异，采用多种治疗方法，提高治疗效果。
2. 个体化治疗：针对患者年龄、性别、病程、病情、生活习惯等因素，制定个性化的治疗方案。
3. 安全性原则：在确保治疗效果的同时，充分考虑治疗方法的毒副作用，确保患者安全。
4. 长期治疗：白癜风治疗周期较长，患者需保持良好的治疗依从性，坚持长期治疗。
三、治疗方案1. 药物治疗：（1）外用药物治疗：选用具有脱色、抗炎、免疫调节等作用的药物，如他克莫司软膏、曲安奈德乳膏等。
（2）口服药物治疗：根据患者病情，选用具有免疫调节、抗氧化、补充微量元素等作用的药物，如硫酸锌、叶酸、维生素E等。
（3）中药治疗：根据中医辨证，选用具有养血润燥、活血化瘀、疏肝理气等作用的中药，如当归、丹参、白芍、枸杞子等。
2. 物理治疗：（1）光疗：采用窄谱中波紫外线（NB-UVB）照射，每周2-3次，连续照射3-6个月。
（2）激光治疗：如点阵激光、308准分子激光等，每月1-2次，连续治疗3-6个月。
3. 心理干预：针对患者心理压力，给予心理支持，帮助患者建立信心，提高治疗依从性。
4. 生活方式调整：（1）合理饮食：建议患者多食用富含黑色素、微量元素的食物，如黑芝麻、核桃、动物肝脏等。
（2）避免暴晒：外出时采取防晒措施，避免紫外线损伤。
（3）保持良好的作息时间，避免过度劳累。
四、疗效评估1. 疗效评估指标：以白斑面积、颜色、皮肤生理功能等为主要评估指标。
2. 疗效评估时间：治疗结束后1个月、3个月、6个月进行疗效评估。
五、注意事项1. 治疗期间，患者需密切配合医生，按时按量用药，遵循医嘱。
白癜风基本知识
一、白癜风百科名片也许你经常能听到白癜风这个名词，知道它是皮肤疾病的一种，然而你对它有真正的了解么?白癜风是一种常见多发的色素性皮肤病。
该病以局部或泛发性色素脱失形成白斑为特征，是一种获得性局限性或泛发性皮肤色素脱失症，是一影响美容的常见皮肤病，易诊断，治疗难。
中医医学称之为“白癜风”或“白驳风”，其实，白癜风就是白斑，但是白斑不一定就是白癜风，白癜风初期时白斑的脱色程度轻，而且与周围正常皮肤的分界模糊不清，这种情况如发生在皮肤较白的人身上，常难及时做处诊断，细观察一下白斑表面是否光滑无皮屑，白斑呈淡白色或乳白色，如果边界模糊不清或朝正常皮肤扩散的话，有可能是白癜风。
在我国古代经常发生。
1、白癜风由来2、白癜风概述3、白癜风分类4、黑色素影响5、白癜风自查6、白癜风症状7、白癜风预防白癜风治疗共识1、【白癜风的由来】白癜风(vitiligo)一词来源于拉丁语vitium,意“缺损”，或vi-tellus,指“小牛白色斑片”。
公元一世纪，罗马医生Celsus 所写DeMedicina 中，可见vitiligo 一词。
V itilig o 在许多古籍中常常出现。
印度文献中，kilas(kil 指白色，as 意抛弃)和palita(pal 含灰色、年老、老年之意)可追溯到公元前1500~1000 年，指的是皮肤上的白色斑片。
佛教圣书Vinay Pitak(624~544B.C.)中记载，患kilas 的人不能做牧师。
印度Manus mriti(200 B.C.)中记载，患svitra(白斑)不受尊重。
《古兰经》中baras 一词意指白色皮肤，常用来描述Jesus 治愈后的状况。
中医称白癜风为“白癜”、“白驳风”等。
中医认为，肺主气，主白色。
白斑是由于气血不足，使皮肤不得营养而变白。
白癜风(vitiligo)是一种常见多发的色素性皮肤病。
该病以局部或泛发性色素脱失形成白斑为特征，是一种获得性局限性或泛发性皮肤色素脱失症，是一影响美容的常见皮肤病，易诊断，难治疗。
白癜风治疗共识的解析
２、儿童白癜风使用激素、光疗及光化学疗法应慎重。 ３、对多种治疗无效，白斑面积＞８０％的患者，可推荐脱色治疗。
五、中医中药治则：补益肝肾、活血祛风、疏肝解郁
进展期病程短的，以调和气血、疏风散湿为主；病程长而发病年龄较轻的以疏肝解郁、活血祛 风为主；病程长而发病年龄较晚者以滋补肝肾，疏肝活血为主。
４、治疗敏感患者可以接受最长疗程为２４个月的窄波ＵⅦ治疗。经过第一阶段的１年治疗
・１３‘
专题讲座 以后，建议休息３个月再继续治疗。
５、节段型、稳定期和口唇部白癜风患者的首选治疗方法为自体表皮移植。
６、皮损面积较大的患者（＞８０％）和／或毁容性的面部皮损患者，并且对治疗药物治疗无反应 者，可以考虑脱色疗法，脱去残留的色素。对这些患者应当建议尽量避免阳光照射并且使用宽谱
・
１ ２，
专题讲座
治疗疗效显著。ＮＢ—Ｕ娜合并叶酸，ｖｉｔＢｌ２治疗，与单独用窄谱ＵＶＢ治疗相比，疗效没有显著
增加。 ７、维生素Ｄ衍生物（钙泊三醇等）
钙泊三醇与紫外线联合治疗，对儿童和成人白癜风都有较好疗效。但也有报道钙泊三醇对白
癜风疗效甚微。 ８、免疫调节剂
他克莫司软膏，治疗白癜风同样是安全有效的，复色效果最好的部位是面部和颈部。优点是 可以长期应用而没有皮肤萎缩等激素样副作用。但他克莫司治疗白癜风的远期效果尚未得到证
二、治疗措施选择应考虑的主要因素：
１．白斑累及的面积 ２．病期：疾病的活动进展部位 ３．患者的年龄 三、白癜风的分） ２期：中度（１０％－－２５％） ３期：中重度（２５％－－５０％） ４期：重度（＞５０％） ２．按疾病活动进展分为４期 静止期、缓慢进展期、中度进展期、快速进展期 ３．按患者年龄分为成人和儿童白癜风 四、治疗原则 １期：轻度局限静止 局部用皮质激素、局部光化学疗法（拟过氧化氢酶／ＵＶＢ，ＰＵＶＡ，钙泊三醇／ＰＵＶＡ）、局部 ３０８ｎｍ光疗、维生素Ｄ衍生物、局部用免疫调节剂、局部用黑素生成素，前列腺素Ｅ２，煤焦油制剂。 ２期：中度
白癜风治疗共识草案
!"#$ % &’()*+, -’$’(,. /$+’0 1(*2 3 4’2 56678 -,.9: ;,9<
这提示了女贞子治疗白癜风有效的机制与促进
GHI#+ 表达有关。
参考文献：
［ =］ ;,((#E J8 1,22 !8 K(*"*) J8 !" #$% 1"’ ’LM(’EE#,$ ,N +"’ GOI#+ (’O
・ ・ =75 酶，其表达和活性决定着黑素合成的速度和产量。 本实验中女贞子处理组的黑素含量增加 =7> ， 酪氨 酸酶基因表达增加 =?977> ， 这提示女贞子提取物对 黑素合成和酪氨酸酶表达有促进作用。此外女贞子 提取物对细胞增殖具有较显著的促进作用。处理后 第 7 天的黑素细胞数比空白对照增加了 <69@>。 女贞 子促进黑素细胞增殖的作用主要出现于第 =A7 天。 目前认为白癜风色素恢复的主要机制是毛囊 外毛根鞘无黑素黑素细胞激活向表皮游移所致。
B/长， 移行和存活有重要的作用 C?D。 ;,(#EE 等 人发现正常人也有一定水平的 B/1 基因表达， 并指 出可能与保持正常黑素细胞的分裂潜能有关， B/1 表达减少很可能会导致黑素细胞生长存活缺陷， 成 为白癜风皮损中黑素细胞丢失的一个主要原因C=D。 另 外 B/1 还能通过对酪氨酸酶蛋白磷酸化修饰， 激活 酪氨酸酶， 促使黑素生成增加CFD。 本实验中女贞子提取 增幅达到 5:96@> 。 物处理后 GHI#+ 的表达明显增加，
白癜风治疗共识（草案）
中国中西医结合学会皮肤性病专业委员会色素病学组
中国中西医结合学会皮肤性病专业委员会 色 素 病 学 组 ， 并达成治疗共识。 5667 年 : 月于杭州讨论了白癜风的治疗， 稳定期 寻常型 （ 局限型 =） 外用糖皮质激素、 补骨脂素、 氮芥、 煤焦油
白癜风治疗方案
白癜风治疗共识中国中西医结合学会皮肤性病专业委员会色素病学组于2005年4月在杭州共同制订了白癜风的治疗共识，2006年4月西安会议作了修订。
1、进展期白癜风（一）寻常型：1.局限型：外用糖皮质激素或其他免疫抑制剂，免疫调节剂（转移因子，胸腺肽等），局部光疗：窄谱中波紫外线、准分子激光、准分子光等，中医中药。
2.散在型、泛发型和肢端型：中医中药，免疫调节剂（转移因子，胸腺肽等），系统用糖皮质激素，光疗：窄谱中波紫外线、准分子激光、准分子光等，局部外用药治疗（参考进展期局限型）。
（二）节段型：参考进展期局限型治疗。
2、稳定期白癜风（一）寻常型：1.局限型：外用补骨脂素类药物、糖皮质激素、氮芥等，自体表皮移植，局部光疗或光化学疗法：窄谱中波紫外线（NBUVB）、准分子激光及准分子光等，中医中药。
2.散在型、泛发型和肢端型：中医中药，光疗或光化学疗法：窄谱中波紫外线（NBUVB），准分子激光、准分子光、PUVA 等，自体表皮移植（暴露部位或患者要求的部位），局部外用药治疗（参考稳定期局限型）。
（二）节段型：自体表皮移植；其他参考稳定期局限型治疗。
3、辅助治疗暴露部位必要时可依据肤色选用深浅不同的遮盖剂，但是不推荐使用遮盖剂，必要时可心理咨询，解除顾虑、树立信心、坚持治疗，补充维生素B，维生素E，叶酸，锌剂，钙剂等可能有一定帮助。
白癜风治疗方法白癜风是一种常见的后天性表皮色素脱失性皮肤病，中医称为“白癜”或“白驳风”，在皮肤上可出现大小不等的圆形或椭圆形白斑，边界清晰，边缘色素较深。
近代研究表明，白癜风除皮肤外，还会累及眼、耳等，该病发生于任何年龄、性别和人种，其中以20~30岁的青年人为多见，一般人的发病率约0.5%到4%，近年来有逐年上升的趋势。
白癜风好发于皱褶及暴露部位，易诊断难治疗，且影响美观。
目前，国内外均缺乏较为满意的疗法，然而中医对此病的论述及治疗已有悠久的历史，积累了丰富的经验，其中在白癜风的治愈率上有较好的疗效。
历年白癜风的诊断标准综述
历年白癜风的诊断标准综述中国中西医结合学会皮肤性病专业委员会色素病学组于2005年4月在杭州共同制订了白癜风的治疗共识，2006年4月西安会议作了修订。
一、进展期白癜风（一）寻常型：1.局限型：外用糖皮质激素或其他免疫抑制剂，免疫调节剂（转移因子，胸腺肽等），局部光疗：窄谱中波紫外线、准分子激光、准分子光等，中医中药。
2.散在型、泛发型和肢端型：中医中药，免疫调节剂（转移因子，胸腺肽等），系统用糖皮质激素，光疗：窄谱中波紫外线、准分子激光、准分子光等，局部外用药治疗（参考进展期局限型）。
（二）节段型：参考进展期局限型治疗。
二、稳定期白癜风（一）寻常型：1.局限型：外用补骨脂素类药物、糖皮质激素、氮芥等，自体表皮移植，局部光疗或光化学疗法：窄谱中波紫外线、准分子激光及准分子光等，中医中药。
2.散在型、泛发型和肢端型：中医中药，光疗或光化学疗法：窄谱中波紫外线，准分子激光、准分子光、PUVA等，自体表皮移植（暴露部位或患者要求的部位），局部外用药治疗（参考稳定期局限型）。
（二）节段型：自体表皮移植；其他参考稳定期局限型治疗。
白癜风临床分型及疗效标准（2003年修订稿）中国中西医结合学会皮肤性病专业委员会色素病学组在1994年制定的《白癜风临床分型及疗效标准（草案）》，经过10年的临床实践，于2003年12月在深圳进行了讨论，修订白癜风临床分型及疗效标准如下：一、白癜风分为二型、二类、二期（一）二型：1、寻常型：①局限性：单发或多片白斑，局限于某一部位；②散在性：散在、多发性白斑，常呈对称分布。
③泛发性：多由散发性发展而来，白斑多相互融合成不规则大片，有时仅残留小片岛屿状正常肤色。
④肢端性：白斑初发于人体的肢端，而且主要分布在这些部位。
2、节段型：白斑为1片或数片，沿某一皮神经节段支配的皮肤区域走向分布，一般为单侧。
（二）二类完全性白斑：白斑为纯白色或瓷白色，白斑中没有色素再生现象，白斑组织内黑素细胞消失或功能完全丧失，对羟二苯丙氨酸（多巴）反应阴性。
白癜风外科治疗共识(2012版)
白癜风外科治疗共识（2012版）中国中西医结合学会皮肤性病专业委员会皮肤外科学组本共识经中国中西医结合学会皮肤性病专业委员会皮肤外科学组委员及国内相关专家讨论制定。
参加起草及讨论的成员(以姓氏汉语拼音为序)：艾勇、曹梅、陈晓栋、陈裕充、戴耕武、邓军、范斌、方方、康旭、李航、李久宏、李梅娇、罗东、彭建中、朴永君、阮杰、孙晶、汤依晨、万苗坚、王学军、尉莉、吴文育、吴信峰、杨顶权、翟建新、张斌、张东晨、张良、赵亮。
白癜风是一种常见的影响美容的获得性皮肤色素脱失性疾病，病因及发病机制仍然不清楚，临床治疗比较棘手。
目前多采用综合疗法治疗白癜风，但是某些类型白癜风对药物治疗反应不好，甚至部分治疗有效的患者也存在某些皮损对治疗疗效不佳的现象。
因此，外科治疗是对顽固性白癜风的有效手段之一，特别是对局限性稳定性白癜风皮损有良效。
一、适应证及术前准备1．白癜风外科治疗适应证：特别适用于药物治疗效果不好的稳定型白癜风，特殊类型的白癜风(包括晕痣、毛发区的白癜风)，病史上无同形反应出现，非瘢痕性体质者。
由于目尚无“稳定”的特定指标，建议其为白斑无进展1年(在停用一切药物及治疗手段、无新皮疹出现、老皮疹无扩展以及无同形反应)。
检测性移植(test grafting)可用来观察可疑病例的“稳定性”。
对于泛发性患者不主张广泛地大面积的手术治疗，一是经费问题；二是因为不能完全排除复发的可能性，医、患双方都要承担复发的风险。
如果患者为了容貌，确实有需求，局部手术治疗也是可行的，只是活动期患者需在辅助药物治疗的前提下，在控制病情的同时进行手术。
某些，如伴有严重心、脑血管性疾病、桥本甲状腺炎和内分泌多腺综合征患者、恶性贫血、系统性红斑狼疮等系统病及口服特殊药物者，不适合进行白癜风移植。
2．适合白癜风手术治疗的年龄：对于治疗的最小年龄尚无一致的观点。
白癜风外科治疗一般在局部麻醉下进行，对于患儿较难以实现，而采用外科治疗的全身麻醉对于儿童存在着较大风险。
白癜风诊疗指南2014
白癜风诊疗指南2014本指南以中国中西医结合学会皮肤性病专业委员会色素病学组制订的白癜风治疗共识（2009版）为基础，经色素病学组、中华医学会皮肤科分会白癜风研究中心部分专家及国内相关专家讨论制定。
白癜风治疗目的是控制皮损发展，促进白斑复色。
一、选择治疗方法时主要考虑因素：1•病期：分进展期和稳定期。
进展期判定参考白癜风疾病活动度评分（VIDA）积分⑴、同形反应、Wood灯。
①VIDA积分：近6周内出现新皮损或原皮损扩大（+4分），近3个月出现新皮损或原皮损扩大（+3分），近6个月出现新皮损或原皮损扩大（+2分）；近1年出现新皮损或原皮损扩大（+1分）；至少稳定1年（0 分）;至少稳定1年且有自发色素再生（-1分）。
总分＞1分即为进展期，》4分为快速进展期；②同形反应：皮肤损伤1年内局部出现白斑。
损伤包括物理性（创伤、切割伤、抓伤）、机械性摩擦、化学性/热灼伤、过敏性（接触性皮炎）或刺激性反应（接种疫苗、纹身等）、慢性压力、炎症性皮肤病、治疗性（放射治疗、光疗）。
白斑发生于持续的压力或摩擦部位，或者是衣物，饰品的慢性摩擦部位，形状特殊，明显由损伤诱发：③Wood灯：皮损颜色呈灰白色，边界欠清，Wood灯下皮损面积大于目测面积，提示是进展期。
皮损颜色是白色，边界清，Wood灯下皮损面积w目测面积，提示是稳定期。
以上3条符合任何一条即可考虑病情进展：④可同时参考激光共聚焦扫描显微镜（简称皮肤CT0和皮肤镜的图像改变，辅以诊断。
2. 白斑面积（手掌面积约为体表面积1%）: 1级为轻度，V 1%; 2级为中度，1%〜5%; 3级为中重度，6%〜50%; 4级为重度，〉50%。
白斑面积也可按白癜风面积评分指数（vitiligo area scoring index ，VASI）来判定。
VASI=2身体各部占手掌单元数）＞该区域色素脱失所占百分比，VASI值为0〜100[3]。
3. 型别：根据2012年白癜风全球问题共识大会（VGICC）及专家讨论，分为节段型、非节段型、混合型及未定类型白癜风。
白癜风诊疗方案
白癜风诊疗共识（2014版） ---- 文字完整版中国中西医结合学会皮肤性病专业委员会色素病学组本指南以中国中西医结合学会皮肤性病专业委员会色素病学组制订的白癜风治疗共识(2009版)为基础，经色素病学组、中华医学会皮肤科分会白癜风研究中心部分专家及国内相关专家讨论制定。
参加起草及讨论的成员(按姓氏汉语拼音排序)：傅雯雯、高天文、何黎、贾虹、李恒进、李铁男、李珊山、卢忠、鲁严、李春英、李强、刘清、马东来、乔树芳、秦万章、宋智琦、孙越、宋秀祖、涂彩霞、温海、王玮蓁、许爱娥、项蕾红、张学军、张建中、郑志忠、赵广、朱光斗。
白癜风治疗目的是控制皮损发展，促进白斑复色。
一、选择治疗方法时主要考虑因素：1．病期：分进展期和稳定期。
进展期判定参考白癜风疾病活动度评分(VIDA)积分、同形反应、Wood灯。
①VIDA积分：近6周内出现新皮损或原皮损扩大(+4分)，近3个月出现新皮损或原皮损扩大(+3分)，近6个月出现新皮损或原皮损扩大(+2分)；近1年出现新皮损或原皮损扩大(+1分)；至少稳定1年(0分)；至少稳定1年且有自发色素再生(一1分)。
总分>1分即为进展期，≥4分为快速进展期；②同形反应：皮肤损伤1年内局部出现白斑。
损伤包括物理性(创伤、切割伤、抓伤)、机械性摩擦、化学性/热灼伤、过敏性(接触性皮炎)或刺激性反应(接种疫苗、纹身等)、慢性压力、炎症性皮肤病、治疗性(放射治疗、光疗)。
白斑发生于持续的压力或摩擦部位，或者是衣物/饰品的慢性摩擦部位，形状特殊，明显由损伤诱发；③Wood灯：皮损颜色呈灰白色，边界欠清，Wood灯下皮损面积大于目测面积，提示是进展期。
皮损颜色是白色，边界清，Wood灯下皮损面积≤目测面积，提示是稳定期。
以上3条符合任何一条即可考虑病情进展；④可同时参考激光共聚焦扫描显微镜(简称皮肤CT)和皮肤镜的图像改变，辅以诊断。
2、白斑面积(手掌面积约为体表面积1%)：1级为轻度，<1%；2级为中度，1%-5%；3级为中重度，6%-50%；4级为重度，>50%。
皮肤科临床路径
皮肤科临床路径白癜风临床路径（2010 年版）一、白癜风临床路径标准门诊流程（一）适用对象。
第一诊断为白癜风（不伴有并发症）（ICD-10:L80 ）。
（二）诊断依据。
根据《临床诊疗指南-皮肤病与性病分册》（中华医学会编，人民卫生出版社）、《临床技术操作规范-皮肤病与性病分册》（中华医学会编，人民军医出版社）、《白癜风治疗共识》（中国中西医结合学会皮肤性病专业委员会，中华皮肤科杂志）。
白癜风为后天获得性色素脱失性皮肤病，一般无自觉症状。
白斑常呈乳白色，大小、形态不一，毛发可正常或变白。
白癜风分为寻常型和节段型。
寻常型皮损一般对称分布，可局限于某些部位或散发、泛发全身，故寻常型又分为局限型、散发型、泛发型和肢端型四个亚型。
节段型一般为单侧，白斑沿某一皮神经节支配区分布。
白癜风根据病情活动与否分为两期：进展期和稳定期。
进展期为原白斑仍在扩大，边界模糊，并且可有新发皮损，可有同形反应；稳定期为原白斑停止发展，并且无新发皮损，无同形反应。
（三）治疗方案的选择。
1. 局部外用药：外用糖皮质激素制剂或免疫调节剂、光敏剂补骨脂素、氮芥酊。
2. 光疗或光化学治疗。
3. 手术治疗：表皮或黑素细胞移植。
4. 系统使用免疫调节药物。
5. 系统小剂量糖皮质激素。
6. 中医中药，辩证施治。
（四）进入路径标准。
1. 第一诊断必须符合ICD-10:L80 白癜风（不伴有并发症）疾病编码。
2. 当患者同时具有其他疾病诊断，但在不需要特殊处理也不影响第一诊断的临床路径流程实施时，可以进入路径。
（五）就诊期间检查项目。
根据患者病情选择的项目：1.伍德灯；2.血常规;3. 甲状腺相关抗体;4. 抗体过筛；5. 免疫球蛋白、T 细胞亚群等。
（六）治疗方案与药物选择。
1．治疗原则（1）进展期白癜风：1）寻常型：① 局限型：可外用糖皮质激素（简称激素）或钙调神经磷酸酶抑制剂（他克莫司、吡美莫司）等，也可外用低浓度的光敏药，如浓度＜0.1 ％的8一甲氧补骨脂素（8-MOP）；局部光疗可选窄谱中波紫外线（NB —UVB）、308nm 准分子激光及准分子光、高能紫外光等。
白癜风治疗共识(2009版)
白癜风治疗共识（2009版）中国中西医结合学会皮肤性病专业委员会色素病学组本指南以中国中西医结合学会皮肤性病专业委员会色素病学组制定的白癜风治疗共识修改稿（2005版）维基础，经过色素病学组及国内相关专家讨论制定。
参与起草的成员（按姓氏汉语拼音排列）：常建民、杜娟、傅雯雯、高天文、李春英、柳曦光、乔树芳、秦万章、涂彩霞、温海、许爱娥、叶庆佾。
赵广。
周春英、朱光斗。
朱铁君。
白癜风治疗目的湿控制皮损的发展，促进白斑复色。
一、选择治疗措施时主要考虑因素1、病期：分为进展期和稳定期。
进展期判定标准参考VIDA积分：近6周内出现新皮损或原皮损扩大（+4分）；近3个月内新皮损或原皮损扩大（+3分）；近6个月内出现新皮损或者原皮损扩大（+2分）；近1年内出现新皮损或原皮损扩大（+1分）；至少1年内稳定（0分）；至少1年内稳定且有发色素再生（-1分）。
总分＞1分维进展期，＞4分为快速进展期。
2、白斑面积（占体表面积）：1级为轻度，＜1%；2级为中度，1%~5%；3级为中重度，6%~50%；4级为重度，＞50%（手掌面积为体表面积的1%）。
3、型别：分为寻常型和节段型。
寻常型又分为局限型：面积为1级，局限于一个解剖区；散发型：面积为2~3级，多个解剖区；泛发型：面积为4级（或＞50%）；肢端型。
4、部位：面部复色效果好，口唇、手足部位复色效果差。
5、年龄：分为成人和儿童白癜风。
疗效儿童好于成人。
6、早期疗效好，病程长治疗效果相对较差。
二、治疗原则（一）、进展期白癜风1、寻常型：①局限型：可外用糖皮质激素（简称激素）或钙调节神经磷酸酶抑制剂（他克莫司、吡美莫司）等，也可外用低浓度的光敏药，如浓度＜0.1%的8-甲氧沙林（8-MOP）；局部光疗可选窄谱中波紫外线（NB—UVB）、308nm准分子激光及准分子光、高能紫外光等。
②散发型、泛发型和肢端型：中医中药、免疫调节剂，VIDA积分＞3分考虑系统用糖皮质激素。
光疗及局部外用药参考进展期局限型。
白癜风治疗共识(2009版)
白癜风治疗共识(2009版)中国中西医结合学会皮肤性病专业委员会色素病学组本指南以中国中西医结合学会皮肤性病专业委员会色素病学组制订的白癜风治疗共识修改稿(2005版)为基础．经色素病学组委员及国内相关专家讨论制定。
参加起草及讨论的成员(按姓氏汉语拼音排列)：常建民、杜娟、傅雯雯、高天文、李春英、柳曦光、乔树芳、秦万章、涂彩霞、温海、许爱娥、叶庆佾、赵广、周春英、朱光斗、朱铁君。
白癜风治疗目的是控制皮损的发展，促进白斑复色。
一、选择治疗措施时主要考虑因素1.病期：分为进展期和稳定期。
进展期判定标准参考VIDA积分：近6周内出现新皮损或原皮损扩大(+4分)；近3个月内出现新皮损或原皮损扩大(+3分)；近6个月内出现新皮损或原皮损扩大(+2分)；近1年内出现新皮损或原皮损扩大(+1分)；至少1年内稳定(0分)；至少1年内稳定且有自发色素再生(-1分)。
总分＞1分即为进展期，＞4分为快速进展期。
2．白斑面积(占体表面积)：1级为轻度，＜1％；2级为中度，l％-5％；3级为中重度，6％-50％；4级为重度，＞50％(手掌面积为体表面积的l％)。
3．型别：分为寻常型和节段型。
寻常型又分为局限型：面积为l级，局限于一个解剖区；散发型：面积为2-3级，多个解剖区；泛发型：面积为4级(或＞50％)；肢端型。
4．部位：面部复色效果好，口唇、手足部位复色效果差。
5．年龄：分为成人和儿童白癜风。
疗效儿童好于成人。
6．病程：早期疗效好，病程长治疗效果相对较差。
二、治疗原则(一)进展期自癜风：1．寻常型：①局限型：可外用糖皮质激素(简称激素)或钙调神经磷酸酶抑制剂(他克莫司、吡美莫司)等，也可外用低浓度的光敏药，如浓度＜0.1％的8-甲氧沙林(8-MOP)；局部光疗可选窄谱中波紫外线(NB-UVB)、308 nm准分子激光及准分子光、高能紫外光等。
②散发型、泛发型和肢端型：中医中药、免疫调节剂，VIDA积分＞3分考虑系统用糖皮质激素。
白驳风的治疗方案
2.物理治疗：
（1）光疗：采用窄波紫外线照射、308准分子激光等，每周2-3次。
（2）电疗：采用磁疗法、电离子导入等，每周2-3次。
3.心理干预：针对患者心理状况，进行心理疏导，帮助患者树立信心，积极配合治疗。
第2篇
白驳风的治疗方案
一、背景介绍
白驳风，医学上称为白癜风，是一种慢性皮肤疾病，以局部或全身性色素脱失为特征。为了提供科学、系统的治疗方案，减少患者病痛，提高生活质量，特制定以下方案。
二、治疗目标
1.缓解症状，控制病情发展。
2.恢复或改善皮肤色素，减少白斑面积。
3.提高患者生活质量，减轻心理负担。
三、治疗原则
1.个性化治疗：根据患者病情、年龄、体质等因素制定个体化治疗方案。
2.综合治疗：采用药物、物理、心理及生活方式调整等多种方法综合治疗。
3.规范治疗：遵循国家相关诊疗指南，确保治疗方案的科学性和合理性。
4.安全性原则：在确保疗效的同时，尽量减少治疗过程中的副作用。
四、治疗方案
1.药物治疗：
-外用药物：根据患者病情选择糖皮质激素、钙调神经磷酸酶抑制剂等药物，每日1-2次，涂抹于患处。
-口服药物：根据患者病情，选用免疫抑制剂、维生素类药物等，每日1次，口服。
-中医治疗：根据患者体质和病情，采用养血润肤、活血化瘀、疏风清热等中药方剂，每日1剂。
2.物理治疗：
-光疗：采用窄波紫外线照射、308准分子激光等，每周2-3次。
-电疗：磁疗法、电离子导入等，每周2-3次。
3.心理治疗：
-心理评估：针对患者心理状况进行评估，了解患者心理需求。
特殊部位白癜风治疗进展
特殊部位白癜风治疗进展白癜风是一种常见的色素脱失性疾病，临床表现为皮肤黏膜白斑，常累及头面、手等暴露部位，各种族均可发病，无明显性别差异，易诊而难治，常影响患者美观和心理健康。
白癜风的发病率大约为1%左右，一般肤色越深的人群发病率越高，如在印度人群发病率高达3%～4%。
针对我国六个不同地区进行的调查结果显示，我国总患病率为0.5 53%。
有关本病的发病机制尚未完全阐明，多数学者认为白癜风是一种多因素性疾病，包括自身免疫学说、遗传学说、黑素细胞自身破坏学说、细胞因子缺乏学说、神经化学学说、氧化应激学说等。
目前认为白癜风可能是多种因素共同作用导致的。
尽管白癜风发病机制尚未完全明确，白癜风的治疗方法如药物、光疗等近十年有了长足的进展和改进，临床医生可以依据《白癜风治疗共识2009版》，根据患者病期、型别、皮损面积、病程等因素制定安全有效、合理的方案。
在白癜风治疗中依然存在很多难题，如黏膜部位、肢端部位、累及毛发部位的白癜风很难治疗，常规治疗方法常疗效不佳，本文就特殊部位白癜风的治疗进行了文献综述，旨在为临床医生治疗难治部位白癜风提供更多的选择。
1、黏膜部位及皮肤薄嫩部位白癜风1.1口唇部1.1.1药物治疗研究表明，前列腺素能诱导黑素细胞的增生，Kapoor等用前列腺素凝胶治疗7例唇部白癜风患者，2次/d，共6个月，其中2例患者复色效果达75%～100%。
不良反应发生率为18%，主要表现为唇部短暂的灼热感。
1.1.2手术治疗稳定期白癜风患者可选用手术治疗，目前有不少手术方法可用于治疗唇部白癜风，包括自体表皮移植和自体黑素细胞移植等。
单纯表皮移植或联合光疗:Malakar等报道应用钻孔移植治疗108例唇部白癜风，结果78例(72%)达到完全复色;32例(30%)出现铺路石样外观。
Gupta等对26例白癜风患者的31处唇部白斑应用吸疱表皮移植进行治疗，31处皮损中27处(87%)完全复色，但其中12例留有长期的色素过度。