【作者】 吴凡；

【导师】 桑红；

【作者基本信息】 南京大学 ， 皮肤性病学， 2014， 硕士

【摘要】 背景寻常型银屑病(psoriasis vulgaris, PV)是一种常见的慢性炎症性皮肤病,主要病理学该表包括角质形成细胞过度增生、炎细胞浸润和真皮层内新生血管形成等,影响世界约2-3%的人口。该病目前尚不可根治,具有皮损可见、易复发等特点,可严重影响患者生活质量,是目前临床上亟待解决的问题。随着医学模式从传统的生物学模式向生物-心理-社会模式转变,越来越多的研究者重视患者生活质量,但多集中在疾病严重程度对患者生活质量的影响,较少报道就医行为对患者生活质量的影响。在发病机制方面,目前认为银屑病是一种Th1/Th2失衡的自体免疫性疾病,黏膜及系统过表达促炎作用的Th1细胞因子和低表达具有抗炎作用的Th2细胞因子在银屑病的发生、维持及复发中起了十分重要的作用。激活T细胞的具体抗原刺激尚未完全明确,但临床观察和实验研究证实微生物超抗原可以激活T细胞,并诱发银屑病的发生。马拉色菌(Malassezia)作为人类皮肤上常见的寄生菌,同时在寻常型银屑病患者皮损中也能分离到。在人体皮肤微环境和(或)防御机制改变时马拉色菌可作为致病菌引起一系列疾病,如花斑糠疹、马拉色菌毛囊炎。马拉色菌与银屑病间的关系也日益受到研究者关注。动物实验显示热灭活的卵圆马拉色菌悬液可使兔背部皮肤出现红斑及白色鳞屑,镜下病理改变出现角化不全、真皮乳头层毛细血管扩张和多形核白细胞浸润等银屑病典型的改变。Lober等利用马拉色菌的细胞碎片在银屑病患者前臂无皮损部位进行斑贴实验,结果显示所有患者在受试部位均出现了新的银屑病皮损。临床上有马拉色菌毛囊炎和花斑糠疹皮损转变为银屑病皮损的报道。有研究显示马拉色菌可诱导银屑病患者外周血单核细胞产生Th1细胞因子,同时使银患者外周血中的辅助性T细胞亚群出现Th1细胞分化偏态性。马拉色菌派生的可溶性成分对银屑病患者多形核白细胞具有趋化作用,同时可以通过细胞内的TLR或NLR信号通路刺激角质形成细胞增殖,提示马拉色菌参与银屑病同形反应的发生。这些提示我们马拉色菌在银屑病的发生发展中可能起到了重要作用。本文分为两部分。第一部分寻常型银屑病患者生活质量及其影响因素调查目的 了解寻常型银屑病患者生活质量情况及其影响因素。方法采用Skindex-29量表对我院门诊和住院部就诊的178例寻常型银屑病患者进行生活质量的横断面调查,设计调查问卷获取人口统计学资料及临床资料和就医行为情况,分析这些因素对生活质量的影响。结果(1)女性生活质量情感领域得分高于男性(t=3.076,P=0.003),女性总得分高于男性(t=2.112,P=0.038)；(2)瘙痒程度与症状领域得分呈正相关(r=0.248,P=0.019)；(3)有家族史患者情感领域得分高于无家族史患者(t=2.171,P=0.033)；(4) 患者就诊医院数量与症状领域得分、情感领域得分、功能领域得分及总得分均呈正相关(r=0.329,P=0.002；r=0.280,P=0.008；r=0.268,P=0.011；r=0.320,P=0.002);(5)使用过偏方的患者情感领域得分高于未使用过偏方的患者(t=2.201,P=0.030),使用过偏方的患者功能领域得分和总得分高于未使用过偏方的患者(t=2.146,P=0.035；t=2.051,P=0.043)。结论(1)性别、瘙痒程度、有无家族史、是否使用过偏方和既往就诊医院数量分别影响寻常型银屑病患者生活质量的不同领域。(2)既往就诊医院数量是寻常型银屑病患者整体生活质量的主要影响因素。第二部分马拉色菌在寻常型银屑病发病机制中作用的初步研究目的 了解我院就诊寻常型银屑病患者皮损中马拉色菌带菌率和菌种构成；观察患者对自制马拉色菌凝胶试剂的反应；通过研究马拉色菌对寻常型银屑病患者血浆中Th1和Th2细胞因子的影响,初步探讨马拉色菌在寻常型银屑病发病机制中的作用。方法对84例寻常型银屑病患者各部位皮损标本进行真菌学检查,并运用生化鉴定方法对临床分离株进行鉴定；自制马拉色菌凝胶试剂对52例患者进行斑贴试验,观察患者皮肤反应；采用酶联免疫吸附试验检测患者血浆中IL-2、IL-12、IFN-γ和IL-4、IL-10、IL-13水平。结果(1)患者一般情况：男61例,女23例,男女比为2.65：1,平均年龄32.93±12.34岁(18岁～68岁),平均病程6.48±7.01年(2月～32年),PASI评分平均值为5.344±5.10分(0.3分～29.50分)；(2)培养阳性率：84例寻常型银屑病患者有34例皮损中培养出马拉色菌,阳性率为40.48%,男女患者培养阳性率差异无统计学意义(χ2=0.118,P=0.731)；不同年龄段患者培养阳性率差异无统计学意义(χ2=0.710,P=0.459)：(3)菌种构成：共得到临床分离株34株,共鉴定出3个种,其中球形马拉色菌18株(52.94%),合轴马拉色菌9株(26.47%),限制性马拉色菌7株(20.59%)。不同性别患者皮损中菌种构成差异无统计学意义(χ2=1.653,P=0.438),不同年龄段患者皮损中菌种构成差异有统计学意义(χ2=15.938,P=0.000)：(4)培养阳性组PASI评分为7.02±6.57,培养阴性组PASI评分为4.20±3.41,分析结果显示培阳性组PASI评分高于培养阴性组(t=2.236,P=0.028)；(5)52例患者中12例对自制马拉色菌凝胶试剂出现反应,表现为红斑、水肿等刺激反应,阳性率为23.08%；(6)患者组血浆中IL-2浓度高于对照组(t=3.127,P=0.002),马拉色菌培养阳性患者组血浆中IL-2浓度高于马拉色菌培养阴性患者组和对照组(F=3.647,P=-0.016),其余细胞因子浓度差异无统计学意义。结论(1)寻常型银屑病患者皮损中马拉色菌带菌率为40.48%,优势菌种为球形马拉色菌；(2)皮损中马拉色菌分离阳性患者较分离阴性患者病情严重；(3) 自制马拉色菌凝胶试剂可以引起寻常型银屑病患者出现刺激性反应,提示马拉色菌可能是引起同形反应的原因之一；(4) 马拉色菌可能通刺激机体上调IL-2的表达与寻常型银屑病的发生有关。更多还原

【Abstract】 BackgroundPsoriasis is a chronic genetically determined, inflammatory disease, which affects approximately 2-3% of the world’s population. The histological changes observed within lesional skin include acanthosis, hypogranulosis, parakeratosis, marked dilatation of blood vessels in the papillary dermis, and infiltration of inflammatory cells. Currently it can’t be cured and could recurrent usually. The life of quality patients with psoriasis vulgaris is hardly impaired, so psoriasis vulgaris has become one of medical issues which need to be solved immediately.With the progress of research means and a lots of immunology research, some scholars have proposed that psoriasis is a T cell-mediated inflammatory diseases, the interactions of T cells and their cytokines with keratinocytes play an important role in the pathogenesis of psoriasis. The specific antigen which activates T cells is unclear, but a growing number of clinical observations and experimental studies confirmed that microbial superantigens can activate T cells and induce the occurrence of psoriasis. Malassezia is a common parasitic microorganism on human skin, which can be separated from the parts which are rich of sebaceous glands, such as scalp and torso. When the microenvironment of human skin changes, Malassezia becomes one pathogene of opportunistic infections, which can lead to tinea versicolor, Malassezia folliculitis and other related diseases. In the last 10 years, with the development of molecular biology techniques, there is evidence that Malassezia plays a role in the pathogenesis of psoriasis.This study is divided into two parts, clinically, we investigate patients’ quality of life and the understanding of this disorder. Fundamentally, we explore the effect of Malassezia in the progression of this disorder.Part one The survey of life quality in patients with psoriasis vulgarisObjective To study the effect of psoriasis vulgaris on the patients’ life quality and investigate patients’ psoriasis vulgaris-related knowledge.Methods 89 patients were rolled in this study, all of them filled in Skindex-29 and a questionnaire about psoriasis vulgaris.Results(1). The total scores of life quality of female was higher than man (t=2.112, P=0.038), the scores in Emotion Domain of female was higher than male (t=3.076, P=0.003).(2). Spearman correlation analysis showed that there was a positive correlation between the degree of itching and symptoms scores in Symptoms Domain (r= 0.248, P= 0.019).(3). The scores in Emotion Domain of patients who have a family history was higher than that of patients who do not have a family history (t=2.171, P=0.033).(4). Spearman correlation analysis showed that there was a positive correlation between the number of hospital visited by the patient and the scores of all the dominant and the total scores (r=0.329, P=0.002; r=0.280, P=0.008; r=0.268, P=0.011; r=0.320, P=0.002 respectively).(5). The scores in the Emotion Dominant and Function Dominant of patients who used the folk prescriptions were higher than those of patients who did not so (t=2.201, P=0.030; t=2.146, P=0.035; t=2.051, P=0.043 respectively).Conclusion(1) Patients’ gender, pruritus, usage of folk prescriptions and the number of visited hospital can markedly effect on patients’ life quality.(2) The number of previous hospital visited by patients is the main factors which can effect patients’ overall life quality.Part two Pilot study of the role of Malassezia in the pathogenesis of vulgaris psoriasisObjective To understand the infection rate and species composition of Malassezia in the lesions of patients with psoriasis vulgaris and to observe the patient’s response to Malassezia homemade gel reagents, meanwhile to investigate the effects of Malassezia on serum Thl and Th2 cytokines in patients with psoriasis vulgaris in order to define their role in the pathogenesis of psoriasis.Methods Examine specimens from the lesions of 84 patients with PV and identified clinical isolates using biochemical methods; underwent patch testing on 52 patients with homemade Malassezia gel reagent, using enzyme-linked immunosorbent assay to measure the level of IL-2, IL-12, IFN-y and IL-4, IL-10, IL-13 in patients.Results(1) The general condition of patients:61 males and 23 females, male to female ratio was 2.65:1, an average age of (32.93±12.34) years old, the average duration was 6.48±7.01 years, and mean PASI score was (5.344±5.10) points.(2) Culture positive rate:84 cases of psoriasis vulgaris lesions in 34 patients cultured Malassezia, the positive rate was 40.48%, the rate of patients with culture-positive men and women showed no significant difference (x2=0.118, P=0.731); patients with culture-positive rates of different age groups showed no significant difference (x2=0.710, P=0.459).(3) Species composition:there were 34 clinical isolates obtained, which were identified into three kinds,18 M. globosa (52.94%),9 M. sympodialis (26.47%),7 M. restricta (20.59%). Different species constitute of gender was not statistically significant (χ2= 1.653, P=0.438), different species constitute of age was statistically significant (x 2=15.938, P=0.000).(4) The PASI index of positive group was 7.02±6.57, and that of negative group was 4.20±3.41, the difference between was statistically significant (t=2.236, P=0.028).(5) There were 52 patient accepted the patch test of Malassezia allergen, and 12 of them showed an irritant reaction to it.(6) Serum interleukin-2 levels were significantly higher in the psoriasis group compared with the control group (t=3.127, P=0.002). Mean levels of IL-2 were significantly higher in psoriasis patients positive for Malassezia yeasts compared with those negative for Malassezia and control subjects (F=3.647, P=0.016).Conclusion(1) The Malassezia carrier rate of patients with psoriasis vulgaris was 40.48%, and the dominant species was M. globosa(2) The condition of patients with Malassezia positive was more serious than patients with Malassezia negative.(3) Psoriasis vulgaris patients showed an irritant reaction to Malassezia, suggested that Malassezia may be one cause of isomorphic response of this disorder.(4) Malassezia may contribute to the occurrence of PV thought their upregulating effects on IL-2.更多还原