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痤疮用药问题一文梳理

2025-3-15 19:11| 发布者: 快好疤| 查看: 242| 评论: 0

摘要: 痤疮,是一种常见的皮肤问题,影响着全球数以百万计的青少年和成年人。探讨痤疮的用药治疗是一个重要的议题。正确的治疗方法不仅能缓解症状,还能预防疤痕的形成。Q1痤疮的外用药物治疗有哪些?如何选用?外用药物治 ...
痤疮,是一种常见的皮肤问题,影响着全球数以百万计的青少年和成年人。探讨痤疮的用药治疗是一个重要的议题。

正确的治疗方法不仅能缓解症状,还能预防疤痕的形成。

Q1痤疮的外用药物治疗有哪些?如何选用?

外用药物治疗是痤疮的基础治疗,轻度及轻中度痤疮可以以外用药物治疗为主,中重度及重度痤疮在系统治疗的同时辅以外用药物治疗。常用的有以下几类[1]:

①维A酸类药物:包括全反式维A酸、异维A酸、阿达帕林、他扎罗汀等。

外用维A酸类药物可作为轻度痤疮的单独一线用药,中度痤疮的联合用药以及痤疮维持治疗的首选。阿达帕林具有更好的耐受性,通常作为一线选择。

②抗菌药物:如过氧化苯甲酰和抗生素(红霉素、克林霉素、氯霉素、及夫西地酸等)。

过氧化苯甲酰是炎性痤疮首选外用抗菌药物,可以单独使用,也可与外用维A酸类药物联合使用;外用抗生素易诱导痤疮丙酸杆菌耐药,故不推荐作为抗菌药物的首选,不推荐单独或长期使用,建议和过氧化苯甲酰、外用维A酸类或者其他药物联合应用。

③其他药物:壬二酸、氨苯砜、二硫化硒、硫磺和水杨酸等。这些药物可作为痤疮外用药物治疗的备选。

Q2口服异维A酸适用于哪类痤疮的治疗?推荐剂量是多少?

(1)结节囊肿型重度痤疮的一线治疗;

(2)其他治疗方法效果不好的中度或中重度痤疮的替代治疗;

(3)治疗意愿较强的轻中度痤疮患者;

(4)暴发性痤疮和聚合性痤疮,可在使用抗菌药物和糖皮质激素控制炎症反应后应用;

(5)伴有瘢痕或瘢痕形成倾向的痤疮患者;

(6)其他治疗无效、频繁复发的痤疮患者;

(7)痤疮伴严重皮脂溢出[2]。

中度至重度痤疮患者的推荐起始剂量为0.25~0.5mg/kg·d,之后可根据患者耐受性、痤疮严重程度和疗效逐渐调整剂量,重度结节囊肿性痤疮可逐渐增加至0.5~1.0mg/kg·d;轻中度痤疮患者可以采取低剂量的连续性或隔日治疗方案(10mg每天或者隔日1次)。建议与食物同服。

Q3维A酸类药物使用中需注意哪些事项?

①皮肤黏膜干燥是最常见的不良反应,建议配合保湿乳液一起使用,以减轻干燥症状。

②短期皮损加重,使用2~4周内可能会出现短期皮损加重现象,这是毛囊上皮松解,使原有深在的痤疮皮损外向化而变得明显,是一过性的,也是治疗开始有效的表现。此时应坚持使用,不要因症状加重而停药。

③儿童慎用维A酸类药物,过量服用可能导致骨结构发育异常、骨骺融合过早。12岁以下儿童尽量不用。

④维A酸类药物有致畸性,孕妇禁用。患者处于备孕中,不建议选用。哺乳期妇女如需用药,应暂停哺乳。肝肾功能明显异常者慎用维A酸类药物,并定期监测肝肾功能。

Q4哪些患者可以选择口服抗生素?

根据最新的痤疮治疗指南和专家共识,不应采取外用或内服抗生素单药疗法治疗痤疮。由于耐药性问题和副作用的考虑,抗生素的使用需要更加谨慎,并倾向于与其他药物联合应用,以提高疗效并减少耐药性的发展。

以下患者可选用口服抗生素[1]:

①中重度痤疮患者首选及中度痤疮外用治疗效果不佳的备选治疗方法;

②炎症反应严重的重度痤疮患者早期可先使用抗菌药物,再序贯使用口服维A酸类药,或维A药酸类药疗效不明显时可改用抗菌药物治疗;

③痤疮变异型如暴发性痤疮或聚合性痤疮的早期治疗。

Q5痤疮常用的口服抗生素有哪些?

首选四环素类药物如多西环素、米诺环素等。四环素类药不能耐受或有禁忌证时,可考虑用大环内酯类如红霉素、罗红霉素、阿奇霉素等代替。磺胺甲唑-甲氧苄啶也可酌情使用。

避免选择β-内酰胺类、头孢菌素类和喹诺酮类等抗菌药物。四环素口服吸收差,耐药率高,应优先选择多西环素和米诺环素。米诺环素在组织中药物浓度高,耐药发生率低。痤疮复发时,应选择既往治疗有效的抗菌药物,避免随意更换。

Q6异维A酸与多西环素能联合治疗痤疮吗?

异维A酸与多西环素合用可能导致假性脑瘤(良性颅内压增高)的发生。这种相互作用可能引发头痛、恶心、呕吐、视觉障碍等颅内压增高的症状。

如果痤疮病情需要同时使用抗生素和抗痤疮药物,可以考虑使用其他与异维A酸无相互作用的抗生素,如红霉素、阿奇霉素等。

Q7螺内酯治疗痤疮所有人都适用吗?

螺内酯是一种利尿剂,也被用作抗雄激素治疗痤疮。该药主要用于治疗女性痤疮患者,特别是那些伴有高雄激素表现的患者,如皮损分布于面中部下1/3,可伴月经不规律、肥胖、多毛、显著皮脂溢出、雄激素性脱发等。

对于男性痤疮患者,由于可能引起乳房发育、性功能低下等不良反应,通常不推荐使用。此外,妊娠期及哺乳期妇女、肾功能不全者,以及对螺内酯过敏的患者不建议使用。

Q8糖皮质激素是否可以用在痤疮治疗中?

糖皮质激素具有抑制肾上腺皮质功能亢进引起的雄激素分泌、抗炎及免疫抑制作用,这些作用使其成为治疗某些类型痤疮的有效药物。然而,糖皮质激素本身也具有诱发痤疮的不良反应,因此在使用时需要权衡利弊,谨慎选择。

根据《规范外用糖皮质激素类药物专家共识》[3],糖皮质激素具有明确的抗炎、抗过敏、抑制免疫及抗增生作用,但也可能诱发或加重局部感染,如加重痤疮。

因此,外用糖皮质激素类药物不是痤疮治疗的首选药物。系统用糖皮质激素可以用在痤疮治疗中,但主要用于暴发性痤疮、聚合性痤疮及较重炎症反应的重度痤疮。并且需要严格掌握用药剂量和疗程,以避免不良反应的发生。通常采取小量短期应用的方式,如口服泼尼松等。

Q9过氧化苯甲酰与阿达帕林凝胶能同时用吗?

由于同时使用过氧化苯甲酰和维A酸类药物(如阿达帕林)可能会相互影响药物的稳定性和效果,建议在不同时间段使用这两种药物。

阿达帕林凝胶属于维A酸类药物,具有一定的光敏性,晚上使用可以避免日光照射,减少药物分解和光敏反应的发生。例如,可以在晚上使用阿达帕林凝胶,而在早晨使用过氧化苯甲酰。
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