The thesis is devoted to the problem of increasing the efficiency of treatment of patients with lipoid necrobiosis by using D-penicillamine in the complex pathogenetic therapy based on the assessment of the epidemiological, clinical, biochemical and histopathological features of the course of dermatosis.
Under observation were 48 patients with a typical form of lipoid necrobiosis, which were divided into 3 groups for further research: group I - without combination with diabetes - 27 patients; Group II - in combination with type II diabetes mellitus - 14; Group III - in combination with type I diabetes mellitus - 7.
An increase in the severity of the pathological process leads to the development of atrophy and complications in the form of ulcers.
In 20 (41.7%) patients with LD with a typical form of the disease, dermatosis proceeded against the background of diabetes or impaired glucose tolerance, and in 28 (58.3%) patients with diabetes or impaired glucose tolerance. Of the 15 (31.3%) patients who applied for the first time, glucose disorders were observed in 7 people, and in 33 (68.7%) patients who applied repeatedly, these disorders were found in 13 people (p<0.05). In 20 patients with LN in combination with diabetes, in 6 (30%) carbohydrate metabolism disorders preceded the development of the skin process, in 2 (10%) they developed simultaneously with it, and in 6 (30%), diabetes was detected for the first time. Insulin resistance and compensatory hyperinsulinemia were found in all patients of group II (p<0.05). In patients of group III, the HOMA-IR index is 6.71±0.30 (p<0.01).
The revealed lipid metabolism disorders in patients of groups II and III indicate the unidirectionality of these changes and the generality of biochemical processes in both groups. In group III, a significantly higher level of hypercholesterolemia, hypertriglyceridemia, an increase in the level of blood serum of LDL and a decrease in the level of HDL were detected, which is probably associated with defective utilization of lipids and carbohydrates and can create conditions for the formation of necrobiotic changes in connective tissue in patients with LD.
A comparative objective assessment of the morphological and functional state of the skin of patients of the three groups on the basis of calculating the indices of pathological changes in the structures of the epidermis and dermis (IpHe, IpVv, IpVc, IpVkv, IpVev) found that the greatest changes occur from the vessels of the MCCR and collagen fibers of the dermis. According to the increasing degree of IpSum, the groups were distributed as follows (with statistical significance p<0.05): I group (16.97±0.711), II group (26±1.212) and III group (27.77±1.209) (p<0,05). This allows us to conclude that in patients with LN, a more severe skin lesion is noted when dermatosis proceeds against the background of type I diabetes.
A comparative assessment of therapeutic pathomorphism in 39 patients with LN after 6 months from the start of using D-penicylamine showed that according to the IrSum values in the skin of patients with LN, the first group is in first place, with a significant margin (3.50), then with approximately the same difference followed by II (2.36) and I (2.23) groups (p<0.05).
A method has been developed for the complex pathogenetic treatment of patients with LD using D-penicillamine. 6 months after the start of treatment, the number of patients with a total area of affected skin up to 2% increased to 31 (79.5%) people. After 1 year, the lesion sites completely disappeared in 14 (35.9%) patients, and in 15 (38.5%) patients the total lesion area was 1.1-2% (p<0.05). At the same time, therapeutic efficacy was significantly higher (p <0.05) in patients with group I ID than in patients of groups II and III - complete clinical remission occurred in 8 (38.1%) people, improvement - in 10 (47,6%). In patients of groups II and III, remission was established in 4 (33.3%) and 2 (33.3%) people, and improvement in 5 (41.7%) and 2 (33.3%) people, respectively. Thus, the best clinical efficacy is observed in patients with LD without a combination with diabetes, worse - in combination with type I diabetes. Analysis of the pathogenetic treatment of patients with LD using D-penicillamine for the severity of its effectiveness confirmed the relationship between the selected treatment method and clinical efficacy (χ2=4.047, p<0.05). This leads to minimization of the aesthetic defect, functional and psychological problems in patients and, as a result, improves the quality of their life.
Key words: lipoid necrobiosis, carbohydrate metabolism, lipid metabolism, morphometry, D-penicillamine.
