RU2701392C1 - Method of treating lobular panniculitis - lipodermatosclerosis patients - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to rheumatology, and can be used for treating lobular panniculitis-lipodermatosclerosis patients in health care facilities, hospitals, polyclinics, and sanatoriums. Symptomatic therapy is accompanied by two-course pharmacopuncture with a braking technique. First course is performed by daily introduction of homeopathic remedies: first into acupuncture points RP6 Placenta compositum 0.5 ml and VB39 – Traumeel S 0.5 ml and in the center of seal Traumeel S in dose 0.5 ml and along the compaction boundary multiple placenta injections compositum in dose of 0.2 ml. Then to the single sealing or each of the seals there introduced are the following mixtures: an anti-inflammatory-antioxidant-lipolytic mixture (IAM) consisting of: Traumeel S 1.2 ml, Ubiquinone compositum 2.2 ml, Solidago compositum 2.2 ml and vein-lymphodrainage mixture (VLM): Placenta compositum 1.2 ml, Cutis compositum 2.2 ml, Lymphomyosot 1.1 ml. One mixture is introduced daily. Introduction of mixtures is alternated daily. Volume of mixes is distributed from the boundary of the seal to the center in a circle, with distance between points of 0.6–0.7 cm, distance between "circles" – at least 1 cm, depth of needle introduction 1.2 cm. Second course is performed by daily successive introduction of the IAM and VLM into the sealed points. Mixtures are introduced from the boundary of the seal to the center along a circle, wherein the distance between points is 0.6–0.7 cm, the distance between the "circles" is not less than 1 cm, the depth of insertion of needle is 1.2 cm, the volume of the preparation per one seal is 0.5 ml.

EFFECT: method provides higher clinical effectiveness by reducing intravascular resistance, manifestations of venous stasis, as well as achieving the expressed analgesic and regenerating effects, the lipolytic and anti-inflammatory effect on subcutaneous fat, which enables to achieve remittance in the patients with lobular panniculitis-lipodermatosclerosis to 6–7 months.

1 cl, 3 ex

Description

The invention relates to medicine, in particular to rheumatology, and can be used for the treatment of patients with lobular panniculitis-lipodermatosclerosis in medical institutions, hospitals, clinics, and sanatoriums.

Treatment of patients with lobular panniculitis-lipodermatosclerosis is a complex medical and social problem. This is due to the severity of damage to the subcutaneous fat, musculoskeletal system, the progressive course of the disease, the high frequency of damage to people of working age, reduced functional abilities, loss of professional and social skills, the difficulty of the patient's physical and psychological adaptation to impaired motor functions [Belov B.S. ., Egorova O.N., Savushkina N.M., Radenska-Lopovok S.G. Panniculites in the practice of an internist // Ter. archive. - 2014 .-- 5 (86). - S. 88-93; Ter Poorten M.S., Thiers V.N. Panniculitis // Dermatol Clin. - 2002 .-- 20 (3). - P. 421-433; Miteva M, Romanelli P, Kirsner RS. Lipodermatosclerosis // Dermatol Ther. - 2010 .-- 23 (4). -P. 375-88].

The therapeutic approach is based on the inpatient, outpatient and home stages and is based on 3 principles: complexity, continuity at all stages, the individual nature of the construction of the rehabilitation program.

The unsatisfactory long-term results of the treatment of panniculitis draw attention to the early stage of this disease, when the reversibility of morphological changes in the tissues is higher, the autoimmune process has not fully formed, there are no severe dysfunctions of the subcutaneous fatty tissue and joints, and serious visceral lesions. At the same time, in about 70% of cases, inflammatory changes in the subcutaneous fat are evident within the first 2–3 months from the debut of the disease, which determines an unfavorable prognosis of the course of lipodermatosclerosis. In this regard, in recent years, the concept of early and active drug therapy has become generally accepted [Choonhakarn C, Chaowattanapanit S. Lipodermatosclerosis: improvement noted with hydroxychloroquine and pentoxifylline // J. Am. Acad. Dermatol. - 2012 .-- 66 (6). - P. 1013-4; Shuster M, Morley K, Logan J. at el. Lipodermatosclerosis secondary to pemetrexed use. // J. Thorac. Oncol. - 2015 .-- 10 (3). - P. 11-2; Carson P, Hong CJ, Otero-Vinas M, Arsenault EF, Falanga V. Liver enzymes and lipid levels in patients with lipodermatosclerosis and venous ulcers treated with a prototypic anabolic steroid (stanozolol): a prospective, randomized, double-blinded, placebo- controlled trial // Int J Low Extrem Wounds. - 2015 .-- 14 (1). - P. 11-8]. These data indicate the relevance of early treatment of patients with lobular panniculitis-lipodermatosclerosis.

Known methods of drug treatment of lobular panniculitis - lipodermatosclerosis. In medical treatment, nonsteroidal anti-inflammatory drugs (diclofenac, indomethacin, meloxicam, aceclofenac, nimesulide, celecoxib, etc.), glucocorticoids, basic anti-inflammatory drugs (aminoquinoline, pentoxifylline, angio-antileptaprilins, angio-antialpileptors, angioplendelaprilins, angioplendelaprintes, plaques, anti-inflammatory drugs, plaques, anti-inflammatory drugs, are commonly used): venarus, detralex, phlebodia, etc.), locally use a variety of alkaloids (capsaicin, espol, etc.) and surgical methods of therapy [Varicose Veins in the Legs: The Diagnosis and Management of Varicose Veins. // National Clinical Guideline Center (UK). - Source London: National Institute for Health and Care Excellence (UK). - 2013; Harlander-Locke M, Jimenez JC, Lawrence PF at el. Endo-venous ablation with concomitant phlebectomy is a safe and effective method of treatment for symptomatic patients with axial reflux and large incompetent tributaries // J. Vasc. Surg. - 2013 .-- 58 (1). - P. 166-72; Boyd K, Shea SM, Patterson JW. The role of capsaicin in dermatology // Prog. Drug. Res. - 2014 .-- 68. - P. 293-306; Choonhakarn C, Chaowattanapanit S. Lipodermatosclerosis: improvement noted with hydroxychloroquine and pentoxifylline // J. Am. Acad. Dermatol. - 2012. - 66 (6), - P. 1013-4].

Nonsteroidal anti-inflammatory drugs have a symptomatic effect. Glucocorticoids have a strong anti-inflammatory effect. The basis of drug therapy are basic anti-inflammatory drugs that suppress the activity of lipodermatosclerosis through an effect on the immune system. One of the main basic drugs is plaquenil, in which the anti-inflammatory and immunosuppressive effects develop after a few months.

The disadvantages of this method include the fact that medications often have a number of undesirable side reactions. All non-steroidal anti-inflammatory drugs can cause side effects from the gastrointestinal tract, kidneys and cardiovascular system [Mashkovsky M.D. Medicines 16th edition // New Wave. - 2012]. Negative effects with prolonged use of glucocorticoids are a violation of fat and carbohydrate metabolism, weight gain, the development of dyslipidemia, diabetes mellitus, Cushing's syndrome, steroid osteoporosis, arterial hypertension, and lesions of the gastrointestinal tract. In addition, these two groups of drugs are not able to significantly affect the long-term prognosis of lipodermatosclerosis.

Plaquenil and other basic drugs also have a high risk of side effects: pathological changes in the eyes, gastrointestinal tract, kidneys, liver and peripheral blood, myelosuppression, as well as the risk of developing hematologic diseases, severe allergic reactions, tuberculosis, opportunistic infections, lymphoproliferative processes. In addition, a periodic assessment of the effectiveness of the basic therapy and clinical and laboratory monitoring of its safety are necessary. One of the most important reasons for inadequate disease control and an obstacle to improving the quality of medical care is also the low adherence of patients with lipodermatosclerosis to basic therapy and the implementation of other medical recommendations (compliance).

Therefore, the question of the widespread inclusion of methods of restorative medicine in the treatment regimen of the underlying disease, the principle of which is a polysystemic effect on the body by activating adaptive-compensatory reactions, while eliminating the risk of unwanted side effects [Razumov AN, Limonov V.I., is becoming increasingly relevant. . Problems of improving the mechanism for controlling the functioning of the sanatorium complex of the Russian Federation // Issues of balneology, physiotherapy and physiotherapy. - 2006. - 5, 3. - S. 5].

A known method of treating patients with lobular panniculitis-lipodermatosclerosis electrophoresis, which consists in the fact that tissue with 10 ml of anesthetic solution is applied to the inflamed skin lesion. The duration of the procedure is 10 minutes, over time, the procedures can last longer. In the absence of side effects, it is necessary to conduct about 20 procedures [Faint J. Panniculitis and the physiotherapist. // Physiotherapy - 1956.- 42 (4). - P. - 9511]. The main disadvantages of this method: insufficient anti-inflammatory effect, expressed in the absence of dynamics of laboratory parameters (erythrocyte sedimentation rate, C-reactive protein and ultrasound data), the rehabilitation method does not directly affect the entire focus or foci of inflammation of the subcutaneous fat and has side effects (risk increase in blood pressure, cardiac arrhythmias, etc.).

There is also known a method of treating patients with lobular panniculitis-lipodermatosclerosis by ultrasonic exposure to the site of inflammation, in which the ultrasound transducer is slowly moved around the site of inflammation throughout the procedure. A part of the body measuring 100-250 cm ^{2 is} exposed to sounding, but if it is necessary to act on a large surface, then it is divided into several fields. Initially, during one procedure, 1-2 fields are voiced, and then up to 3-4 fields. The ultrasound intensity is from 0.05 to 0.8 W / cm2, the maximum duration of scoring is up to 15 minutes. Sessions are carried out daily or every other day, for a course of treatment of 6-14 procedures [Damian DL, Yiasemides E, Gupta S, Armor K. Ultrasound therapy for lipodermatosclerosis // Arch. Dermatol. - 2009 .-- 145 (3). - P. 330-2].

The main disadvantages of the method: ultrasonic exposure can change the course of pathological processes. At the same time, through small doses of ultrasound, their stimulation is provided, and with the help of large doses, their inhibition. Due to the complexity of this procedure and the presence of a fairly extensive list of contraindications (acute inflammatory process, pathology of the cardiovascular, pulmonary, gastrointestinal, renal, nervous and hematopoietic systems, cancer process, tendency to bleeding and pregnancy), the appointment of ultrasound therapy is limited. It is also necessary to carry out several procedures at precisely defined periods of the disease; subsequent lymphatic drainage is necessary. In addition, serious complications may occur in the post-procedural period.

It is also known to treat patients with lobular panniculitis-lipodermatosclerosis by treating inflamed subcutaneous fat with laser therapy. Procedures are carried out with a defocused or focused laser beam. With a large irradiation site, it is divided into several fields with an area of not more than 80 cm2 each. The impact in this case is carried out by a defocused beam alternately or according to a labile technique: the emitter is slowly moved in a spiral to the center with the capture of healthy tissues 3-5 cm along the perimeter of the pathological focus (scanning with a laser beam). The exposure time per field should not exceed 5 minutes. The total time should not exceed 20-30 minutes. Moreover, the irradiation area should not exceed 400 cm2 per procedure. When conducting laser puncture, the radiation is directed to acupuncture points. The exposure time for each point is from 20 to 60 s, the total exposure time for 1 procedure is 5-10 minutes [Abu-Own A, Scurr JH, Coleridge Smith PD. Effect of leg elevation on the skin microcirculation in chronic venous insufficiency. // J. Vasc. Surg. - 1994 .-- 20 (5). - R. 705-15].

The main disadvantages of this method: the procedure is quite expensive, can only be used in specialized medical centers, only at the stationary stage and has side effects (the procedure cannot be performed for people who have diabetes, have cancer or blood disease, and are also in a state of pregnancy) . For a long-term result, treatment should be carried out in conjunction with other physiotherapeutic procedures, such as mesotherapy and ultrasound therapy.

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Del Canto C, Marcos

V et al. Contribution of endermology to improving indurations and panniculitis / lipoatrophy at glatiramer acetate injection site. // Adv Ther. - 2012. - 29(3). - P. 267-75]Also, for the treatment of patients with lobular panniculitis-lipodermatosclerosis, the pharmacopuncture of glatiramer acetate is also used. The procedure of pharmacopuncture consists in subcutaneous or intradermal injection of the drug into the lesion area of 4-6 points. The use of glaciramer acetate 20 mg once a day for 12 days in pharmacopuncture is considered promising [Rubio

D

Del Canto C, Marcos

V et al. Contribution of endermology to improving indurations and panniculitis / lipoatrophy at glatiramer acetate injection site. // Adv Ther. - 2012 .-- 29 (3). - P. 267-75]

The main disadvantages of this method: targeted injection of drugs is more painful than conventional injection. Places for the usual (subcutaneous, intramuscular) injection are chosen so as to minimize pain, while pharmacopuncture points are often located in places of high sensitivity, where the injections are especially painful, and the pain does not go away immediately after the injection, sometimes lasting a day, and then 2-3 days. In addition, with conventional injections, as a rule, they are limited to one injection, while with a point injection of such injections it is necessary to do several, which, of course, significantly increases the pain of the procedure. The additional experiences that the patient undergoes with this method, apparently, became the reason that doctors are reluctant to resort to it, and in patients it causes real fear, and only the desire to get rid of the disease makes them suffer pain. A number of drugs with a normal injection gives almost no reactions, while those introduced at some acupuncture points, close to the nerve pathways, they often cause quite a strong reaction. Also, when drugs are introduced at the points of the drug, the introduction of which into the blood is contraindicated, there is a danger of violating this contraindication if the most strict control of the procedure is not observed, since many pharmacopuncture points are located in areas where large blood vessels pass under the skin. A doctor who has not mastered topographic anatomy can easily make a mistake by introducing the medicine into one of the internal organs or into some important tissue and thereby causing a serious complication. Since the number of injections with a point injection is much greater than with subcutaneous and intramuscular, the danger of causing an abscess in the first case, of course, is much greater.

The closest analogue is a method of treating patients, which consists in exposure to ultrasound therapy in combination with mesotherapeutic administration of homotoxicological drugs. Ultrasound therapy is carried out at a frequency of 880 kHz, with a power of 1 watt per cm ² in continuous mode for 6 minutes per zone 2 times a week No. 10. Mesotherapy with homotoxicological preparations, 1.1 ml lymphomyosotol, Coenzyme compositum, Ubiquinone compositum 2.2 ml in the form of a cocktail in the affected area 2 times a week No. 10 [Zubkova S.A. Ultrasound therapy and mesotherapeutic administration of homotoxicological drugs in the complex treatment of patients with edematous fibrosclerotic panniculopathy. Reflexoter. and complementary honey. 2012.1 (1). S. 62-64; Sukhareva M.L., Egorova O.N., Belov B.S., Pushkova O.V. Optimization of traditional technologies of rehabilitation therapy for lobular panniculitis // Traditional medicine. 2015].

The main disadvantages of this method: insufficient analgesic and anti-inflammatory effect, expressed in the absence of dynamics of laboratory parameters (erythrocyte sedimentation rate, C-reactive protein and ultrasound data), rehabilitation is carried out only at the stationary stage and includes only 10 procedures, which does not allow to influence the long-term prognosis disease and achieve remission, the effect of the treatment is short-term, only symptomatic, there is no continuity at the outpatient and home stages of rehabilitation.

Achievable technical result is to increase the effectiveness of treatment by reducing intravascular resistance, manifestations of venous stasis, as well as achieving pronounced analgesic and regenerating effects, the implementation of lipolytic and anti-inflammatory effects on subcutaneous fatty tissue, which allows achieving remission in patients with lobular panniculitis-lipodermatosclerosis to 6- 7 months

Due to the achieved results, the proposed method of treatment improves the quality of life of the patient, due to a significant reduction in pain, improving the functional status and locomotor function of the musculoskeletal system, increasing motor activity (power of movement of the knee and ankle joints), preventing deformation of the soft tissues of the legs, reducing the need patients in symptomatic therapy.

The developed method can be used both in a hospital and in an outpatient setting.

The specified technical result is achieved by the fact that against the background of symptomatic therapy, pharmacopuncture is performed by the braking method in two courses,

the first course is performed by daily administration of homeopathic medicines:

a) first, at the acupuncture points of RP6 Placenta compositum, 0.5 ml each and VB39 - Traumeel C 0.5 ml each and to the center of the seal Traumeel C at a dose of 0.5 ml and multiple injections of the placenta compositum 0.2 mg dose at the compaction border ,

b) then, mixtures are introduced into the points of a single seal or each seal: an anti-inflammatory-antioxidant-lipolytic mixture (PAS) consisting of: Traumeel C 1.2 ml, Ubiquinone compositum 2.2 ml, Solidago compositum 2.2 ml, and vein - lymphatic drainage mixture (VLS): Placenta compositum 1.2 ml, Kutis compositum 2.2 ml, Lymphomyozot 1.1 ml;

moreover, one mixture is administered daily, the introduction of mixtures is alternated daily;

the mixture is injected from the border of the seal to the center in a circle (thereby injecting drugs around the entire perimeter of the seal). We found that for the introduction of the drug around the perimeter, it is necessary that the distance between the points was 0.6-0.7 cm, the distance between the "circles" was at least 1 cm, the depth of the needle was 1.2 cm, and the total number of drugs amounted to: PAS is 5.6 ml and VLS - 4.5 ml;

the second course is carried out by daily sequential injection of two mixtures into the compaction points: an anti-inflammatory-antioxidant-lipolytic mixture (PAS), consisting of: Traumeel C 1.2 ml, Ubiquinone compositum 2.2 ml, Solidago compositum 2.2 ml, and veno lymphatic drainage mixture (VLS): Placenta compositum 1.2 ml, Cutis compositum 2.2 ml, Lymphomyosis 1.1 ml;

moreover, the mixture is introduced from the border of the seal to the center in a circle, wherein: the distance between the points is 0.6-0.7 cm, the distance between the "circles" is at least 1 cm, the depth of the needle is 1.2 cm, the volume of the drug per seal is 0.5 ml (the presented regimen is also optimal since the drug is administered along the entire perimeter of the seal).

Each course consists of 10 pharmacotherapy procedures. Procedures are performed daily, except Saturday and Sunday. The second course of treatment is carried out 3 months after the first.

The proposed method provides an increase in the effectiveness of treatment due to the new combination of acupuncture points, locality of action and double exposure to them. On the one hand, the action of a needle on acupuncture points creates an artificial dominant that switches pathological impulses on itself and contributes to the destruction of the components of the pathological reaction. As a result, conditions arise for normalizing the functional state of the nervous system.

On the other hand, with the introduction of drugs into active points (RP6 and VB39) and compaction points, the strength and duration of their exposure increase several times.

In addition, the proposed combination of drugs, the sequence and depth of their administration provide for their gradual penetration into the circulatory system, followed by their distribution throughout the body, which allows to reduce intravascular resistance, manifestations of venous stasis, as well as pronounced analgesic and regenerative effects, has a lipolytic and anti-inflammatory effect on subcutaneous fat (TFA).

Example No. 1

Patient N., 43 years old, was admitted with complaints of a painful crimson compaction of the left lower leg, pain in the left ankle joint, pastiness of the left lower leg and foot.

Medical history. He considers himself sick for about 9 months, when the first painful redness appeared on the left lower leg. After 4 months, the compaction increased in size to 10 cm, the pain began to have a constant aching character and there was a pastiness of the left leg and foot. She took nimesulide 100 mg 2 times a day for 2 months, locally - heparin ointment 2 times a day for 4 weeks - without effect. He was consulted by a phlebologist, diagnosed with chronic venous insufficiency, it was recommended to take Detralex 500 mg 2 times a day for 2 months, plaquenil 400 mg / d and wearing compression hosiery - with an unsatisfactory effect.

Objectively: on the medial-anterior and medial-posterior surfaces in the lower third of the left leg, a painful (YOUR pain 45 mm) diffuse (15 cm) crimson seal. The symptom of the “saucer” is positive. Pastosity of the left lower leg, its circumference in the affected part is 39 cm compared to the right lower leg in a similar place of 35 cm, and the left foot. Pastosity of the left ankle joint and limitation of its mobility.

Diagnosis: Lobular panniculitis-lipodermatosclerosis. Chronic venous insufficiency IV class (CEAR).

At the stationary stage, the patient continued to take non-steroidal anti-inflammatory (nise 100 mg 2 times a day) and aminoquinoline (plaquenil 400 mg per day) drugs, and a pharmacopuncture course was started according to the method we developed.

At the outpatient and home stages, the patient continued to take plaquenil 400 mg per day and occasionally (on “demand”) for pains in the left ankle joint, 100 mg per day.

Initially and after 3.5 months, the localization, size, color and level of pain were determined on the 100 mm visual analogue scale YOUR, the circumference of the lower extremity with signs of inflammation of lipodermatosclerosis, blood parameters of peripheral inflammation and the results of ultrasonography of the skin and subcutaneous fat (performed on the apparatus Voluson 730 Expert linear multi-frequency sensor frequency of 10-16 MHz), the presence of vascularization in the inflamed areas was detected using high-energy Doppler.

After 3.5 months of therapy according to the proposed method, the seal, which was distributed on the medial-anterior and medial-posterior surfaces, was localized only on the medial surface in the lower third of the left lower leg, YOUR pain (for which the doctor presses the center of the seal with the index finger to whiten the nail plate , the patient points to the emoticon. The doctor writes a digital result.) - from 45 mm to 10 mm, size - from 15 cm to 6 cm and color - from crimson to pale pink, erythrocyte sedimentation rate - from 21 to 10 mm / h, C-reactive protein - from 10.3 to 4.7 mg / l. Symptom "saucers" - from positive to mild. The pastosity of the left lower leg, its circumference in the affected part, decreased from 39 cm to 35 cm. The configuration and mobility of the left ankle joint normalized. According to ultrasonography of the skin and subcutaneous fatty tissue densification during therapy, the thickness of the subcutaneous fatty tissue decreased from 108 microns to 87 microns, the boundaries of this zone were uneven and not clear enough with normalization of vascularization. The acoustic density and size in the hypoechoic zone increased from 3 units to 21 units and from 21 mm to 72 mm, respectively.

Example No. 2

Patient R., 52 years old, was admitted with complaints of painful crimson compaction of the legs, pain in the ankle joints, pasty of the legs and feet.

Medical history. Considers himself ill for about 3 years, when the first appeared painful redness on the left lower leg. After 1.5 years, a similar seal appeared on the right lower leg. Consulted by a phlebologist, the diagnosis of chronic venous insufficiency, it is recommended to take Detralex 500 mg 2 times a day for 2 months with a second course after 2 months and wearing compression hosiery with an unsatisfactory (insufficient) effect. After 2.7 months of the disease, the inflammatory process acquired a hyperpigmented diffuse spread to the middle third of the legs with edema of the feet, took Detralex 500 mg 2 times a day, diclofenac 150 mg per day, plaquenil 600 mg per day and wearing compression hosiery with insufficient effect.

Objectively: on the medial-anterior and medial-posterior surfaces up to the middle third of the legs, painful (YOUR pain 45 mm) diffuse (25 cm) brown-crimson seals. The "saucer" symptom is sharply positive. Pastility of the legs: the circumference of the right lower leg is 39 cm and the left is 42 cm. Peripheral edema of the feet and lower third of the lower legs, more on the left. Pastosis of the ankle joints and limitation of their mobility. Pronounced venous pattern of the lower extremities.

Diagnosis: Lobular panniculitis-lipodermatosclerosis. Chronic venous insufficiency IV class (CEAR).

At the stationary stage, the patient is on the background of continued administration of non-steroidal anti-inflammatory (nize 100 mg 2 times a day), aminoquinoline (plaquenil 600 mg per day) drugs and venotonics (detralex 500 mg 2 times a day for 2 months with a second course in 2 months .), a pharmacopuncture course has been started, according to the developed method.

After 3 months of break, a mixture of PAS and VLS was introduced, according to the developed method.

At the outpatient and home stages, the patient continued to take plaquenil 600 mg per day, 100 mg daily, and 2-month courses of detralex 500 mg 2 times a day.

Initially and after 3.5 months, the localization, size, color and level of pain were determined on the 100 mm visual analogue scale of YOUR pain, the circumference of the lower legs with signs of inflammation of lipodermatosclerosis, the blood parameters of peripheral inflammation and the results of ultrasonography of the skin and subcutaneous fat (performed on the apparatus Voluson 730 Expert linear multi-frequency sensor frequency of 10-16 MHz), the presence of vascularization in the inflamed areas was detected using high-energy Doppler.

After 3.5 months of therapy according to the proposed method, the seals that spread on the medial-anterior and medial-posterior surfaces were localized only on the medial-lateral surface in the lower third of the legs, YOUR pain - from 45 mm to 10 mm, size - from 25 cm to 10 cm and color - from brown-crimson to light brown, erythrocyte sedimentation rate - from 28 to 12 mm / h, C-reactive protein - from 12.1 to 3.9 mg / l. The symptom of the “saucer” is from sharply positive to moderately pronounced. The pastosity of the lower legs and their circumference in the affected part decreased in the right lower leg from 39 cm to 34 cm and the left lower leg from 42 cm to 37 cm. The configuration and mobility of the ankle joints were normalized. According to ultrasonography of the skin and subcutaneous fatty tissue densification during therapy, the thickness of subcutaneous fatty tissue decreased from 114 μm to 94 μm, the boundaries of this zone were uneven and not clear enough with normalization of vascularization. The acoustic density and size in the hypoechoic zone increased from 3 units to 21 units and from 285 mm to 155 mm, respectively.

In example No. 3, we present the result of standard therapy.

Patient A, 47 years old, complained of a painful bright crimson seal of the left lower leg, pain in the knee joints, pastiness of the left lower leg and foot.

Medical history. He considers himself a patient for about 1.5 years, when, after prolonged physical activity, painful redness first appeared on the left lower leg. Consulted by a phlebologist, the diagnosis of chronic venous insufficiency, it was recommended to take Detralex 500 mg 2 times a day for 2 months with a second course after 2 months and wearing compression hosiery with unsatisfactory effect (compaction increased in size and pain intensified, pain in the knees was first noted joints). Consulted by rheumatologists, the diagnosis of osteoarthritis, bilateral gonarthrosis, Art II, FC 0-1, recommended the use of non-steroidal anti-inflammatory drugs (diclofenac 150 mg / day), chondroprotectors (arthra 600 mg twice a day for 5 months) and the recommendation of a phlebologist. After 6 months of therapy, a significant effect of the treatment on compaction was not revealed, and the patient turned to the FGBNU NIIR them. V.A. Nasonova. Hospitalized at the Institute with a diagnosis of lobular panniculitis-lipodermatosclerosis; osteoarthritis, bilateral gonarthrosis, art. II, FC 0-1; chronic venous insufficiency of the IV class (according to CEAP).

Objectively: on the medial-anterior surface up to the middle third of the legs, the painful (YOUR pain is 50 mm) diffuse (24 cm) bright crimson seal. The symptom of the “saucer” is positive. Peripheral edema of the feet and lower third of the legs, more on the left (the circumference of the left leg is 35 cm). Joints without features, pain in the projection of the "crow's feet" of the knee joints (YOUR pain is 40 mm). Pronounced venous pattern of the lower extremities. On other systems without features.

At the stationary stage, therapy was carried out for 18 days with non-steroidal anti-inflammatory drugs (nize 100 mg 2 times a day), chondroprotectors (arthra 600 mg 2 times a day) and venotonics (detralex 500 mg 2 times a day for 2 months with a second course after 2 months).

At the outpatient stage, for 3.5 months the patient continued to take 100 mg daily, arthritis 600 mg 2 times a day and 2-month courses of detralex 500 mg 2 times a day - with an unsatisfactory effect.

Initially and after 3.5 months, the localization, size, color and level of pain were determined on the 100 mm visual analogue scale of YOUR pain, the circumference of the lower legs with signs of inflammation of lipodermatosclerosis, the blood parameters of peripheral inflammation and the results of ultrasonography of the skin and subcutaneous fat (performed on the apparatus Voluson 730 Expert linear multi-frequency sensor frequency of 10-16 MHz), the presence of vascularization in the inflamed areas was detected using high-energy Doppler.

After 3.5 months of therapy, the seal spread to the posterior surface, i.e. Three surfaces in the lower third of the left tibia - the medial-anteroposterior surface - were already involved in the inflammatory process. YOUR seal pain remained unchanged (initially 50 mm and after 3.5 months 50 mm), the size of the seal increased from 24 cm to 29 cm, the color changed - from bright crimson to crimson, erythrocyte sedimentation rate - from 28 to 32 mm / h, C-reactive protein - from 12.1 to 13.9 mg / L. The symptom of the “saucer” - after 3.5 months it became sharply positive. The pastosity of the left tibia and its circumference in the affected part increased from 35 cm to 39 cm. According to ultrasonography of the skin and subcutaneous fatty tissue of the compaction, the thickness of the subcutaneous fatty tissue increased from 110 μm to 119 μm during therapy, the boundaries of this zone are uneven and not clear enough. The acoustic density and size in the hypoechoic zone ranged from 231 mm to 274 mm.

Thus, the proposed method for the treatment of lobular panniculitis-lipodermatosclerosis improves the effectiveness of treatment due to the new combination of acupuncture points, locality of action and double exposure to them, as well as a combination of drugs, which allows to reduce intravascular resistance, manifestations of venous stasis, as well as pronounced analgesic and regenerative effects, has a lipolytic and anti-inflammatory effect on subcutaneous fat.

The proposed method of treatment was used in 56 patients with lobular panniculitis-lipodermatosclerosis (52 women and 4 men) aged 18 to 80 years old, with a disease duration of 2 months to 11 years, with damage to the skin and subcutaneous fatty tissue of the legs, ankles and knees. The control group consisted of 20 patients with lobular panniculitis-lipodermatosclerosis aged 18 to 80 years, with a disease duration of 1.9 months to 11.2 years, with damage to the skin and pancreas of the lower legs, ankle and knee joints.

The work was carried out in the FSBI NIIR them. V.A. Nasonova.

An analysis of the main group of patients revealed that in 20 patients (36%), pancreatic inflammation occurred in the spring and summer, in 70% of cases it was asymmetric, mainly localized on the medial surface of the lower leg (75%), followed by dystrophy and the development of the “glass” symptom "(79.2%, p = 0.00556). The average node size was 9.8 ± 4.1 cm with moderate soreness (YOUR pain = 35.0 ± 26.3 mm and up to 5 seals in 57% of patients. The diameter of the middle third of the affected lower leg was significantly greater than that on the healthy side - 44 , 7 ± 5.6 cm and 40.3 ± 4.4 cm, respectively (p = 0.003). Depending on the duration of the disease, the main variants of the course were identified: acute (up to 3 months), subacute (from 3 months to 6 months) and chronic (more than 6 months).

In 20 cases (37.7%) aged 51.8 ± 15.7 years, an acute course of the disease was observed, characterized by the development of pink seals without clear boundaries for 1.47 ± 0.3 months (p = 0.001). The subacute course of the disease was observed in 12 patients (22.6%) aged 57.50 ± 12.1 years with an inflammatory process duration of 7.4 ± 5.7 months, red-purple seals and a positive “glass symptom” of 91 , 67% of cases. In 21 patients (39.6%) aged 56.1 ± 11.9 years, a chronic course was diagnosed with a disease duration of 43.3 ± 24.0 months, clearly defined crimson-brown seals in 17 cases (80.95 %) a symptom of a "glass" was detected. The risk of developing this symptom increased by 2.3 times in the group with a chronic course, compared with that in acute (95%, CI 1.2-4.4, p = .003).

After 3.5 months of therapy according to the proposed method in 78% of cases, the localization of compaction regressed to the medial surface of the lower third of the legs. Assessment of pain by patients on a visual analogue scale significantly decreased by 71.6%. The size of the inflamed lesion decreased by 17.4 ± 6.2 cm with a predominance of pink over compaction in 67% of patients. The “saucer” symptom neutralized in 64% of patients, which was associated with a significant decrease in peripheral edema and circumference in the affected part of the lower leg by 8.3 ± 1.9 cm.

The proposed treatment method allowed to normalize the configuration and mobility of the ankle and knee joints in 58% of patients. According to the results of ultrasonography of the skin and subcutaneous fatty tissue compaction during therapy, the thickness of subcutaneous fatty tissue decreased by 103 ± 76 μm, the borders and vascularization of this zone were normalized in 73% of patients. The acoustic density increased by 19.7 ± 6.4 units, the size of the hypoechoic zone decreased by 137.2 ± 67.8 mm. By the 4th month, 41% of patients managed to cancel non-steroidal anti-inflammatory drugs.

In the control group, lobular panniculitis-lipodermatosclerosis was asymmetric in 65% of cases, mainly localized on the medial surface of the lower leg (70%), followed by dystrophy and the development of the symptom of the “glass” (75%, p = 0.00556). The average node size was 10.1 ± 3.4 cm with moderate soreness (YOUR pain = 35.3 ± 25.7 mm and up to 5 seals in 60% of patients. The diameter of the middle third of the affected lower leg was significantly greater than that on the healthy side - 43 , 8 ± 5.4 cm and 41.1 ± 3.9 cm, respectively (p = 0.05). In 9 cases (45%) an acute course of the disease was revealed, in 5 patients (25%) - subacute and in 6 (30%) - chronic course of the disease.After 3.5 months of therapy with non-steroidal anti-inflammatory drugs and venotonic drugs, a satisfactory effect was revealed in 25% of cases, in the form of a decrease in pain by 15.2 ± 6.3 mm and compaction size by 2.6 ± 1.4 cm compared to the initial levels of the indicators.The “saucer” symptom did not have significant regression compared to the beginning, which was associated with peripheral pasticity of the lower legs, the circumference of the affected part of the lower leg increased by 2 as a result of observation , 3 ± 1.6 cm. According to ultrasonography of the skin and subcutaneous adipose tissue, during treatment, the thickness of subcutaneous adipose tissue increased by 73 ± 26 μm, the acoustic density decreased by 9.6 ± 4.1 units, the size of the hypoechoic zone increased by 89.7 ± 46.3 mm.

Thus, the proposed method of treatment significantly reduces pain, improves the functional status and locomotor function of the musculoskeletal system, increases motor activity (power of movement of the knee and ankle joints), prevents deformation of the soft tissues of the legs, reduces the need for patients with symptomatic therapy, reduces activity diseases and, in some cases, achieve remission in patients with lobular panniculitis-lipodermatosclerosis up to 6-7 months.

Claims (2)

1. A method of treating patients with lobular panniculitis-lipodermatosclerosis, including symptomatic therapy, characterized in that, against the background of symptomatic therapy, pharmacopuncture is performed by the braking method in two courses, the first course is carried out by daily administration of homeopathic preparations: first, at the acupuncture points of RP6 Placenta, compositum 0.5 ml and VB39 - Traumeel C 0.5 ml each and into the center of compaction Traumeel C at a dose of 0.5 ml and multiple injections of Placenta compositum at a dose of 0.2 ml at the compaction border; Then, mixtures are introduced into the points of a single seal or each seal: an anti-inflammatory-antioxidant-lipolytic mixture (PAS), consisting of: Traumeel C 1.2 ml, Ubiquinone compositum 2.2 ml, Solidago compositum 2.2 ml, and veno-lymphatic drainage mixture (VLS): Placenta compositum 1.2 ml, Cutis compositum 2.2 ml, Lymphomyozot 1.1 ml; moreover, one mixture is administered daily, the introduction of mixtures is alternated daily; the volume of the mixture is distributed by introducing from the border of the seal to the center in a circle, with a distance between the points of 0.6-0.7 cm, the distance between the "circles" is at least 1 cm, the depth of the needle is 1.2 cm; the second course is carried out by daily sequential introduction to the compaction points of PAS and VLS; moreover, the mixture is introduced from the border of the seal to the center in a circle, with the distance between the points of 0.6-0.7 cm, the distance between the "circles" of at least 1 cm, the depth of the needle 1.2 cm, the volume of the drug per seal is 0 5 ml. 2. The method according to p. 1, characterized in that the second course of treatment is carried out 3 months after the first.