
[Pigmentary Changes in Scar Tissue]
Table 1. Contents of pigmentary changes in scar tissue
----------------------------------------
Introduction
Hypo-Pigmented scar
apparently Hypo-Pigmented scar
Hyper-Pigmented scar
Conclusion
----------------------------------------
Wound healingÀÇ °úÁ¤Àº 'wound->erythema->dyspigmentation->scarring/healing'°ú °°ÀÌ ¼øÂ÷ÀûÀ¸·Î ÁøÇàµÈ´Ù. ÇÏÁö¸¸, ½ÇÁ¦´Â woundÀÇ °µµ¿¡ µû¶ó ¼¯¿©¼ ³ªÅ¸³ª¸ç ±× ±¸¼ººñ°¡ ´Þ¶óÁø´Ù. µû¶ó¼, Ä¡·áµµ ÀÌ¿Í °°Àº ´Ü°è¿¡ µû¶ó ´Ù¾çÇÑ ¹æ¹ýÀ¸·Î ´ëÀÀÇØ¾ß ÇÑ´Ù.
¶ÇÇÑ ´«À¸·Î º¸ÀÌ´Â »ö¼Ò¿Í ½ÇÁ¦ ÇǺΠÁ¶Á÷ ³»¿¡¼ ÀϾ´Â Çö»óÀº ´Ù¸¦ ¼ö ÀÖ´Ù. ´Ü¼øÈ÷ ´«À¸·Î º¸ÀÌ´Â »ö¼Ò°¡ melanocyteÀÇ ¼ýÀÚÀÇ °¨¼Ò ȤÀº ±â´É ÀúÇÏ »Ó ¾Æ´Ï¶ó, ´Ù¸¥ opticalÇÑ factorµµ ÀÖ´Ù. µû¶ó¼ Ä¡·á Àü ´Ù¾çÇÑ »óȲÀ» °í·ÁÇØ¾ß ÇÑ´Ù.
¿ì¸®¿¡°Ô ¡®¹Ù½ºÆ¼À¯ Å×Å©´Ð¡®À¸·Î À¯¸íÇÑ ¡¯GJ Goodman¡®Àº ÈäÅÍÀÇ ´Ü°è¸¦ acne scar¸¦ ¿¹¸¦ µé¾î, young scar¿¡¼ old scar·Î ¼³¸íÇϰí ÀÖ´Ù(Dermatol Surg, 2007;33:1175–1188). ÇÊÀÚ°¡ ¾î¶°ÇÑ Á¾·ùµç 'scar'¿Í ¿¬°üµÈ Ä¡·á¸¦ Çϰųª ¿¬±¸¸¦ ÇÏ´Â °æ¿ì °¡Àå ¸¹ÀÌ Âü°íÇÏ´Â ³í¹®ÀÌ´Ù.
Áï ÃʱâÀÇ eyrthema³ª post inflammatory hyperpigmentation, post inflammatory hypopigmentation µî macular scar¸¦ ¡®grade I¡¯À¸·Î Á¤Çϰí, ÀÌÈÄ old scar·Î °¥¼ö·Ï hypertrophy³ª atrophy°¡ ½ÉÇØÁö´Â Çö»óÀ» ´Ü°èº°·Î ±¸ºÐÇÏ¿© ±â¼úÇϰí ÀÖ´Ù(Table 2).
Table 2. GoodmanÀÌ Á¦¾ÈÇÑ ÈäÅÍÀÇ grading system ¹× ÀÌ¿¡ ´ëÇÑ Ä¡·á¹æ¹ý ¿¹½Ã
´ëºÎºÐÀÇ scar´Â °ÑÀ¸·Î º¸±â¿¡ paleÇØ º¸ÀÌ´Â °æ¿ì°¡ ¸¹´Ù. ÇÏÁö¸¸ scarÀÇ »ö¼Ò¿¡ ´ëÇØ¼´Â ¸¹Àº °ü½ÉÀÌ ¾ø´Â °ÍÀÌ Çö½ÇÀÌ´Ù. ¶ÇÇÑ ÀÌ¿Í ¿¬°üµÈ ¿¬±¸¸¦ ã¾Æº¸±âµµ ¾î·Æ´Ù.
ÀϺΠ»ö¼Ò´Â »ö¼ÒÄ§ÂøÀÌ µÇ¾î Àִµ¥ ÀÌ¿Í °ü·ÃÇÏ¿©¼´Â melanotrophic hormoneÀÎ ACTH³ª MSH°°Àº hormoneÀÌ melanocyteÀÇ functionÀ̳ª migration¿¡ °ü¿©ÇÒ °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖÀ» »ÓÀÌ´Ù.
ÇÊÀÚ´Â scar¿Í »ö¼Ò¿ÍÀÇ °ü°è¿¡ ´ëÇÏ¿© ±â¼úµÈ ¿¬±¸ °á°ú¿Í Ä¡·á °æÇèÀ» ¹ÙÅÁÀ¸·Î scar tissue¿¡¼ º¸ÀÌ´Â »ö¼Ò º¯È¸¦ ´ÙÀ½°ú °°ÀÌ ºÐ·ùÇÏ¿´´Ù(Table 3).
Table 3. Pigmentary changes in scar tissue
-----------------------------------------------------------------------
[1] Hypo-Pigmented scar (Decreased number or activity of melanocyte)
[2] apparently Hypo-Pigmented scar (Normal number or activity of melanocyte)
[3] Hyper-Pigmented scar (Increased number or activity of melanocyte)
-----------------------------------------------------------------------
[1] Hypo-Pigmented scar (Decreased number or activity of melanocyte)
¡®Hypo-pigmented scar¡¯´Â Ä¡·á°¡ ½±Áö ¾ÊÀº ÈäÅÍÀÌ´Ù. ÀϹÝÀûÀ¸·Î wound healing °úÁ¤¿¡¼ ÃÖÁ¾ °á°ú·Î ³ªÅ¸³´Ù. ÇÏÁö¸¸, dermal remodelling °úÁ¤¿¡¼ ´ëºÎºÐÀÇ scar°¡ Ãʱ⿡´Â Àú»ö¼Ò·Î paleÇÏ°Ô º¸ÀÌ´Â °æ¿ì°¡ ´ëºÎºÐÀÌ´Ù. ÀÌ´Â Ãʱâ ÁøÇǰ¡ hypocellularÇϰí, collagen bundleÀÌ Ç¥ÇÇ¿Í parallelÇÑ °æÇâÀ» º¸À̰í, rete ridge effacement, ±×¸®°í, skin appendage°¡ ¾ÆÁ÷ ÃæºÐÈ÷ Çü¼ºµÇÁö ¾Ê¾Ò±â ¶§¹®ÀÌ´Ù.
Hypo-pigmented scar°¡ »ý±â´Â ¿øÀÎÀº,
1) Ç¥Çǰ¡ ¼Õ»óÀ» ¹ÞÀº ÈÄ Àç»ýµÇ´Â °úÁ¤¿¡¼ melanocyte°¡ ÁÖº¯ Á¤»óÁ¶Á÷¿¡¼ ÃæºÐÈ÷ migrationÇÏÁö ¾Ê°Å³ª,
2) melanocyte°¡ Á¤»óÀûÀÎ ±â´ÉÀ» ÇÏÁö ¾Ê±â ¶§¹®ÀÌ´Ù.
ÀÌ¿Í °°Àº ±âÀüÀ¸·Î, Àú»ö¼Ò¸¦ º¸ÀÌ´Â ÈäÅÍ¿¡ ´ëÇÑ Ä¡·á´Â ÀϹÝÀûÀ¸·Î ¡®vitiligo Ä¡·á¡¯¿¡ ÁØÇÏ¿© Ä¡·áÇÏ¸é µÈ´Ù. ´ÙÀ½°ú °°Àº Ä¡·á ¹æ¹ýµéÀ» °í·ÁÇØ º¼ ¼ö ÀÖ´Ù.
(1) Phototherapy with ¡®313 nm narrow band UVB¡¯, ¡®308 nm Excimer laser¡¯
¡®Hypopigmented scar¡¯¿¡¼ °¡Àå ¸ÕÀú ½ÃµµÇØ º¼ ¸¸ÇÑ Ä¡·á ¹æ¹ýÀÌ´Ù. ÇÏÁö¸¸, Hypopigmented scar¿¡¼ÀÇ melanocyte´Â ±× ±â´ÉÀÌ ¶³¾îÁ® ÀÖ´Â °æ¿ì°¡ ´ëºÎºÐÀÌ´Ù. µû¶ó¼, phototherapy¿¡ ¹ÝÀÀÇÏÁö ¾Ê´Â °æ¿ìµµ ¸¹´Ù.
»ö¼Ò·¹ÀÌÀú·Î ½Ã¼ú ÈÄ »ý±ä ÈäÅÍ ÈÄ ¹ß»ýÇÑ Àú»ö¼ÒÄ§ÂøÀÇ °æ¿ìµµ nUVB Ä¡·á¿¡ ÀϽÃÀûÀ¸·Î ¹ÝÀÀÇÏÁö¸¸, ¿À·£ ±â°£ Ä¡·á ÈÄ¿¡ ´Ù½Ã Àú»ö¼ÒÄ§ÂøÀ» ³²±â´Â °æ¿ìµµ ÀÖ´Ù. ¶ÇÇÑ, ÀÌ·± °æ¿ì Excimer laser¿¡µµ Àß ¹ÝÀÀÇÏÁö ¾Ê´Â´Ù(Dermatol Surg, 2008;34:1423–6).
ÇÊÀÚµµ ÈäÅÍ ÈÄ ¹ß»ýÇÑ Àú»ö¼ÒÄ§Âø¿¡ ´ëÇÑ ´Ù¾çÇÑ ÀÓ»ó°âÇèÀÌ ÀÖ´Ù. ȯÀÚ´Â ³»¿ø 1³âÀü ·¹ÀÌÀú¸¦ ÀÌ¿ëÇÑ Á¦¸ð ½Ã¼úÀ» ¹ÞÀº ÈÄ ¹ß»ýÇÑ Àú»ö¼Ò Ä§ÂøÀ¸·Î ³»¿øÇÏ¿´´Ù(Figure 1A). ȯÀÚ Áø¼ú¿¡ ÀÇÇÏ¸é ¹°ÁýÀÌ »ý±ä ÈÄ, 1ÁÖÈÄ µÎ²¨¿î µüÁö°¡ Á¦¸ð ½Ã¼úÇÑ ºÎÀ§¿¡ 2ÁÖ°£ Áö¼ÓµÇ¾ú´Ù°í ÇÑ´Ù. ÀÌÈÄ µüÁö ¶³¾îÁø ÀÚ¸®°¡ ´Ù¼Ò ÆäÀÎ ÈÄ »óó´Â È£Àü µÇ¾úÀ¸³ª, Àú»ö¼Ò Ä§ÂøÁõÀÌ Áö¼ÓµÇ¾î ³»¿øÇÏ¿´´Ù. ȯÀÚ´Â ³»¿ø Ãʱâ nUVB¸¦ ÀÌ¿ëÇÏ¿© Ä¡·áÇÏ¿´À¸³ª ¸¸Á·ÇÒ ¸¸ÇÑ È¿°ú¸¦ º¸ÀÌÁö ¾Ê¾Ò´Ù. ÀÌÈÄ ¡®0.025% tretinoin¡¯À» º´ÇàÇÏ¿© Ä¡·áÇÏ¿© È¿°úÀûÀ¸·Î Ä¡·áÇÑ »ç·ÊÀÌ´Ù(Figure 1B).
Figure 1. ·¹ÀÌÀú Á¦¸ð ÈÄ ¹ß»ýÇÑ Àú»ö¼Ò(A), °ú 'nUVB + 0.025% tretinoin' Ä¡·á ÈÄ ÀÓ»ó ¼Ò°ß(B).
(2) Fractional lasers
Fractional laser´Â ´Ù¾çÇÑ Á¾·ùÀÇ scar Ä¡·á¿¡ Ȱ¿ëµÇ°í ÀÖ´Ù. ÇÏÁö¸¸ ÀÌ¿Í °°Àº ÈäÅ͸¦ Ä¡·áÇÏ´Â °úÁ¤¿¡¼ ºÎ°¡ÀûÀ¸·Î Àú»ö¼Ò°¡ È£ÀüµÇ´Â °æ¿ì°¡ ¸¹ÀÌ º¸°íµÇ°í ÀÖ´Ù(Fractional resurfacing for the treatment of hypopigmented scars. Dermatol Surg 2007;33:289–94).
¡®ÈäÅÍ ÈÄ ¹ß»ýÇÑ Àú»ö¼Ò¡¯ »Ó ¾Æ´Ï¶ó ¡®¹é¹ÝÁõ Ä¡·á¡¯¿¡ À־µ ³Î¸® ½Ã¼úµÇ°í ÀÖ´Ù.
´Ù¾çÇÑ Á¾·ùÀÇ fractional laser°¡ Ä¡·á¿¡ ÀÀ¿ëµÇ´Âµ¥, ±¹³»¿¡¼µµ ÇÑ½Â°æ ¼±»ý´ÔÀÌ CO2 fractional laser¸¦ ÀÌ¿ëÇÑ ¸¹Àº ÀÓ»ó »ç·Ê¸¦ ¹ßÇ¥ÇÑ ¹Ù ÀÖ´Ù(British J Dermatol, 2012;166,658–661),
ÃÖ±Ù¿¡´Â hypo-pigmented scar¸¦ ¡®1,550 nm Er:glass Fractionated Laser¡¯¿Í ¡®Topical Bimatoprost¡¯¸¦ º´ÇàÇÏ¿© È¿°úÀûÀ¸·Î Ä¡·áÇÑ »ç·Êµµ º¸°íµÈ ¹Ù ÀÖ´Ù(Dermatol Surg, 2012;38:995–1001).
ÀÌ¿Í °°Àº Ä¡·á ±âÀüÀº ÁÖº¯ Á¤»ó melanocyte°¡ fractional laser ½Ã¼ú ÈÄ migration ÇÏ¸é¼ repopulation µÇ¸é¼ »ö¼Ò°¡ È£ÀüµÈ´Ù. ÇÏÁö¸¸, ºÎ°¡ÀûÀ¸·Î fractional laser°¡ fibroblast¸¦ ÀÚ±ØÇÏ¸é¼ collagen remodelling°ú ÇÔ²² SCF µî°ú °°Àº 'melanocyte¸¦ ÀÚ±ØÇÏ´Â cytokineµé'À» ºÐºñÇÏ°Ô ÇÑ´Ù. ÀÌ·Î ÀÎÇÏ¿© melanocyteÀÇ ¼ö¿Í ±â´ÉÀÌ È°¼ºÈ µÇ´Â °ÍÀ¸·Î »ý°¢µÈ´Ù.
Fractional laser¸¦ ÀÌ¿ëÇÑ hypo-pigmented scarÀÇ Ä¡·á´Â. ¡®atrophic scar¡¯¿¡ ¡®hypo-pigmentation¡¯ÀÌ µ¿¹ÝµÇ¾î ÀÖÀ» ¶§ ¿ì¼±ÀûÀ¸·Î °í·ÁÇØº¼¸¸ÇÑ Ä¡·á¹æ¹ýÀÌ´Ù.
(3) Topical Retinoids
Topical retinoid´Â photo-aged skin¿¡ ÀÖ¾î¼ ³Î¸® »ç¿ëµÇ¾î ¿Â ¾àÀçÀÌ´Ù.
»ö¼ÒÄ¡·á¿¡ ÀÖ¾î¼ topical retinoid´Â 2°¡Áö »ó¹ÝµÈ ±â´ÉÀÌ ÀÖ´Ù.
1) Repigmentation: melanocyteÀÇ differentiationÀ» ÃËÁø ½ÃÄѼ, melanogenesis¸¦ stimulation ½ÃŲ´Ù.
2) Depigmentation: mature melanocyteÀÇ apoptosis¸¦ À¯¹ßÇÏ¿©, melanocyte¸¦ Á¦°ÅÇÏ´Â ±âÀüÀ¸·Î ¹Ì¹éÈ¿°ú À¯¹ß
Topical retinoid´Â melaninÀÌ Ç¥ÇÇ¿¡¼ °í¸£°Ô ºÐÆ÷Çϵµ·Ï µµ¿ÍÁÖ°í, stratum corneum¿¡ ÀÛ¿ëÇÏ¿© Ç¥ÇÇ¿¡ ´Ù¸¥ ¾àÀç°¡ Àß Åõ°ú µÉ ¼ö ÀÖµµ·Ï µµ¿ÍÁÖ´Â ÀÛ¿ëÀ» ÇÑ´Ù. ¶ÇÇÑ tyrosinase activity¿¡µµ ÀÛ¿ëÇϴµ¥ tyrosinase activity¸¦ Áõ°¡½Ã۱⵵ Çϰí, ¾ïÁ¦Çϱ⵵ ÇÏ´Â ±âÀüÀÌ Áõ¸íµÈ ¹Ù ÀÖ´Ù. ÀÌ¿Í °°Àº ±âÀüÀ¸·Î topical retinoid°¡ ¡®Àú»ö¼Ò¡¯ ȤÀº ¡®°ú»ö¼Ò¡¯ÀÇ °³¼±¿¡ µµ¿òÀ» ÁØ´Ù.
(4) Topical Immunomodulatory drugs: Topical Calcineurin inhibitors (Tacrolimus or Pimecrolimus)
Calcineurin inhibitor´Â 'activated T-cell¡®¿¡¼ ³ª¿À´Â °¢Á¾ cytokineµéÀ» ¼¼Æ÷ ´ÜÀ§¿¡¼ ¾ïÁ¦ÇÑ´Ù. ÀÌ¿Í °°Àº ÀÛ¿ëÀ¸·Î 'activated T-cell'¿¡ ÀÇÇØ¼ melanocyte°¡ ÆÄ±« µÇ´Â °ÍÀ» ¸·¾Æ ÁØ´Ù. ¶ÇÇÑ topical calcineurin inhibitor´Â keratinocyte¿¡ ÀÛ¿ëÇÏ¿© melanocyte¿Í melanoblast proliferationÀ» Áõ°¡½ÃŲ´Ù(H.Y. Kang, FK506 increases pigmentation and migration of human melanocytes. British J Dermatol, 2006;155,1037–1040).
(5) Topical Bimatoprost: Prostaglandin analogue
Bimatoprost´Â Glaucoma Ä¡·áÁ¦·Î °³¹ßµÈ ¾àÀçÀÌ´Ù. ÇÏÁö¸¸ Ä¡·á µµÁß ¼Ó´«½çÀÌ ±æ¾îÁö°í, ´«°¡ ÁÖº¯¿¡ »ö¼Ò Ä§ÂøÀÌ ³ªÅ¸³ª´Â °ÍÀ» ¹ß°ßÇϰí ÃÖ±Ù¿¡´Â ¡®Å»¸ð Ä¡·á(J Am Acad Dermatol, 2012;66:794-800)¡¯ ¹× ¡®Àú»ö¼ÒÄ§ÂøÀÇ Ä¡·á(Dermatol Surg 2012;38:995–1001)¡¯¿¡ ½Ãµµ µÇ°í ÀÖ´Ù. Åë»óÀûÀ¸·Î bimatoprost¸¦ ¹Ù¸¥ ÈÄ »ö¼ÒÄ§ÂøÀº 3°³¿ù ÀÌÈÄ¿¡ »ý±ä´Ù.
Bimatoprost¿¡ ÀÇÇÑ »ö¼ÒÄ§Âø¿¡¼ ½ÃÇàÇÑ Á¶Á÷°Ë»ç¿¡¼ ½ÇÁ¦ melanocyte ¼ö³ª Å©±âÀÇ º¯È´Â ¾ø¾úÁö¸¸, keratinocyte ·ÎÀÇ transfer°¡ Áõ°¡µÇ¾î ÀÖ´Â ¼Ò°ßÀ» º¸¿´´Ù. ´Ù¸¥ In vitro ½ÇÇè¿¡¼µµ ½ÇÁ¦ melanocyteÀÇ function¿¡ Á÷Á¢ÀûÀ¸·Î ¿µÇâÀ» ÁÖÁö´Â ¾Ê´Â °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖ´Ù.
[2] apparently Hypo-Pigmented scar (Normal number or activity of melanocyte)
¾Õ¿¡¼ ¾ð±ÞÇÑ ¹Ù¿Í °°ÀÌ ´ëºÎºÐÀÇ scar´Â °ÑÀ¸·Î º¸±â¿¡ paleÇØ º¸ÀÌ´Â °æ¿ì°¡ ¸¹´Ù. ÇÏÁö¸¸ ½ÇÁ¦ melanocyteÀÇ ¼ö¿Í ±â´É°ú´Â °ü°è¾øÀÌ paleÇØ º¸ÀÌ´Â °æ¿ìµµ ÀÖ´Ù(Acta Derm Venereol, 2001;81:326–328).
2001³â ¿µ±¹¿¡¼ 16¸íÀÇ paleÇØ º¸ÀÌ´Â scar¸¦ ´ë»óÀ¸·Î ÇÏ¿´´Ù. ÈäÅÍ Á¶Á÷°ú ÁÖº¯ Á¤»óÁ¶Á÷À» °¢°¢ °Ë»çÇÏ¿©, ÈäÅÍ Á¶Á÷ ³»ÀÇ,
1) ¡®melanocyte ¼ö(Mel-5, c-kit, NKI-betab)¡¯¿Í
2) ¡®melanin pigmentÀÇ ¾ç(Fontana-Masson stain)¡¯À» ºñ±³ÇØ º¸¾Ò´Ù.
¿¬±¸ °á°ú ÈäÅÍ Á¶Á÷°ú ÁÖº¯ Á¤»óÁ¶Á÷ÀÇ 'melanocyte ¼ö'¿Í 'melanin pigmentÀÇ ¾ç'¿¡´Â º¯È°¡ ¾ø¾ú´Ù. ¿ÀÈ÷·Á, wound healing Ãʱ⿡´Â ÁÖº¯ melanocyte°¡ scar tissue·Î migration Çϸé¼, 'melanocyteÀÇ ¼ö°¡ Áõ°¡'ÇÏ´Â °æ¿ìµµ ÀÖ¾ú´Ù.
ÀÌ¿Í °°ÀÌ °ÑÀ¸·Î¸¸ paleÇÏ°Ô º¸ÀÌ´Â ÀÌÀ¯(apparently Hypo-Pigmented scar)´Â ´ÙÀ½°ú °°Àº ÀÌÀ¯ÀÌ´Ù.
1) ÁÖº¯ Á¤»ó Á¶Á÷°úÀÇ vascularityÀÇ Â÷ÀÌ ¶§¹®.
ÈäÅÍ Á¶Á÷ ³»¿¡ blood vesselÀÇ ¾çÀÌ ÁÖº¯ Á¤»óÁ¶Á÷ º¸´Ù Àû±â ¶§¹®¿¡ paleÇØ º¸ÀδÙ. NoradrenalineÀ» ÇÇÇÏ ÁÖ»çÇϸé ÁÖº¯ Á¤»ó Á¶Á÷º¸´Ù paleÇØ º¸À̴µ¥ ÀÌ´Â Ç÷°ü ¼öÃà¿¡ ÀÇÇØ¼ ¹ß»ýÇÏ´Â Çö»óÀÌ´Ù.
2) Á¤»óÁ¶Á÷¿¡¼ collagen fiber´Â randomÇÏ°Ô ¹è¿µÇ¾î Àִµ¥, ÈäÅÍ Á¶Á÷ ³»¿¡¼´Â circular ÇÏ°Ô ¹è¿µÇ¾î ÀÖ´Ù. ÀÌ·Î ÀÎÇØ¼ light reflectionÀÌ Àû±â ¶§¹®¿¡ paleÇÏ°Ô º¸ÀδÙ(Anderson & Parrish. The optics of human skin. J Invest Dermatol, 1981;77:13–19).
3) ÈäÅÍ Á¶Á÷¿¡¼ Ç¥ÇÇÀÇ ±¼°î ¶§¹®ÀÌ´Ù. Áï ÈäÅÍ Á¶Á÷À§¿¡ Àִ ǥÇÇ´Â Á¾Á¾ ¡®¾ã¾ÆÁ® ÀÖ´Â °æ¿ì(epidermal thinning, rete ridge flattening)¡¯°¡ ¸¹´Ù. ÀÌ·Î ÀÎÇÏ¿© optical density°¡ ¶³¾îÁ®¼ pale ÇÏ°Ô º¸ÀÏ ¼ö ÀÖ´Ù.
[3] Hyper-Pigmented scar (Increased number or activity of melanocyte)
Wound healing °úÁ¤¿¡¼µµ °ú»ö¼ÒÄ§ÂøÀÌ »ý±æ ¼ö ÀÖ´Ù(Hyper-Pigmented scar). Wound healing ÈÄ ¿ø·¡ ÀÖ¾ú´ø »ö¼Ò¼º º´º¯ÀÌ ´õ ÁøÇØÁö°Å³ª, ¿ø·¡ ÀÖ¾ú´ø º´º¯ÀÌ ¾ø¾îÁö¸é¼ ±âÁ¸¿¡ Á¸ÀçÇÏÁö ¾Ê¾Ò´ø »ö¼Ò°¡ ¹ß»ýÇÑ °æ¿ìÀÌ´Ù.
Hyper-Pigmented scar°¡ »ý±â´Â ±âÀüÀº wound healing °úÁ¤¿¡¼ ¹ß»ýÇÏ´Â ¿©·¯ °¡Áö cytokine°ú °ü¿©ÇÑ´Ù. Wound healing °úÁ¤¿¡¼ fibroblast´Â ¸Å¿ì Áß¿äÇÑ ¿ªÇÒÀ» ÇÑ´Ù. ÀÌ¿Í °°Àº fibroblast´Â melanocyte ¹× Keratinocyte¿Í ¹ÐÁ¢ÇÑ ¿¬°ü °ü°è°¡ ÀÖ´Ù(Figure 2. Imokawa G. Biochem J, 1998, Pigment Cell Res, 2004).
Figure 2. Relationship with Fibroblast, Melanocyte and Keratinocyte
Wound healing °úÁ¤¿¡¼ fibroblast¿¡ ÀÇÇØ¼ À¯¹ßµÈ ´Ù¾çÇÑ cytokineÀÌ Ç¥ÇÇÀÇ melanocyte¸¦ ÀÚ±ØÇÏ¿© melanocyteÀÇ ±â´É°ú ¼ö°¡ Áõ°¡µÇ°Ô µÈ´Ù. ÀÌ Áß °¡Àå Áß¿äÇÑ ¿ä¼Ò´Â SCF¿Í HGFÀÌ´Ù.
´ÙÀ½Àº fibroblast°¡ Ç¥ÇÇÀÇ »ö¼ÒÄ§Âø¿¡ ¿µÇâÀ» Áشٴ ±Ù°ÅÀÌ´Ù.
1) Dermatofibroma´Â ÀÓ»óÀûÀ¸·Î °ú»ö¼ÒÄ§ÂøÀ» º¸ÀÌ´Â ¾ç¼ºÁ¾¾çÀÌ´Ù. Fibroblast°¡ Áõ°¡µÇ´Â ÁúȯÀÎ dermatofibroma¿¡¼ SCF¿Í HGF°¡ Áõ°¡µÈ ¼Ò°ßÀ» º¸¿´´Ù(Shishido et al. J Invest Dermatol, 2001).
2) ¿ª½Ã fibroblastÀÇ ÀÌ»ó°ú °ü·ÃµÈ systemic sclerosisµµ °ú»ö¼ÒÄ§ÂøÀÌ Æ¯Â¡ÀûÀÎ ÁúȯÀÌ´Ù. Systemic sclerosis¿¡¼ ½ÃÇàÇÑ ¿¬±¸¿¡¼ SCF°¡ Áõ°¡µÈ ¼Ò°ßÀ» º¸¿´´Ù(Yamamoto et al. Br J Dermatol, 2001)
3) Neurofirboma ȯÀÚ¿¡¼ Ư¡ÀûÀÎ °ú»ö¼ÒÄ§ÂøÀ» º¸ÀÌ´Â º´º¯Àº ¡®cafe-au-lait macule¡®ÀÌ´Ù. ÀÌ »ö¼Ò¼º º´º¯¿¡¼ ¿ª½Ã SCF¿Í HGF°¡ Áõ°¡µÈ ¼Ò°ßÀ» º¸¿´´Ù(Br J Dermatol, 2003).
4) ¾ÆÁÖ´ë¿¡¼ ±â¹Ì ȯÀÚ¿¡¼ ½ÃÇàÇÑ ¿¬±¸¿¡¼µµ À¯»çÇÑ °á°ú¸¦ º¸¿´´Ù. ±â¹ÌÁ¶Á÷¿¡¼ Á¤»óÁ¶Á÷¿¡ ºñÇÏ¿© SCF¿Í c-kitÀÌ Áõ°¡µÇ¾ú´Ù°í º¸°íÇÏ¿´´Ù(Br J Dermatol, 2002).
Fractional laser·Î ±â¹Ì¸¦ Ä¡·áÇÏ¿´´Ù´Â ¼¾ç ³í¹®ÀÌ ÀÖ´Ù. ÇÏÁö¸¸, ÀÌ´Â ¼¾çÀεéÀÌ ±â¹Ì¿¡ ´ëÇÑ Áø´ÜÀ̳ª ÀÌÇØ°¡ ºÎÁ·Çؼ »ý±â´Â Çö»óÀÌ´Ù(J Am Acd Dermatol, 2009;60:197, Semin Cutan Med Surg, 2008;27:63-71). ½ÇÁ¦ ÀÓ»ó¿¡¼ ±â¹ÌȯÀÚ¿¡°Ô fractional laser¸¦ ½Ã¼úÇÏ¸é ¿ÀÈ÷·Á ¾ÇȵǴ °æ¿ì°¡ ´ëºÎºÐÀÌ´Ù. ÀÌ´Â fractional laser ½Ã¼ú ÈÄ fibroblast°¡ activation µÇ¾î ¹ß»ýÇÏ´Â Çö»óÀ¸·Î ÃßÁ¤µÈ´Ù(Table 4).
Table 4. Suspected mechanism of worsened melasma by fractional laser
-------------------------------------------------------------
Fractional photothermolysis
--> activation of fibroblast in dermis
--> release of various cytokines from fibroblast (SCF, c-kit)
--> stimulate the basal melanocyte of melasma by SCF & c-kit
--> clinicaly worsened melasma
-------------------------------------------------------------
¡®Hyper-Pigmented scar¡¯ÀÇ Ä¡·á ¹æ¹ýÀº ¡®laser toning¡¯°ú ¡®°¢Á¾ ¾àÀ硯¸¦ º´ÇàÇÏ´Â ¹æ¹ýÀÌ´Ù. ÇÏÁö¸¸, ±âÁ¸ÀÇ PIH³ª Melasma¿Í °°Àº ´Ù¸¥ »ö¼Ò¼º º´º¯¿¡ ºñÇÏ¿© Ä¡·á¿¡ ¹ÝÀÀÇÏÁö ¾Ê´Â´Ù.
Laser toningÀº 2010³â JID¿¡ °í´ë ±èÀÏȯ ±³¼ö°¡ ¹ßÇ¥ÇÑ ¡®Subcellular SPTL¡¯¿¡ ÀÌ·ÐÀû ±â¹ÝÀ» µÐ Ä¡·á ¹æ¹ýÀÌ´Ù(Figure 3).
Figure 3. Laser Toning for Melasma and PIH
¾ÖÃÊ¿¡´Â ±â¹Ì¸¦ ÁÖ¿ä Ä¡·á targetÀ¸·Î Àû¿ëµÇ¾úÀ¸³ª, ´Ù¾çÇÑ °ú»ö¼ÒÄ§ÂøÀÇ Ä¡·á¿¡ ¼º°øÀûÀ¸·Î Àû¿ëÇÑ º¸°í°¡ ÀÖ´Ù(Treatment of PIH with laser toning: JEADV, 2009:23;1197–1223).
Low fluenceÀÇ 1064 nm Q-switched Nd:YAG laser beamÀ» Á¶»çÇϸé, melanocyte³ª dermal melanophage´Â Á¤»óÀûÀ¸·Î »ì¾Æ ÀÖÀ¸¸é¼, ÀÎÁ¢ keratinocyte³ª melanocyteÀÇ melanosomeÀº ÆÄ±«µÇ´Â °ÍÀ» ¹ß°ßÇÏ¿´´Ù. À̶§ melanocyte¸¦ °üÂûÇØ º¸´Ï, dendrite°¡ Àß·Á¼ ³ª°¡°í melanosomeÀÌ »ç¶óÁø °ÍÀ» ¾Ë°Ô µÇ¾ú´Ù. ¶ÇÇÑ ¾Æ´Ï¶ó PAR-2ÀÌ °¨¼ÒµÇ¾ú°í, TRP-1À̳ª TRP-2°ú °°Àº tyrosinase¿Í ¿¬°üµÈ proteinÀÌ °¨¼ÒµÇ¾î ÀÖ´Â °ÍÀ¸·Î º¸¾Æ, »ö¼ÒÀÇ Ä¡·á°¡ »ó´ç±â°£ Áö¼ÓµÉ °ÍÀ» ¿¹ÃøÇÒ ¼ö ÀÖ´Ù(TRP: Tyrosinase Related Protein).
Scar remodelling ÀÌÈÄ »ö¼ÒÄ§ÂøÀ» ¿¹¹æÇÏ´Â °¡Àå ÁÁÀº ¹æ¹ýÀº ¡®inflammationÀ» ¾ïÁ¦¡¯ÇÏ´Â °ÍÀÌ´Ù. ÇǺδ Àڿܼ±À̳ª laser °°Àº ¿ÜºÎ ¼Õ»ó¿¡ ¹ÝÀÀÇÏ¿© ¿°ÁõÀ» ¸¸µç´Ù. ¡®¾ó¸¶³ª ¿°Áõ¹ÝÀÀÀ» ÃÖ¼ÒÈ ÇÏ´À³Ä¡¯°¡ °ú»ö¼ÒÄ§ÂøÀÇ ¹ß»ý ºóµµ¸¦ ÁÙÀÏ ¼ö ÀÖ´Ù. µû¶ó¼ anti-inflammatory agent°¡ °ú»ö¼ÒÄ§Âø ¿¹¹æ¿¡ ¸Å¿ì Áß¿äÇÏ´Ù. µû¶ó¼, °¡Àå °·ÂÇÑ anti-inflammatory agentÀÎ ¡®steroid¡¯¸¦ Ä¡·á ÀüÈÄ Åõ¿©ÇÏ¿©¾ß ÇÑ´Ù.
Topical steroid´Â °ú»ö¼ÒÄ§ÂøÀ» ¿¹¹æÇϰí, °¢Á¾ ¾àÀ縦 bufferingÇÏ´Â È¿°ú°¡ ÀÖ´Ù. ¶ÇÇÑ ±× ÀÚü·Îµµ ¹Ì¹éÈ¿°ú°¡ ÀÖ´Ù. Wound healing °úÁ¤¿¡¼ ÀûÀýÇÏ°Ô topical steroid¸¦ Ȱ¿ëÇϸé wound healing °úÁ¤¿¡¼ ¾î´À Á¤µµ °ú»ö¼ÒÄ§ÂøÀ» ¿¹¹æÇÒ ¼ö ÀÖ´Ù. ÇÏÁö¸¸ wound healingÀÌ ÃæºÐÈ÷ ÀÌ·ç¾îÁöÁö ¾ÊÀº »óÅ¿¡¼ topical steroid³ª systemic steroid¸¦ Åõ¿©ÇÏ´Â °ÍÀº ½ÅÁßÇÏ°Ô °áÁ¤ÇØ¾ß ÇÑ´Ù. Steroid°¡ wound healing °úÁ¤À» ¾ïÁ¦ÇÒ ¼öµµ Àֱ⠶§¹®ÀÌ´Ù.
Hyper-Pigmented scarÀÇ È¿°úÀûÀÎ Ä¡·á À¯Áö¸¦ À§ÇÏ¿©¼´Â »ö¼Ò°¡ ´Ù½Ã »ý¼ºµÇÁö ¾Êµµ·Ï ¾ïÁ¦ÇÏ¿©¾ß ÇÑ´Ù. À̶§ melanocyte¿¡¼ ±Ùº»ÀûÀ¸·Î »ö¼ÒÀÇ »ý¼ºÀ» ¾ïÁ¦ÇÏ´Â °ÍÀÌ Áß¿äÇÏ´Ù(inhibition of tyrosinase activity).
°¡Àå °í½ÄÀûÀ¸·Î ¿À·¡ »ç¿ëµÇ¾î¿Â ¾àÀç´Â ¡®Hydroquinone¡¯ÀÌ´Ù. HydroquinoneÀº tyrosinase activity¸¦ ¾ïÁ¦ÇÏ¿© ¡®dopa°¡ melaninÀ¸·Î ¹Ù²î´Â step¡¯À» ¾ïÁ¦ÇÏ¿© melanin Çü¼ºÀ» ¾ïÁ¦ÇÑ´Ù.
¡®Topical retinoid¡® ¶ÇÇÑ ¿À·£ ±â°£ melasma¿Í PIHÀÇ Ä¡·á¿¡ Ȱ¿ëµÇ¾î ¿Ô´Ù. ÇöÀç ÀÓ»ó¿¡¼ »ö¼Ò Ä¡·á ¸ñÀûÀ¸·Î »ç¿ëµÇ´Â retinoid´Â ÁÖ·Î tretinoin (all-trans-retinoid acid)ÀÌ´Ù.
TretinoinÀÌ »ö¼Ò Ä¡·á¿¡ µµ¿òÀ» ÁÖ´Â ±âÀüÀº Á¤È®ÇÏ°Ô ¿¬±¸µÇÁö´Â ¾Ê¾ÒÁö¸¸,
1) epidermal turn over¸¦ ÃËÁøÇÏ¿© bleaching¿¡ °ü¿©Çϰí,
2) 'UVB-induced tyrosinase'¿Í 'TRP-1 __EXPRESSION__'À» ¾ïÁ¦ÇÏ¿©, melanin synthesis¸¦ ¹æÇØÇÏ´Â °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖ´Ù.
ÇÏÁö¸¸, µÎ °¡Áö ¾àÀç ¸ðµÎ Àå´ÜÁ¡ÀÌ ÀÖ¾î, ÇöÀç´Â ÀÌ·¯ÇÑ ¾àÀçµéÀ» º´ÇÕÇÑ 'Triple Combination Cream'ÀÌ ÀÓ»óÀûÀ¸·Î ³Î¸® »ç¿ëµÇ°í ÀÖ´Ù(Role of Retinoid in Pigmentary Disease, Am J Clin Dermatol, 2009:10;251-260).
´ëÇ¥ÀûÀÎ 'triple combination cream'ÀÎ Kligman Formula´Â ¡¯hydroquinone 5%¡®, ¡¯retinoic acid (tretinoin 0.1%)¡®, ¡¯steroid (dexamethasone 0.1%)¡®°¡ ÀÏÁ¤ÇÑ ºñÀ²·Î ¼¯¿©ÀÖ´Â formulaÀÌ´Ù. Kligman°ú Willis´Â ÀÌ ¼¼ °¡Áö ¾àÀç Áß ÇÑ °¡Áö¸¦ »©´Â °æ¿ì, ±× È¿°ú°¡ ¸¹ÀÌ ¶³¾îÁö´Â °ÍÀ» ¹ß°ßÇÏ¿´´Ù. ¶ÇÇÑ, ÀÌ ¼¼ °¡Áö ¾àÀ縦 º´ÇÕÇÏ¿© Ä¡·áÇÏ¿´À» ¶§, °¢ÀÚÀÇ ¾àÀç°¡ °¡Áö°í ÀÖ´Â ºÎÀÛ¿ëÀ» ³·ÃçÁÙ ¼ö ÀÖ´Â °Í ¶ÇÇÑ ¾Ë°Ô µÇ¾ú´Ù. °á·ÐÀûÀ¸·Î Kligman formula´Â melanocyteÀÇ melanin »ý¼ºÀ» È¿°úÀûÀ¸·Î ¾ïÁ¦ÇÑ´Ù.
ÇÏÁö¸¸ scar remodeling ÈÄ ¹ß»ýÇÏ´Â ¸ðµç ¹®Á¦¸¦ ÇÑ °¡Áö ¹æ¹ýÀ¸·Î ¿¹¹æ ¹× Ä¡·áÇÒ ¼ö´Â ¾ø´Ù. ´Ù¾çÇÑ »óȲÀÌ Á¸ÀçÇϱ⠶§¹®ÀÌ´Ù. Topical agent¸¦ ¼±ÅÃÇÔ¿¡ À־µ ´ÙÀ½°ú °°Àº ¿øÄ¢À» °¡Áö°í ½ÃÇàÇϸé È¿°úÀûÀ¸·Î °ú»ö¼Ò Ä§ÂøÀ» Ä¡·áÇÒ ¼ö ÀÖ´Ù(Figure 4).
Figure 4. Treatment Strategy for PIH
*Disclosure------------------------------------------------------
.2013³â 12¿ù 2ÀÏ ¼¿ï¼º¸ðº´¿ø¿¡¼ °³ÃÖµÈ Á¦18Â÷ ´ëÇѹ̿ëÇǺοܰúÇÐȸ ½ÉÆ÷Áö¾ö¿¡¼ ¹ßÇ¥µÈ ³»¿ëÀÔ´Ï´Ù.