Trade-offs Between Risks and Benefits of Drug Treatment for Skin Diseases 用这些药物治疗皮肤病值得吗？
A 25-year-old woman presents with redness of the hands and reports the intermittent occurrence of tiny vesicles, and scaling, accompanied by itching on the palms, fingers, and dorsal sides of the hands. She has a history of childhood eczema and asthma. On physical examination, the patient was afebrile with normal vital signs. The blood and urine laboratory investigation does not show abnormal findings.
Her medical history disclosed that she was administered with Cyclosporine [1] initially, one year later, the topical corticosetroids was given additionally, most recently, 6 months ago, she was administered with Azathioprine [2] to replace Cyclosporine and topical steroids. Her eczema is well controlled by this strong immunuosuppressant as seen on Fig.1A.
She have to carry on the treatment to clear the rashes, which inevitably comes back upon stopping usage. But the side effects of the drugs make her frustrated. She is on the horns of dilemma. Finally she decided to seek third party opions.
She was given 2 months of natural washout for her prior immunosuppressants, following with the herbal TCM medicine initiated. The eczema flares up intesively due to immunosuppressants withdrawal, 2 months later, she responded to the herbal treatment well, with the eczematous lesion subsiding and flaked off. Her eczema is in complete remission at the end of treatment month 13 on Fig.1F and Fig.2F [3]. There is no relapse on the follow-up till date.
The underlying thinking of this case is that the potent immnuosuppressants do offer potentially significant therapeutic benefits, but they were found to carry risks of serious, possibly life-threatening adverse events meanwhile:
- Cyclosporine (ciclosporin) [1] is used for Kidney, Liver, and Heart Transplantation, Rheumatoid Arthritis and serious Psoriasis. However it can cause Nephrotoxicity [US Boxed Warning], Hypertension [US Boxed Warning], Skin Cance [US Boxed Warning], Infections [US Boxed Warning] etc.
- Azathioprine [2] is used for Kidney Transplants, it can cause Malignancy [US Boxed Warning], Gastrointestinal toxicity, Hematologic toxicity, Hepatotoxicity and Malignancy.
Risk-benefit trade-off refers to the balance of negative and positive effects on achieving a goal, such as health. For medical decisions, a risk-benefit trade-off usually refers to the perception of the anticipated balance of improvements and deteriorations in health from a given choice. To make good decisions about treatment, patients should understand the trade-offs. What is the magnitude of the benefit? What is the magnitude of the harm? Are you overtreated? The benefit of treatment must be weighed against its harms.
25岁女孩有儿童湿疹和哮喘病史。2年前她的手指手掌背侧偶尔奇痒无比之后出现小水泡。她的体温正常。血液尿液实验室检查结果正常。
她的治疗史显示她服用环孢霉素治疗，一年之后，另加外用皮质类固醇药膏治疗。在6个月前，口服咪唑硫嘌呤替代环孢霉素和皮质激素。她的湿疹从外表上看，用这些强效的免疫抑制剂控制的不错，如图Fig.1A. Fig.2A
她不得不依赖免疫抑制剂来控制她的皮肤湿疹，一旦停用，湿疹随即反弹发作。免疫抑制治疗带来的副作用让她焦虑不安，却又无法停用，她骑虎难下，进退两难。最后她决定戒除免疫抑制剂去寻求其他治疗方案。
她选择服用植物中药治疗，清洗免疫抑制剂2个月后，她的皮肤出现免疫抑制剂戒断综合征，湿疹水泡反弹。有继续中药治疗两个月后，湿疹显著缓解，皮疹水泡持续消退，在治疗到13个月结束时，她的湿疹已经完全消退。随访至今未有反弹出现。如图Fig.1F Fig.2F.
病例反思：强效免疫抑制剂治疗效果的确即快又显著，但可能会导致危及生命安全的副作用，这样的治疗值得吗？
- 环孢霉素是美国FDA批准治疗肾肝心脏的器官移植药，类风湿关节炎和严重银屑病用药。它会导致肾毒，高血压，皮肤癌，感染。副作用均为FDA黑色方框警告。
- 咪唑硫嘌呤是美国FDA批准治疗肾脏的器官移植药。它会导致消化道肠道毒，血液毒性，肝脏损伤。副作用均为FDA黑色方框警告。
对于医疗而言，药物的利弊得失分析尤为重要。为了做出明智的治疗选择，必须问：治疗带来的好处有多大？治疗带来的伤害有多大？好处是否抵消伤害？
