潘卫利

【脱发真是令人烦恼】 当人类的祖先从爬行变成站立行走，又走出丛林深处之后，身上的体毛慢慢退去，毛发也分化成了硬毛和毳毛。 毳毛俗称汗毛，而硬毛组成了胡须和头发。 经过自然的选择，人类直立行走后，把茂密的头发留下来，是为了保护头皮免受外界压力和光线的影响，并在头顶建立缓冲带，防止过冷和过热。 但是这个世界，充满了希望也充满了挑战。 战争、贫困、瘟疫、无知愚昧、环境污染和全球气候变暖，不但消灭了野生动植物，也给人类自身带来了极大危害。 人类的进化，相较于我们的祖先，变得更加不确定性。 “不能输在起跑线上”是当今中国爸爸妈妈的生活座右铭。 胎教、学前教育、小学的多样化兴趣班、中学为重点高中的拼搏、高中为名牌大学而奋斗。大学毕业后就更加不能停息。 脑筋动得多了，头发就缺了营养。 在每天熬夜中度过的人，随着墨水喝得越来越多，位置越来越高，口袋的也钱越来越多。 但是照照镜子，摸摸头，却发现发现自己的头发越来越少了。 这个世界就是这样，有得到的，总是有失去的。 失去头发最多影响美观，但是失去亲人，却会带来长久的痛苦，就像这次新冠疫情。 其实头发少也挺好的，节省了打理的时间，也让我们有了一双没有遮挡的慧眼 ，更容易把这个变幻莫测的世界看得真真切切明明白白。 在我们每一个人一出生时，上帝给我们的10万个毛囊，就在这纷扰的环境中迅速的变少。 毛囊的活力决定着毛发的生长。毛囊在出生后只会减少，不会增加，所以留得青山在是重中之重。只要90%的毛囊处于生长期，头顶的毛发就生机勃勃，郁郁葱葱。 头发的寿命大概是2～8年。寿命到后脱落，可以再生长，只要毛囊还在，就有希望，就像雨后的春笋。 但是它可没有像春笋长得这么快。一到春天，农贸市场的笋马上就会堆积如山。 头发一个月才长1公分。不过有时候感觉头发长得够快了，因为记得刚理了发，怎么又要去美发店了。 在这个男性主宰的世界里，女性的生存更困难，更辛苦。所以上帝给女性的头发的生长周期更长，所以更经得起折腾。 因此在这个世界上，我们经常看到男性精英们，西装革履的，晃动着头发稀疏或者亮亮的脑袋在发表演讲。 男人也不容易，要主宰这个世界当然要付出很多血本，也需要足够的体力和精神的支持，而且好像精神的压力更耗费体力。没办法，谁让我们是男人呢！ 我们需要越来越多的雄性激素来激活我们身体的潜能，这是自然的选择，女性也一样。 科技的发展，空前的加速了人类社会前进的步伐。 人工智能、物联网、大数据已经是人尽皆知的科学代名词。 然而人类在自身问题面前依然裹足难行。  我们发现了雄激素的代谢产物二氢睾酮对毛囊有毒性。但是用来对付二氢睾酮产生的药物却只有区区几种。 导致头发越来越少的原因，除了雄激素代谢之外，还有营养不良、药物、内分泌疾病及缺铁性贫血，还有自身免疫疾病和自身炎症疾病。 医生总是说，脱发有非疤痕性的，还有疤痕性的，还有很多很多，要搞清楚这些，本身就够伤脑经的，我的天那，还会引起脱发！

keywords: anagen, catagen, telogen.–––––––––––––––––––Late stageIn the late stage of the disease, the inflammation decreases and numerous miniaturized hair follicles and telogen follicles are present. The number of miniaturized follicles increases with chronicity and these may simulate hair follicles in late anagen stage. Such hairs are found in the middle or upper dermis and have been described as nanogen. They represent an intermediate stage between vellus and terminal anagen hair follicles. In horizontal sections there is generally no hair shaft production although occasionally a very thin incompletely keratinized form is produced, correlating with empty infundibula seen on the scalp (Fig. 22.72). In vertical sections the proximal end of the hair shaft acquires a ragged appearance rather than the normal club shape. They can sometimes display histological features of anagen, catagen, and telogen phases simultaneously with evidence of growth and involution in the form of mitotic activity and apoptosis.晚期(斑秃）在疾病晚期，炎症减轻，出现大量微小化毛囊和休止期毛囊。微小化毛囊的数量逐渐增加，可与生长末期的毛囊相似。这样的毛发出现在真皮中上部，被成为nanogen，他们代表了介于毳毛和终毛生长期毛囊之间的中间阶段。在水平切片中，一般是没有毛干的，但偶尔会有一个非常细的角化不完全的毛干结构，可在头皮上见到空的漏斗部（图22.72）。在垂直切片中，毛干末梢近端呈锯齿状外观而不是正常的球形。组织学上有时表现为生长期、退行期和休止期同时存在，既有有丝分裂活性，又有凋亡的改变。Fig. 22.72 Alopecia areata, nanogen hair: the hair shaft shows a decrease in the thickness of the epithelial component with fusion of the internal and external root sheaths. In place of a hair shaft, detritus of amorphous keratin is present.图22.72 斑秃，nanogen发：毛干显示上皮厚度减少，内外毛根鞘融合。毛干处，存在无定形角质物的碎屑。In longstanding alopecia areata the majority of the hair follicles are in catagen and telogen. Since the inflammatory infiltrate does not affect follicles in these growth phases, inflammation may be absent in the subcutaneous tissue (Fig. 22.73).73,84 Inactive alopecia areata can resemble androgenetic alopecia with many miniaturized terminal follicles (Fig. 22.74).在持续时间长的斑秃中，大多数毛囊处于退行期和休止期。在这两个生长阶段，由于炎症浸润不累及毛囊，所以皮下组织可能没有炎症存在（图22.73）。稳定期斑秃可类似于雄激素源性脱发，有很多微小化毛囊（图22.74）。Fig. 22.73 Alopecia areata, late stage (A, B): there is a remarkable increase in catagen/telogen follicles, and a sparse peribulbar lymphocytic infiltrate with stellae is evident.图22.73 斑秃，晚期（A、B）：退行期和休止期毛囊显著增加，毛球周围散在的淋巴细胞浸润伴毛囊索很明显。Numerous stellae are present in the deep dermis and the subcutaneous tissue and these may be accompanied by an inflammatory cell infiltrate and melanin pigment(Fig. 22.75). In some cases there may be destruction of the hair follicle by the aforementioned infiltrate and histiocytes and giant cells (Fig. 22.76).大量毛囊索存在于真皮深部和皮下组织，可能伴有炎症细胞浸润和黑素沉着（图22.75）。在一些病例中，可能出现因上述浸润导致的毛囊破坏以及组织细胞和多核巨细胞（图22.76）。Fig. 22.74 Alopecia areata, late stage: the similarity to androgenetic alopecia is striking due to the extensive miniaturization and absence of an inflammatory cell infiltrate.Masson's trichrome stain.图22.74 斑秃，晚期：类似于雄激素源性脱发，因广泛的毛囊微小化且缺乏炎症细胞浸润。Masson三色法。Fig. 22.75Alopecia areata: different views of follicular stellae infiltrated by lymphocytes.图22.75 斑秃：淋巴细胞浸润毛囊索的不同视野。–––––––––––––––––––––––––––––––未完待续 （浙江省人民医院皮肤科 陆威 译）2017-11-16

Laboratory tests are not usually necessary for the diagnosis but they may be of value in detecting associated conditions, particularly autoimmune disease. The hair-pull and hair-pluck tests show an increase in the number of telogen and dystrophic anagen hairs. The remaining anagen hairs are dystrophic because the continuous inflammatory process results in premature transformation into catagen and telogen phase. This abbreviatedgrowth cycle results in many terminal follicles with poorly keratinized short stems that break readily (exclamation mark hairs). Histologically, alopecia areata is characterized by three basic features:normal numbers of follicular units and hair follicles in the initial stages with loss of follicles in the recalcitrant and most chronic phases；an increase in the number of catagen and telogen follicles；a lymphocytic infiltrate of variable severity affecting the bulbs of the   anagen follicles and the catagen and telogen follicular stellae.实验室检查通常不是诊断斑秃所特需的，但是可以帮助发现与其相关的疾病，尤其是自身免疫性疾病。拉发试验和拔发试验显示休止期和营养不良的生长期头发数量增加。残留的生长期毛发生长不良，这是因为持续的炎症导致生长期毛囊提前进入退行期和休止期。这种变短的生长周期是许多终毛毛囊毛干角化不全，易于折断。组织学上，斑秃有三个基本的特征性表现：毛囊单位和毛囊的数量正常；退行期和休止期的毛囊的数量增加；在生长期毛囊的毛球和退行期与休止期的毛囊锁周围有不同程度的淋巴细胞浸润。It is important to remember that the histopathological features depend on the stage of the disease.需要注意的是，斑秃的组织病理表现随疾病的发展阶段而不同。All the changes in alopecia areata described in vertical sections are better observed in horizontal sections (Fig.22.65).This is particularly true of hair bulb lymphocytic infiltration (Fig. 22.66). Nevertheless, the inflammatory infiltrate is not always visible. The frequency with which this and otherhistological changes are observed depends on the stage of the illness when the biopsy is performed. In each particular affected area the established lesion isobserved in the center of the patch of alopecia and the more active features are evident at the edge adjacent to the normal scalp.横切面比纵切面中更易观察的斑秃的病理变化（图22.65）。尤其是毛球部的淋巴细胞浸润（22.66）。然而，炎症细胞浸润并不会总被看到。这种及其他病理学上改变被观察到几率取决于活检时疾病所处的阶段。脱发斑的中心是充分发展的皮损，而在脱发斑边缘靠近正常头皮的部位则是活动期的损害。图22.65 斑秃：(A)纵切面显示毛囊数量的明显减少，可以看到毛球周围淋巴细胞浸润；（B）横切面显示正常数量的毛囊，左上侧的毛囊处于退行期和休止期。Early stagesIn the early stages of the disease there is an increase in the number of  catagen and telogen follicles. Telogen counts exceed those seen in telogen effluvium (Fig.22.67). The follicles show a variable inflammatory       lymphocytic infiltrate in the peribulbar region (Figs22.66,22.68). This may occasionally be very mild, evenin more active lesions. This is        particularly noticeable in the atypical, diffuse, and ophiasic forms.76 Sometimes plasma cells are observed. The presence of eosinophils in the stellae and within the hair bulbshas been described as an early and typical feature (Fig. 22.69).77 The earliest changes are loss of structural integrity of the centrally located supramatrical upper bulbar region and shrinkage of hair bulbs.78 The hair matrix is infiltrated by lymphocytes and there is also pigment incontinence, matrix cell necrosis, and vacuolar damage.79 The inflammatory infiltrate is especial lyprominent in terminal hair follicles, the bulbs of which are located in thesubcutaneous tissue (Fig. 22.70). Pigment incontinence may be very conspicuous and lead to the formation of clumps of melanin pigment (pigmentcasts) in the distorted hair bulb and follicular streamer (Fig. 22.71).80 The infiltrate is composedof an admixture of CD4+ and CD8+ T lymphocytes.  studies have shown deposits of C3, IgG, and IgM along the basement membrane of the        inferior part of the hair follicle. Once the follicle enters catagen stage and progresses to telogen the inflammatory cell infiltrate decreases. lymphocytic infiltration is accompanied by progression to catagen and telogen. Following this, the follicle rapidly returns to anagen and the cycle repeats itself. Due to this continuous cycle and the accompanying inflammatory process, the follicles go through two important morphological changes:• trichomalacia characterized by short, incompletely keratined (pencilpoint) hairs which are susceptible to trauma；• mini aturization of some anagen follicles.早期在本病早期，退行期和休止期毛囊的数量增加，休止期毛囊数量比休止期脱发中的还要多（图22.67）。在毛囊的毛球周围有不同程度的炎症性淋巴细胞浸润（图22.66,22.68）。即便是在病情活动皮损内，炎症浸润也可以是很轻微的。这种现象在非典型性、弥漫性和匍行簇集性类型中尤为明显。有时候也可以看到浆细胞浸润。早期的典型特征是在毛囊索和毛球内部出现嗜酸性细胞（图22.69）。最早的变化是位于中央毛囊球区域上部毛母质上结构完整性的缺失和毛囊球的收缩。毛母质中有淋巴细胞浸润，并出现色素失禁、毛母质细胞凋亡和空泡化改变。炎症浸润在终毛毛囊尤为显著，终毛毛球位于皮下组织中（图22.70）。色素失禁可以是非常明显的，在弯曲的毛囊球以及毛囊条索中可以导致黑色素的凝集形成（22.71）。炎症细胞是CD4+和CD8+T淋巴细胞的混合。研究显示炎症毛囊下端基底膜可以看到C3、IgG、IgM的沉积。毛囊进入退行期至休止期后，炎症细胞浸润即逐步减少。随后，毛囊迅速重回生长期，然后重复循环。由于这个过程不断循环，并伴有炎症过程，因此毛囊会发生两个中重要的形态学变化：毛软化：特征是毛发变短，角化不充分（铅笔样），容易折断;一些生长期毛囊的微小化。图22.67 斑秃：休止期毛囊的球的纵切面，在残余毛囊中可以看到炎症细胞浸润图22.68 斑秃：退化中的毛囊。上图为纵切面。右侧的毛囊可以看到炎症细胞浸润，毛干也同时受累图22.69 斑秃，毛囊索：伴有嗜酸性细胞的淋巴细胞浸润图22.70 斑秃 上半部分毛囊球为淋巴细胞所浸润，转化为一个休止期毛囊，并伴有嗜伊红基底膜；下半部分显示为伴有淋巴细胞浸润和色素失禁的毛囊索。所有的显微下图片都是在皮下脂肪组织水平下拍摄。图22.71 斑秃，毛囊索：可以看到少量的炎症细胞浸润，大量的噬黑素细胞––––––––––––––––––––––––––未完待续  （浙江省人民医院皮肤科 皇幼明医生译）2017-11-15

读专著，学专业英语！Prognosis in alopecia areata isvariable and not very predictable in the individual patient. Nevertheless, it has been observed that theprognosis tends to be good in patients who have experienced hair growth withlonglasting remissions between episodes. Spontaneous remission can be expectedin 34–50% of patients within 1 year, although almost all will experience morethan one episode of the disease. Contrariwise,those who have had persistent hair loss or brief or incomplete remissions havea poor prognosis. Severity of alopecia areata at time of first consultation andresponse to therapy is an important prognostic factor.The outlook is particularly poor in those patients with onset of the diseasebefore puberty, those with a family history of the disease (present in 25% ofcases), and those with alopecia totalis and alopecia universalis.7 Atopic patients appear to suffer a more severe formof alopecia areata. 斑秃患者的预后是可变的，且在个别患者中不可预测。然而，在那些发作间歇期有头发生长并伴有持续缓解的患者，预后较好。虽然几乎所有的患者都会经历不止1次的发作，仍可预测34%-50%的患者1年内可达自然缓解。反之，那些有永久性脱发或有短的或不完全缓解的患者预后较差。首次就诊时斑秃的严重程度和对治疗的反应是预后的重要因素。在青春期前期发病并伴有家族史（25%的病例存在家族史）的患者和全秃、普秃的患者预后尤其差。特应性患者的斑秃显得更为严重。 Pathogenesis andhistological features发病机制和组织学特征 Experimentalstudies have shown that alopecia areata is basically an organ-specificautoimmune disease thought to result from a collapse of hair follicle immuneprivilege, driven by cellular immunity with autoantibody production representinga secondary phenomenon. Autoantibodiesto a diverse range of antigens including smooth muscle cells, gastric parietalcells, thyroid cells, and components of anagen hair follicles have beendescribed.  实验研究表明，斑秃本质上是一种器官特异性自身免疫性疾病，是由于毛囊免疫耐受失效，细胞免疫驱动且继发自身抗体产生所致。针对多种抗原包括平滑肌细胞、胃壁细胞、甲状腺细胞以及毛囊抗原成分的自身抗体已被描述。It isunknown whether induction of the disease results from exposure to exogenous orendogenous antigens and whether it represents a consequence of an immunereaction to normal or aberrant epitopes. However, recent research suggests thatthe pathogenesis involves at least four events:failureof the anagen hair follicle to maintain its privileged immunity (the inner rootsheath and hair matrix do not express, or express very low level of, majorhistocompatibility complex class Ia antigens and maintains an active NK cellsuppression) resulting in exposure of epitopes, which initiate an immuneresponse。antigenpresentation, activation, and response of the lymphocyte to antigen-presentingcells,migrationof activated inflammatory cells and infiltration of hair follicles,damage tothe hair follicle by the inflammatory cell infiltrate. 目前还不清楚该病是否因外源性或内源性抗原的暴露所致，以及本病是否代表了正常或异常抗原表位的免疫反应的结果。然而，最近的研究表明，发病机制包括至少四个方面：生长期毛囊不能维持其免疫耐受（内根鞘和毛基质不表达，或表达极低水平的主要组织相容性复合体Ia抗原并维持活跃的NK细胞抑制）引起抗原表位暴露，从而启动免疫应答。抗原呈递、淋巴细胞活化和对抗原呈递细胞的反应活化的炎症细胞迁移和毛囊浸润炎症细胞浸润损伤了毛囊 It has been proposed that neurotrophins playa role in the pathogenesis of the disease. These represent a family ofstructurally and functionally related proteins that are important not only inthe development and maintenance of cutaneous innervation but also in control ofhair follicle development and cycling. Since neurotrophins and their receptorsare differentially expressed in subsets of immune cells in alopecia areata, arole for these proteins in the pathogenesis appears likely.  现已提出，神经营养因子在疾病的发病机制中起一定的作用。神经营养因子代表了一系列结构和功能相关的蛋白质，它们不仅对皮肤神经的发育和维持提供支持，而且在调控毛囊发育和生长周期中也起着重要作用。由于神经营养因子及其受体在斑秃患者的免疫细胞亚群中的表达不同，故这些蛋白可能在发病机制中起一定的作用。The increased frequency of alopecia areata ingenetically related individuals suggests that there is a genetic link to thedisease. Amongst the general population the condition does not display amendelian pattern of expression since the resultingphenotype demonstrates variable degrees of hair loss. It has been proposed thatexpression of alopecia areata involves a complex interaction of multiple genes,in which major genes control susceptibility to the disease while other minorones modify the phenotype.有家族史的个体发生斑秃的几率增加提示本病与遗传有关。在普通人群中，本病的表型为不同程度的脱发，不符合孟德尔遗传模式。有人提出，斑秃是多基因相互作用的结果，其中主要的基因控制对本病的易感性，其他次要基因决定疾病的表型。 Manyillnesses with an autoimmune basis have been associated with specific humanleukocytic antigens (HLA). Alopecia areata has been studied in association withboth HLA class I and class II. The most relevant associations have been foundwith the HLA class II antigens (HLA-DR, -DQ, -DP). The molecular basis of thisgenetic association is supported by the fact that HLA binds and presentspeptides derived from self and foreign protein antigens to the immune systemfor recognition and activation. More than 80% of all cases evaluated in onestudy were positive for the antigen DQB1*03 (DQ3), suggesting that this antigenis a marker for susceptibility. Furthermore, in patients with alopecia totalisand universalis, the frequency of the antigens DRB1*0401 and DBQ1*0301 (DR4 andDQ7) is significantly increased. HLA-DR5 has been linked to the early-onset and severe form of alopeciaareata.许多具有自身免疫基础的疾病与人类白细胞抗原（HLA）相关。斑秃已被研究证实与HLA I类和II类抗原均相关。已发现与HLA II类抗原（HLA-DR,-DQ,-DP）关联性最强。这种遗传关联的分子基础可被HLA结合并呈递来自自身和外源性蛋白抗原的肽类供免疫系统识别和激活的事实支持的。在一项研究中超过80%的病例DQB1 * 03（DQ3）抗原阳性，表明该抗原可作为易感性的标记抗原。此外，在全秃和普秃患者中，DRB1 0401和DBQ1 * 0301（DR4和DQ7）抗原的几率明显增加。HLA-DR5已被证实与早发和严重的斑秃相关。 Theeffect of stress on the pathogenesis is unclear and controversial, although ithasbeen suggested that it can trigger the disease. It has been observed that substance P and nerve growth factor could beacting as key mediators of stress-induced hair growth-inhibitory effects, throughkeratinocyte apoptosis, inhibition of hair follicle proliferation, and catageninduction.  On theother hand, stress in relation to alopecia areata was studied in a Turkishhospital after two consecutive earthquakes. The number of patients admittedwith alopecia areata before and after the earthquakes did not increase,suggesting that stress per se is not a primary trigger.  应激在发病机制中的作用并不清楚且存在争议，虽然已有研究证实应激可诱发斑秃。有研究观察发现P物质和神经生长因子可以作为应激诱导毛发生长抑制效应的主要介质，通过角质形成细胞凋亡，抑制毛囊增殖，诱导退行期。另一方面，土耳其的一家医院曾研究连续两次地震后应激与斑秃的关系。在地震前后，斑秃患者的数量并未增加，证实了应激本身并不是主要诱因。–––––––––––––––––––––––––––––––––––未完待续 （浙江省人民医院皮肤科 李亚丽博士译）2017-11-14

Keywords: growth (anagen, 生长期), cessation (catagen，退行期), and rest (telogen，休止期) phases.Temporal triangular alopecia颞部三角形脱发Clinical features临床特征Temporal triangular alopecia (congenitaltriangular alopecia, Brauer nevus)1was described by Saboreau in 1905.2 It usually appears in the early years oflife rather than at birth.3,4 Familial cases rarely occur.5 Occasionally, the diseasepresents in adults.6,7颞部三角形脱发（先天性三角形脱发，Brauer痣），由Saboreau在1905年报道。它通常出现在生后的几年，而不是在出生时。家族性的病例罕见发生。偶见于成年人。 It involves one sideof the scalp and characteristically presents as a singlepatch of alopecia withits base directed towards the frontotemporal area (Fig.22.54).8 Occasionally, other areas are affected and, exceptionally, patientsshow bilateral involvement.7 Clinical examination reveals vellus hairs in thealmost complete absence of terminal hairs andinflammatory changes (Fig.22.55).本病仅累及一侧头皮，特征性表现为单一的三角形脱发斑，其底边朝向额颞区(Fig.22.54)。偶尔其它区域也可受累，极罕见的情况下出现两侧受累。临床检查发现局部毳毛，终毛几乎完全消失和炎症改变(Fig.22.55)。Fig. 22.54Triangularalopecia: note the characteristic triangular patch of alopecia.三角形脱发：注意特征性的三角形脱发斑。Fig. 22.55Triangularalopecia: in this close up view inflammatory changes are absent.三角形脱发：在这个近视图特写中可看到炎性改变缺如。Temporal triangular alopecia has been describedin association withaplasia cutis, phakomatosis pigmentovascularis,mental retardation, epilepsy,leopard syndrome, and congenital heart diseasewith renal and genitalabnormalities.9–13有报告颞部颞部三角形脱发和皮肤发育不良、色素血管性斑痣性错构瘤、智力低下、癫痫、豹皮综合征、先天性心脏病伴肾脏和生殖器畸形有关。Pathogenesis and histological features发病机制和组织学特征The genetic basis of the disease is uncertain buta dominant trait has beensuggested.14本病的遗传基础尚不清楚，有人提出为副显性特征。 The epidermis and dermis are normal, but thereare almost no terminal hairsand the number of vellus hairs is increased. Thesebaceous and eccrine glandsare normal. Fibrous stellae and inflammation areabsent (Fig. 22.56). In general,the histological appearanceis very similar to that of a normal skin biopsy.表皮和真皮正常，毳毛的数量增加，但几乎没有终毛。皮脂腺和小汗腺正常。没有纤维索和炎症(Fig.22.56)。总之，这个疾病的组织学表现和正常的皮肤活检非常相似。Fig. 22.56Triangularalopecia: this biopsy is taken from the edge of a lesion. One terminal hairfollicle is present on the right side of the field (unaffected scalp).Miniaturized vellus hairs are seen in the left half (affected scalp). There areno stellae or inflammatory cells.三角形脱发：活检取自皮损的边缘。在视野的右侧有一个终毛的毛囊（非受累的头皮）。微小化的毳毛可在视野的左侧看到（受累处头皮）。没有纤维索或炎症细胞。 Differential diagnosis 鉴别诊断The differential diagnosis includes other causes of circumscribed non-scarringalopecia, particularly alopecia areata and tinea capitis. In the formerthe bulbs of anagen follicles are surrounded and infiltrated by lymphocyteand in the latter the microscopic findings of fungal organisms by hydroxidepotassium (KOH) or PA S and/or culture of the hair shaft are sufficient toestablish a diagnosis.鉴别诊断包括其他原因引起的非瘢痕形成性脱发，尤其是斑秃和头癣。在前者的生长期毛囊周围浸润有淋巴细胞，而后者在显微镜下可看到真菌的产物，通过氢氧化钾（KOH）或PAS染色，和或发干培养，上面这些检查足以来确立诊断。（颞部三角形脱发文章完）本文译文：浙江省人民医院樊莎莎医师   2017-11-10

斑秃患者不但有毛发的改变，也会有甲的损害。同时斑秃也会和很多疾病和药物等多因素有关，在临床诊断时要多注意问病史，做相应检查。（译者注）Nail changes may be present in patients with alopecia areata and include pitting, spotted lunula, and red lunula. Changes may be seen in one, several, or all of the nails. Trachyonychia (twenty-nail dystrophy) occurs in up to 3% of patients (Fig. 22.64). The dystrophy may precede, coincide with, or occur after resolution of the episode of alopecia.Alopecia areata has been associated with many other diseases. Some of these have an autoimmune etiology such as Hashimoto's thyroiditis, type I (insulin dependent) diabetes,Addison's disease, vitiligo, hereditary thrombocytopenia (pseudo-von Willebrand disease),myasthenia gravis, polymorphism in the interleukin-1 receptor antagonist gene, lupus erythematosus, autoimmune polyendocrinopathy-candidiasis-ectodermal dysplasia syndrome(autoimmune polyglandular syndrome-1), common variable immunodeficiency, relapsing polychondritis, kidney-pancreas transplant recipients taking ciclosporin and after allogeneic bone marrow transplantation. Other associations include lichen planus, atopy, human immunodeficiency virus (HIV)infection, twenty-nail dystrophy, Down's syndrome, cytomegalovirus and Epstein-Barr virus infection, celiac disease in children, chemotherapy, interferon-alpha (IFN-a ), ribavirin,ciclosporin A, rifampicin, borderline tuberculoid leprosy, and ocular alterations (keratoconus,symptomless punctate lens opacities). Alopecia areata has also developed in a patient with pili annulati. There appears to be an increased incidence of nuchal nevus flammeus in patients with severe alopecia areata.甲改变可以在斑秃患者中表现出来。主要改变是凹点、半月斑点和红半月。甲改变可以累积单个甲，多个甲，或者所有甲。（早期改变时要跟真菌感染甲病鉴别，所有甲板都累及了，与真菌感染的鉴别就简单了，因为真菌感染很少引起全部甲受累，虽然极少数情况下也会有。译者注）二十甲营养不良发生在3%以上的病人中。斑秃跟很多其它疾病相关。者其中有一些是自身免疫病因，如桥本甲状腺炎、I型糖尿病（胰岛素依赖型）、爱迪森病、白癜风、遗传性血小板减少症（假性von Willebrand 病），重症肌无力、多态性白介素-1受体拮抗基因、红斑狼疮、自身免疫性多内分泌病-念珠菌病-外胚层发育不良综合症（自身免疫性多腺体综合症-1型）、寻常性变量免疫缺陷、复发性多软骨炎、服用环孢菌素多肾-胰移植受体、同源骨髓移植后。其它相关疾病或原因包括扁平苔癣、异位性、人类免疫缺陷病毒感染、二十甲营养不良、唐氏综合征、巨细胞病毒和E-B病毒感染、儿童腹腔疾病、化疗、肿瘤坏死因子-alpha、病毒唑、环孢菌素、利福平、界线结核风样麻和眼改变（圆锥形角膜、无症状点状浑浊晶状体）。在环状发患者中也会发生斑秃。在严重的斑秃患者中，颈部鲜红斑痣的发生率似乎也增加了。Fig. 22.64 Alopecia areata: (A, B) in this patient there is severe involvement of all 20 nails (trachyonychia). Courtesy of L.M. Gómez,MD, Universidad Pontificia Bolivariana, Medellín, Colombia. 在这个病人中，有严重的20甲累及。–––––––––––––––––––––––––––––––––（浙江省人民医院皮肤科 潘卫利译），2017-11-13

Alopecia areata斑秃Clinical features临床特征Alopecia areata is an organ-specific autoimmunedisease in which large numbersof hair follicles undergo progression intocatagen and telogen while smaller numbers enter an abnormal anagen stage.斑秃是一种器官特异性自身免疫性疾病，表现为大量毛囊进入退行期和静止期，而少数进入异常的生长期。 The condition is quite common, affecting up to 1%of the population. The frequency of a family history is very high, ranging from10% up to 42% of cases. It is more common in individuals between 15 and 40years of age and about 60% of cases occur before the age of 20.1 The disease is very rare in newborns and youngchildren.2 Exceptionally, however, congenital cases may occur.3 There appears to be a higher incidence in Kuwaitichildren.这个疾病非常常见，累及1%的人群。家族史的出现频率非常高，从10%到高达42%。15～40岁的人更常见，并且大约60%的病例在20岁前发病。新生儿和幼儿罕见。先天性病例罕见。有资料显示科威特儿童的发生率相对较高。图A Alopecia areata: typical annularnoninflammatory foci of alopecia.斑秃：典型表现为环状的非炎性的局部脱发。The degree of involvement is very variable andcan range from verymild disease where the hair loss is difficult to detect through to veryseverecases with diffuse hair lossaffecting the entire scalp or even the whole body(Fig. 22.57). Any hair-bearing surface may be affected (Fig. 22.58). A typicalpatient presents with an abrupt development ofpatches of nonscarring alopeciain different patterns: circumscribed, bandlike inthe temporo-occipitalregion (ophiasic), bandlike in the frontoparietalregion in a ‘sisaipho’ pattern(ophiasis inversus); (Fig. 22.59),5 and reticular. When these patches extendand become confluent, involving the entire scalp,the appearance is known asalopecia totalis (Fig. 22.60). If there is hair loss on the entire body the conditionis referred to as alopecia universalis (Fig. 22.61).6,7 Even in the mostsevere forms of alopecia totalis and universalisone can observe isolated smallgroups of unaffected hair follicles, allowingdistinction from telogen effluvium.疾病受累程度变化范围很大。极轻的斑秃，可能难以发现脱发；极重度的累及整个头皮甚至全身弥漫性脱发（图22.57）。任何毛发被覆的部位都可受累（图22.58）。典型的表现为突发的非瘢痕性脱发斑，可以为局限性的，在颞枕区发生带状（匍行性），额顶部带状马蹄形（逆蛇形斑秃）（图22.59）和网状。当这些脱发斑扩大和融合时累及整个头皮，被称为全秃（图22.60）。当全身毛发脱落时称为普秃（图22.61）。即使在最严重的全秃和普秃中，也可观察到孤立、未受累的小群毛囊，可以与静止期脱发相鉴别。fig B  Alopecia areata: typical annularnoninflammatory foci of alopecia.斑秃：典型表现为环状的非炎性的局部脱发。Fig. 22.58Alopecia areata: note the loss of eyelashesin the middle third of the upper eyelid.斑秃：注意上眼皮中间三分之一的睫毛的缺失。AFig. 22.59B Fig.22.59Alopecia areata: this broad band of alopeciin the occipital region is known as ophiasis (A). In the frontoparietal region it is knownas ophiasis inversus, or a ‘sisaipho’pattern (B).斑秃：这种在枕部宽带状的脱发被称为匍行性脱发（A）。在额顶部的这种脱发被称为逆蛇形斑秃，或‘马蹄形’型脱发。Fig. 22.60Alopecia areata totalis:in this patientthere is complete loss of scalp hair.全秃：这个病人所有的头皮头发都脱光了。Fig. 22.61Alopecia areatauniversalis: in its most extreme form there is loss of hair affecting the wholebody. There is loss of eyebrows in addition to scalp involvement.普秃：在最极端的形式中，头发的丧失影响了整个身体。除了头皮受累，眉毛也有缺失。Alopecia areata may occasionally present with apattern mimickingandrogenetic alopecia.8 The proportion of patients who eventually developalopecia totalis and universalis varies but isaround 7%.9 Alopecia totalis ismore frequent in children.偶尔斑秃可表现为与雄激素源性脱发相似的模式。最终发展为全秃和普秃的患者比例不定，大约占7%。全秃在儿童更常见。 Examination of the involved scalp generallyreveals that except for theabsence of hair, the skin appears normal,follicular openings are preserved,and there is no evidence of scarring (Fig. 22.62). In occasional cases, however,edema and erythema are observed. Hair color mayappear normal or itmay show mild lightening and loss of sheen. Inthe periphery of the patchesof alopecia one typically finds exclamation markhairs, which are short andbecome thinner as they gradually approach thescalp (Fig. 22.63). They area very characteristic feature but may also beseen in trichotillomania.11 Theprocess usually affects pigmented hairs. Nonpigmented hairs appear to bemore resistant, at least temporarily.对受累头皮进行检查，可以发现局部没有毛发，但皮肤外观正常，毛囊开口保留，且没有疤痕的表现（图22.62）。然而偶有病例可出现水肿和红斑。毛发颜色可以正常或轻度变淡及失去光泽。脱发斑边缘头发松动，易于拔起，可为典型的惊叹号状发，表现为发干短，并且越接近头皮越细（图22.63）。这是非常特征性的表现，但也可见于拔毛癖。该病通常累及色素性毛发，而无色素性毛发较少累及，至少病程短。

工作日每天早上7:30~8:00, 浙江省人民医院皮肤科的医生们就开始英文专著早读会。我们发布中英文报告，有兴趣的医生可以和我们一起学习。在专业英语专有名词翻译中，难免会有些不规范用词的中文译文，欢迎广大读者批评指正。Keywords: growth (anagen, 生长期), cessation (catagen，退行期), and rest (telogen，休止期) phases.Differential diagnosis（鉴别诊断）The most important differential diagnoses are diseases which present withdiffuse nonscarring alopeciaincluding telogen effluvium, alopecia areata, andtrichotillomania.最重要的鉴别诊断是那些表现为弥漫性非瘢痕性脱发的疾病，包括休止期脱发、斑秃、和拔毛癖。 Although androgenetic alopecia may show increasednumbers of telogenhairs, telogen effluvium is clinically morediffuse and there are no miniaturizedhair follicles. It is important, however, to notethat both diseasesmay present simultaneously and that chronic telogeneffluvium may uncoveroccult androgenetic alopecia.虽然雄激素源性脱发可以出现静止期毛发数量增加，但临床上静止期脱发更加弥漫，并且没有毛囊的微小化。然而，值得注意的是的是这两个疾病可以同时发生，慢性静止期脱发可能会提示隐匿的雄激素源性脱发。 Alopecia areata may show miniaturized hairfollicles, particularly invery chronic cases. Characteristically, however,there is a major increase inthe number of hair follicles in catagen, telogen,and anagen and usually asparse peribulbar lymphocytic infiltrate ispresent, sometimes accompaniedby eosinophils. Without adequate clinicalinformation, distinction may beimpossible.斑秃可以出现一些微小化的毛囊，特别是在非常慢性病程的病例中。然而，特征性的主要表现是在退行期、静止期和生长期毛囊数目增加，并通常在毛球周围有少量的淋巴细胞浸润，有时伴随嗜酸性粒细胞浸润。在没有足够临床信息时，鉴别诊断通常是不可能的。 In trichotillomania there are increased numbersof hair follicles in catagenand telogen but in addition there istrichomalacia (short, incompletely keratinizedhairs), pigmented casts, and distortion of hairshafts.在拔毛癖中退行期和静止期毛囊数目增加，另外还有毛软化（短，没有完全角化的毛发），色素管型和毛干扭转。（雄激素源性脱发文章完）–––––––––––––––––––––––––––––––––––––本文译文：浙江省人民医院樊莎莎医师   2017-11-10

工作日每天早上7:30~8:00, 浙江省人民医院皮肤科的医生们就开始英文专著早读会。我们发布中英文报告，有兴趣的医生可以和我们一起学习。Histologically, terminal hairsprogressively transform to vellus hairs（Figs 22.49,22.50）.There is adecrease in the size of the dermal papilla, bulb size, and hair shaft diameter.Although the total hair count is normal, it will appear reduced if the count istaken at the junction of the dermis and subcutaneous fat, since by definitionterminal hairs are diminished in number. Even though these changes may also beseen in vertical sections (Fig. 22.51), they are more difficult to interpretand quantify.组织学上终毛进行性转化为毳毛。真皮乳头，毛囊球部以及毛干直径大小会减少。虽然毛囊总数是正常的，但因为终毛数量减少以至于真皮和皮下脂肪交界水平的毛囊计数减少。尽管纵切面中也可见到这些变化，但是他们更难以解释和量化。Androgenic alopecia: almost all hairfollicles are miniaturized and sebaceous glands appear prominent. Masson'strichrome stain.雄性脱发:几乎所有的毛囊是小型化和皮脂腺显得突出。 Masson三色染色。Androgenicalopecia, follicular unit: the miniaturization process is complete and noterminal follicles are left.雄性脱发：毛囊单位:小型化过程完成，终端毛囊残留。Androgenic alopecia, vertical section: onlytwo hair follicles reach the subcutaneous fat. The rest are miniaturizedfollicles in the mid dermis.雄性脱发：垂直部分:只有两个毛囊达到皮下脂肪。余下的是在真皮中层的小型化毛囊。Along with these changes, there is areduction in the duration of the hair follicle cycle at the expenses of theanagen phase. Therefore in patients with evolving androgenetic alopecia, orwhen it is fully established, it is very common to find an increment in thenumber of catagen and telogen follicles. The histological picture of the femalevariant is identical.随着这些变化,在毛囊周期中的生长期的持续时间会减少。因此，在雄激素脱发进展期患者,或者当诊断完全确立时，找到生长中期和静止期毛囊数量的增加是很常见的。女性类型的组织学图片是相同的。 A mild to moderate lymphocytic inflammatorycell infiltrate frequently surrounds the upper third of the hair follicle. Theminiaturization of hair follicles affects the whole of the hair follicleincluding, finally, the arrector pili muscle and the sebaceous gland.在毛囊的上1/3部分的周围常常有轻度到中度的淋巴细胞浸润。毛囊的小型化影响整个毛囊,包括最后，影响到竖毛肌和皮脂腺。 In the deeper sections, hair bulbs are presentat different depths, and focally they may be completely absent, only follicularstellae remaining. These stellae are seen in a variety of conditions andreflect either miniaturized follicles or else follicles that have enteredcatagen or telogen stage. As the stellae mature, they become lessvascularized, presenting as fibrous scars with a blue-gray hue. In lateandrogenic alopecia the stellae becomes abnormally thick and could impede thegrowth of the follicle (Fig. 22.52).在更深的切片中，毛球出现在不同的深度，在局部可以完全消失，仅留有毛囊索。毛囊索可见于不同的情况，反应了毛囊的微小化，或是毛囊进入了退行期或休止期。随着毛囊索成熟，其中血管减少，毛囊索最终成为灰蓝色的纤维疤痕。在雄脱末期，毛囊索变得异常厚，可能阻碍毛囊的生长Androgenic alopecia, follicular stellae (a,B): as the follicles undergo miniaturization they leave behind numerousfollicular stellae. 雄性脱发：毛囊索卵泡 (a,B): 随着毛囊小型化，遗留了许多毛囊索。The terminal to vellus hair ratio (7:1) ismuch reduced and varies from 1:1 or even 1:2. Although initially the number ofhair follicles is normal, in longstanding disease there can be a realreduction. A biopsy may therefore show a decrease in hair follicle density inaddition to diminution in size of the individual hair follicles. Sometimes theappearances may be more suggestive of a scarring alopecia (Fig. 22.53).终毛/毳毛的比例从7：1可以大幅减少到1：1甚至1：2。尽管在疾病的初始阶段毛囊的数量是正常的，但随着病程的发展，其数量会减少。因此活检会显示除了毛囊缩小，还有毛囊密度的降低。有时候表现更像疤痕性脱发。Androgenic alopecia, final stage:follicular units and miniaturized hair follicles are rare. In this advancedstage connective tissue has almost completely replaced follicular structuresand the appearances resemble a scarring alopecia.雄性脱发：最后阶段:毛囊单位和小型毛囊是罕见的。在这个进展阶段结缔组织几乎已经完全取代了毛囊结构，表现像疤痕性脱发。Differential diagnosisThe most important differential diagnosesare diseases which present with diffuse nonscarring alopecia including telogeneffluvium, alopecia areata, and trichotillomania.首先应与弥漫性非疤痕形成性脱发鉴别：包括休止期脱发，斑秃和拔毛癖。 Although androgenetic alopecia may showincreased numbers of telogen hairs, telogen effluvium is clinically morediffuse and there are no miniaturized hair follicles. It is important, however,to note that both diseases may present simultaneously and that chronic telogeneffluvium may uncover occult androgenetic alopecia.虽然雄激素源性脱发可以出现休止期毛发数量增加，但临床上休止期脱发更加弥漫，并且没有毛囊的微小化。重要的是这两个病可以同时发生，慢性休止期脱发可能会提示隐匿的雄激素源性脱发。 Alopecia areata may show miniaturized hairfollicles, particularly in very chronic cases. Characteristically, however,there is a major increase in the number of hair follicles in catagen, telogen,and anagen and usually a sparse peribulbar lymphocytic infiltrate is present,sometimes accompanied by eosinophils. Without adequate clinical information,distinction may be impossible.斑秃可能显示小型毛囊,尤其是慢性病例。然而典型的是，生长中期,静止期的毛囊数量明显增加。同时有毛球周围淋巴细胞浸润。有时还伴有嗜酸性粒细胞。没有足够的临床信息,鉴别是几乎是不可能的。 In trichotillomania there are increasednumbers of hair follicles in catagen and telogen but in addition there istrichomalacia (short, incompletely keratinized hairs), pigmented casts, anddistortion of hair shafts.在拔毛发癖中，退行期和静止期毛囊数量增加，另外还有毛软化(短,没有完全角化的头发)，色素管型和毛发扭转。（浙江省人民医院皮肤科 丁扬医生译）2017-11-9

Lanugo 毫毛Lanugo (/ləˈnuːɡoʊ, -ˈnjuː-/; from Latin lana "wool") is very fine, soft, usually unpigmented, downy hair that is sometimes found on the body of a fetus or newborn baby. It is the first hair to be produced by the fetal hair follicles, and it usually appears at about five months of gestation. It is normally shed before birth, around seven or eight months of gestation, but is sometimes present at birth. It disappears on its own within a few days or weeks.毫毛 毫毛是非常纤细、柔软的，通常是无色素的，绒毛似得毛发，它有时候发现在胎儿或新生儿的体表。它是有胎儿毛囊产生的最早的毛发，且通常在孕5个月时出现。正常情况下，出生前，约7～8个月时脱落，但是有时在出生后也会见到，且在数天或数周内消失（俗称胎毛）Vellus hair 汗毛 (在很多字典上，也把它翻译成毫毛，与lanugo混淆）Vellus hair is short, fine, light-colored, and barely noticeable thin hair that develops on most of a person's body during childhood. Exceptions include the lips, the back of the ear, the palm of the hand, the sole of the foot, some external genital areas, the navel and scartissue. The density of hair  the number of hair follicles per area of skin – varies from person to person. Each strand of vellus hair is usually between 2 mm and 2cm  long and the follicle is not connected to a sebaceous gland.汗毛汗毛是一种短小，纤细、浅色的体毛，几乎不容易注意到。在儿童期多数人出会出现汗毛。唇、耳背、掌跖、某些外生殖器区域、肚脐眼和瘢痕组织没有汗毛。汗毛的密度因人而异，（西方人通常比我们中国人密度高，译者注）。汗毛通常2mm～2cm之间，汗毛毛囊不与皮脂腺连接。Terminal hair 刚毛Terminal hair are the "normal" long, thick hair that grow on the scalp, face,chest and arms before puberty; after puberty they also grow at secondary hair sites i.e. on the axillae, arms and legs. These grow from follicles that have sebaceous glands. In conditions such as male and female pattern baldness, hairs in these so-called 'terminal follicles' can gradually become thinner and shorter to mimic vellus hairs.刚毛刚毛是一种“正常”长的、粗的毛发，青春期前生长在头皮、脸部、胸部和手臂。青春期后刚毛也可以长在第二毛发位点，如腋下、手臂和下肢。这些毛囊伴有皮脂腺生长。在男性型和女性型脱发中，这种所谓刚毛毛囊会逐渐变成纤细而短小的类似于汗毛的毛发。–––––––––––––––––––––––––––––––––––––浙江省人民医院皮肤科 潘卫利译，2017-11-12

老子的“道法自然”与《黄帝内经》“得顺者生,得逆者败”《老子·二十五章》中说:“人法地,地法天,天法道,道法自然。”一句“道法自然”将关于“道”的深刻含义,全都包含在内。人作为“道”之所生、“道”之所化的存在物,按照“道法自然”的原则,人的一切活动包括养生都必须遵循自然界的普遍规律,若违背了这个自然规律,则“莫能终其天年”。所以,人的生命活动要符合自然规律,才能够使人长寿,这是道家养生的根本观点。顺应自然规律,只有适其自然,顺应自然,方能“负阴而抱阳,冲气以为和”(《老子·四十二章》),人才能健康长寿。老子“道法自然”思想对中医学防病养生理论有着巨大的影响,如在《灵枢·海论》云:“得顺者生,得逆者败。知调者利,不知调者害。”意思是说若能顺应人体的内在经络、气血运行的规律,便可以通过运动、导引等方法获得健康长寿;反之,若不知道身体内的这些规律,在日常生活中违背这些规律,则会损害自身的健康。又如《素问·宝命全形论篇》曰:“人以天地之气生,四时之法成。”《灵枢·岁露》载:“人与天地相参也,与日月相应也。”《素问·四气调神大论篇》记载:“四时阴阳者,万物之根本也。 所以圣人春夏养阳,秋冬养阴,以从其根。”《灵枢·本神》云:“故智者之养生也,必顺四时而适寒暑,和喜怒而安居处,节阴阳而调刚柔。如是则僻邪不至,长生久视。”这些都是强调顺应自然规律,以养生长寿的具体内容。此外,《黄帝内经》中的养生保健,还强调充分发挥人的主观能动性,提出了通过锻炼身体和“治未病”等手段以达到健康长寿的目的。“法于阴阳,和于术数”,这样才能使五脏功能协调,正气充盛,既要创造条件,以避开四时不正常的气候,还要适当地运用导引、按摩、吐纳等强健身体、调摄精神的方法,保全并延长生命,预防疾病的发生。综上所述,中医经典著作《黄帝内经》中的“治未病”、“恬淡虚无”、“得顺者生,得逆者败”等养生防病思想与《老子》中的“治未乱”、“少私寡欲”、“道法自然”等哲学论述有诸多相通之处。由此可见,中国传统文化为中医养生防病思想提供了理论基础,是中医养生防病思想体系形成的重要理论来源和文化根基。

《老子·四十六章》说:“祸莫大于不知足,咎莫憯于欲得。”认为,天下最大的祸患莫过于不知足,最大的罪过莫过于贪得无厌。不知道珍惜现有的,过分追逐名利,势必招来灾祸和不幸。故指出应“致虚极,守静笃,万物并作,吾以观其复。夫物芸芸,各复归其根,归其根曰静”(《老子·十六章》)。“致虚极”就是说达到空虚的极限,“守静笃”就是坚守静以致虚无。人只有在虚静的状态下才能观察清楚身外的事物。老子主张淡泊名利、少私寡欲、知足常乐、无为自然,故提出“致虚极”,“守静笃”的养神主张。《老子·四十五章》说:“清静为天下正”,只有清静才能保持心的正常功能,这种清静无为的养生思想,与中医学防病养生的思想十分吻合。传统中医认为,精神意志活动化生于五脏精气,情志不畅为内伤病的重要致病因素,充分发挥情志的作用,重视精神的调养,是《黄帝内经》中养生防病学说中预防疾病和防止衰老的重要指导原则。《黄帝内经》中强调养生当以调摄精神意志为第一要务。如《素问·阴阳应象大论篇》中说:“是以圣人为无为之事,乐恬淡之能,从欲快志于虚无之守,故寿命无穷,与天地终,此圣人之治身也。”意为明达事理的人,懂得调和阴阳的重要性,不做对养生不利的事,而能顺乎自然,以安闲清静为最大快乐,使自己的精神意志始终保持无忧无虑的境界,因而可以长寿。《素问·上古天真论篇》明确指出:“内无思想之患,以恬愉为务,以自得为功,形体不敝,精神不散,亦可以百数。”其中“以恬愉为务,以自得为功”,就是说,摄生的要务,在于保持心境恬静、愉快,而要做到经常乐观,又必须知道满足,不要奢望过高。“恬淡虚无,真气从之,精神内守,病安从来。”(《素问·上古天真论篇》)指生活淡泊质朴,心境平和宁静,外不受物欲之诱惑,内不存情虑之激扰,物我两忘的境界,疾病就不容易发生。《素问·生气通天论篇》中亦云:“清静则肉腠闭拒,虽有大风苛毒,弗之能害。”提倡思想宁静,意志平和调顺,人体正气充盈,腠理紧密,即使有很强烈的致病因素侵犯,也无法伤害人体。所以清净养神,无私少欲,心境平和,身体也会达到平衡状态,有利于防病祛疾,保持身心健康。

《黄帝内经》中“治未病”的思想不但包括了未病先防,还包括了既病防变的思想。如《灵枢·百病始生》:“是故虚邪之中人也,始于皮肤……留而不去,则传舍于络脉……留而不去,传舍于经……留而不去,传舍于输……留而不去,传舍于伏冲之脉……留而不去,传舍于胃肠。”论述外感病的一般传变规律,即由表入里,由浅及深。故治疗邪在皮毛,当以表散;在经脉,当通经脉;入里,当从里泄邪。由于疾病的传变,逐次加重,故当早期及时治疗,防其传变,否则必贻误时机,使预后不良。又如《素问·玉机真藏论篇》曰:“肝受气于心,传之于脾,气舍于肾,至肺而死;心受气于脾,传之于肺,气舍于肝,至肾而死;脾受气于肺,传之于肾,气舍于心,至肝而死。”阐述了“五脏相通,移皆有次”的传变原理,故《素问·刺热篇》云:“病虽未发,见赤色者刺之,名曰治未病。”这是中医“治未病”理论在实际应用中的具体体现。“五脏相通,移皆有次”的思想对后世医家有深远的影响。汉代张仲景的《金匮要略》中就有“见肝之病,知肝传脾,当先实脾”的经典论述。这对临床实践具有重要的指导意义。如临证常见的肝气郁结证,除精神郁闷、胸胁苦满等症状,还常出现纳差、食减、腹胀等脾病症状,故治肝病之时,常适时加用健脾之法。如临床常用的的逍遥散,疏肝兼有健脾的功效,另外还有抑木扶土的痛泻要方等等。再如叶天士治温热病强调“先安未受邪之地”,当邪热在卫分时,除用清热益胃的石膏、知母外,还加入养阴滋肾的阿胶、龟版,以防邪热进一步耗伤肾阴。 《老子》的“少私寡欲”与《黄帝内经》“恬淡虚无”老子的道家思想重视精神养生,追求人们生命的自由、平等,追求人与大自然的和谐相处,认为应该以平等的心胸对待万物,天地万物都存在与人类平等的价值。在与自然万物共处时,不能有太多贪欲。《老子·第十二章》说:“五色令人目盲,五音令人耳聋,五味令人口爽,驰骋畋猎令人心发狂,难得之货令人行妨。是以圣人为腹不为目,故去彼取此。”因此,《老子·第十九章》主张“见素抱朴,少私寡欲”。并且主张“去甚,去奢,去泰”(《老子·第二十九章》),意思是要外表单纯,内心淳朴,减少私心,降低欲望,去掉极端的、奢侈的、过分的东西,认为过分地求生存反而会致死亡。精神养生的关键就是虚静。

    《老子》又称《道德经》,系春秋时期道家创始人老子所作。老子即老聃,姓李名耳,字伯阳,楚国苦县(今河南鹿邑东)厉乡曲仁里人。《老子》对中国哲学发展具有深刻影响,被道教作为重要经典收入《道藏》。 道家所主张的“道”,是指天地万物的本质及其自然循环的规律。 自然界万物处于经常的运动变化之中,道即是其基本法则。道家文化不仅是中国文化的重要组成部分,也对中医防病养生思想的形成起到了重要作用。笔者就《老子》与《黄帝内经》的防病养生学术思想的关系作一探讨。 　《老子》的“治未乱”与《黄帝内经》的“治未病”《老子》十分注重防患于未然,主张于祸乱发生之前就应警惕提防,并采取措施防止。如《老子·六十四章》说:“其安也,易持也。其未兆也,易谋也。其脆也,易破也。其微也,易散也。为之于其未有也,治之于其未乱也。合抱之木,生于毫末;九层之台,作于纍土;百仞之高,始于足下。”这种防微杜渐的思想在《黄帝内经》中亦得到充分的体现。《黄帝内经》中“治未病”的有关论述和内容与《老子》“治未乱”有相似之处。如《素问·四气调神大论篇》说:“圣人不治已病治未病,不治已乱治未乱,此之谓也。夫病已成而后药之,乱已成而后治之,譬犹渴而穿井,斗而铸锥,不亦晚乎?”意指高明的医生不治已病,不是等有了病之后再治,而是“治未病”,即在没有病之前就要进行预防。又如在《灵枢·官能》中曰:“上工救其萌芽,下工守其已成,因败其形。”《素问·刺热篇》曰:“病虽未发,见赤色者刺之,名曰治未病。”都强调高明的医者治病于未发。这种“治未病”的思想与《老子》的“治未乱”有密不可分的关系。经过实践证明,这种以预防为主的“治未病”的方法在临床上往往起到事半功倍的作用。《素问·宝命全形论篇》云:“天覆地载,万物悉备,莫贵于人。”指出了世间万物,人是最宝贵的,我们应该珍惜生命,注重养生,做到“未病先防”。