same time. Certain keratoplasties such as 2-5% coal tar, 5-10% pityrolum, 3% salicy lic acid, 3-5% sulfur, 0. 1-0.5% anthralin and calcipotriol are used for the treatment ofof skin disease with parakeratosis such as psoriasis 9) Keratolytics Keratolytics such as 5-10% salicy lic acid, 10% resorcin, 10% sulfur, 20-40% urea, 5-10% lactic acid. 10-30% acetic acid and 0.01-0 1% retinoic acid etc are used for the improvement of hyperkeratosis 10)Astringent The functions of certain astringents such as 0.2-0.5% silver nitrate, 2% alum, 5% inflammation and inhibition of sebaceous and eccrine gland af exudation, alleviation of formaldehyde etc are coagulation of protein, decrease I1)Immuno-enhancement agents Imiquimod will enhance local immunity and therefore can be used for the purposes of treating condyloma acuminatum, warts and solar keratosis 12)Sunscreen 5% titanum dioxide, 10% zinc oxide, 5%-10%PABA and 5% quinin etc will block the penetration of ultra violet light, therefore treating polymorphic solar eruption, LE, phototoxic drug eruption, solar urticaria and porphyria etc 13)Depigmetation agents 3% hydroquinone, 20% azelaic acid, kojic acid and arbutin can inhibit me lanin synthesis and decrease hyperpigmention, therefore treating melasma and postinflammatory hyperpigmentation 14)Immunomodulator Tacrolimus and Pimcrolimus are both calcineurin inhibitors, thereby selectively suppressing t ell ac itivity. They can be topically used for treating dermatitis, eczema, psoriasis, and vitiligo etc 15) Corticosteroids Topical corticosteroids are a category of topical agents of great importance in dermatology, having anti-inflammatory, immunosuppressive, and anti-mitogenic activity They are classified into 4 groups according to potency, and can be used for the purpose of treating various skin diseases a. Hydrocortisone acetate(0.5%-2.5%)and methylprednisone(0. 25-0. 1%)belong to the idly potent group b. Hydrocortisone butyrate(0. 1%), dexamethasone(0. 1%), triamic inolone(0. 1%), pivalic acid dexamethasone(0.03%)and mometasone furoate etc belong to the moderately c. Fluocinonide(0.5%), betamethasone pentanoate(0.1%)and halcinonidedcorten(0. 1%) belong to the potent group d. Clobesol propionate (0.05%)and halometasone(0.05%) belong to the very potent group Long-term topical application will have certain side effects such as skin atrophy, telangiectasia, acne, hyperpig mentation and folliculitis etc. Therefore long-term use is not recommended for face and infants. Moreover, systemic absorption may occur after long-term application 2. Preparations of topical agents Different vehicles have d ifferent properties and are important for the effect of topical
same time. Certain keratoplastics such as 2-5% coal tar, 5-10% pityrolum, 3% salicylic acid, 3-5% sulfur, 0.1-0.5% anthralin and calcipotriol are used for the treatment of of skin disease with parakeratosis such as psoriasis. 9) Keratolytics Keratolytics such as 5-10% salicylic acid, 10% resorcin, 10% sulfur, 20-40% urea, 5-10% lactic acid, 10-30% acetic acid and 0.01-0.1% retinoic acid etc are used for the improvement of hyperkeratosis. 10) Astringent The functions of certain astringents such as 0.2-0.5% silver nitrate，2% alum，5% formaldehyde etc are coagulation of protein, decrease of exudation, alleviation of inflammation and inhibition of sebaceous and eccrine glands. 11) Immuno-enhancement agents Imiquimod will enhance local immunity and therefore can be used for the purposes of treating condyloma acuminatum, warts and solar keratosis. 12) Sunscreen 5% titanum dioxide, 10% zinc oxide, 5% -10%PABA and 5% quinin etc will block the penetration of ultra violet light, therefore treating polymorphic solar eruption, LE, phototoxic drug eruption, solar urticaria and porphyria etc. 13) Depigmetation agents 3% hydroquinone, 20% azelaic acid, kojic acid and arbutin can inhibit melanin synthesis and decrease hyperpigmention, therefore treating melasma and postinflammatory hyperpigmentation. 14) Immunomodulator Tacrolimus and Pimcrolimus are both calcineurin inhibitors, thereby selectively suppressing T ell acitivity. They can be topically used for treating dermatitis, eczema, psoriasis, and vitiligo etc. 15) Corticosteroids Topical corticosteroids are a category of topical agents of great importance in dermatology, having anti-inflammatory, immunosuppressive, and anti-mitogenic activity. They are classified into 4 groups according to potency, and can be used for the purpose of treating various skin diseases. a. Hydrocortisone acetate(0.5%-2.5%) and methylprednisone (0.25-0.1%) belong to the mildly potent group. b. Hydrocortisone butyrate(0.1%), dexamethasone(0.1%), triamicinolone(0.1%), pivalic acid dexamethasone (0.03%) and mometasone furoate etc belong to the moderately potent group. c. Fluocinonide(0.5%), betamethasone pentanoate (0.1%) and halcinonidedcorten (0.1%) belong to the potent group. d. Clobesol propionate (0.05%) and halometasone (0.05%) belong to the very potent group. Long-term topical application will have certain side effects such as skin atrophy, telangiectasia, acne, hyperpigmentation and folliculitis etc. Therefore long-term use is not recommended for face and infants. Moreover, systemic absorption may occur after long-term application. 2. Preparations of topical agents Different vehicles have different properties and are important for the effect of topical
agents D)Aqueous solution This is composed of water and water soluble drug 2)Powder It is composed of 10% zinc oxide, 70% talc powder, 10%0-20% starch and the d 3 Lotio It is composed of calamine, zinc oxide, talc powder, water and the drug 4) Tincture It is the ethanol solution of certain d 5)Paste It is composed of cream, zinc oxide powder, talc powder and the drug 6)Ointment It is composed of lanolin, petrolatum and the dru eMulsion Emulsion is the result of emulsification of the oil and water mixture. and can be classified into oil in water(o/w) and water in oil( w/o)phase. Cream is actually a semisolid emulsion system containing oil and water 8)Gel Gel is semisolid preparation of high molecular weight polymers and the drug 9)Oil It is composed of vegetable oil, volatile solvent and the drug 3. Principles of topical agent usage 1)Choice of correct topical agents This is based on correct diagnosis of certain skin disease. For example, anti-funga agent is used for cutaneous fungal infection, corticosteroid is used for allergic skin disease, and keratoplastic is suitable for parakeratosis 2)Choice of correct vehicle This is based on symptoms and characteristics of skin lesion a Acute skin lesion Powder and shake lotion are chosen when there are erythema and papules without exudation. If there exist erosion and a lot of exudation, wet compressing of solut ion is recommended. When there is erosion with little exudation, paste can be used b Sub-acute skin lesion Paste and oil are recommended for sub-acute lesions with little exudation and emulsion or paste when there's no erosion c Chronic lesions Emulsion. ointment. and tincture etc can be chosen d Pruritus without primary lesion Emulsion, tincture and ointment can be used 3Things to be noticed. a History of drug allergy must be inquired before application, and the topical agent usage must be stopped whenever there's any indication of allergy or irritation. b Patients must be taught how to use topical agents correctly c Different topical agent is to be used for d ifferent patients according to sex, age and site of lesion d Topical agent of high irritation such as anthralin, high concentration salicy lic acid is not
agents. 1) Aqueous solution This is composed of water and water soluble drug. 2) Powder It is composed of 10% zinc oxide, 70% talc powder, 10%-20% starch and the drug. 3) Lotions It is composed of calamine, zinc oxide, talc powder , water and the drug. 4) Tincture It is the ethanol solution of certain drugs. 5) Paste It is composed of cream, zinc oxide powder, talc powder and the drug. 6) Ointment It is composed of lanolin, petrolatum and the drug. 7) Emulsion Emulsion is the result of emulsification of the oil and water mixture, and can be classified into oil in water(o/w) and water in oil(w/o) phase. Cream is actually a semisolid emulsion system containing oil and water. 8) Gel Gel is semisolid preparation of high molecular weight polymers and the drug. 9) Oil It is composed of vegetable oil, volatile solvent and the drug. 3. Principles of topical agent usage. 1) Choice of correct topical agents This is based on correct diagnosis of certain skin disease. For example, anti-fungal agent is used for cutaneous fungal infection, corticosteroid is used for allergic skin disease, and keratoplastic is suitable for parakeratosis. 2) Choice of correct vehicle: This is based on symptoms and characteristics of skin lesion. a. Acute skin lesion Powder and shake lotion are chosen when there are erythema and papules without exudation. If there exist erosion and a lot of exudation, wet compressing of solution is recommended. When there is erosion with little exudation, paste can be used. b. Sub-acute skin lesion Paste and oil are recommended for sub-acute lesions with little exudation, and emulsion or paste when there’s no erosion. c. Chronic lesions Emulsion, ointment, and tincture etc can be chosen. d. Pruritus without primary lesion Emulsion, tincture and ointment can be used. 3)Things to be noticed. a.History of drug allergy must be inquired before application, and the topical agent usage must be stopped whenever there’s any indication of allergy or irritation. b.Patients must be taught how to use topical agents correctly. c.Different topical agent is to be used for different patients according to sex, age and site of lesion. d.Topical agent of high irritation such as anthralin, high concentration salicylic acid is not
to be used for infants face and skin fold e. It is recommended that the concentration of the agent be increased gradually, and agents must be changed frequently to prevent drug resistance Physical Therapy 1. Electro-th erapy 1)Electrodessication High-frequency electric power with high voltage and low intensity is used in electrodessication to ablate small warts, solar keratosis and pyogenic granuloma etc 2)Electrocoagulation As for electrocoagulation, volatage is relatively lower but intensity higher than that used in electrodessication. Relatively larger benign tumors or lesions can be ablated with this method. Patients using pacemaker must not receive e ither electrodessication or electrocoagulation therapy 3)Electrocautery Electrocautery is utilized for the ablation of warts, pyogenic granuloma, and small benign tumors 2. Infrared therapy At a wavelength ranged between 760-1500nm, infrared ray can dilate blood vessels, improve circulation, alleviate inflammation and enhance recovery. The indications of infrared therapy include cutaneous inflammation, chronic ulcer and frostbite 3. Ultraviolet therapy and photochemotherapy 1)Uitraviolet (UV therapy Ultraviolet has 3 subtypes: UVa(wavelength 320-400nm), UVB (wavelength 290-320nm)and UvC (wavelength 200-29Onm), and the former two are used for medical purposes. UVA and UVB can accelerate blood circulation, quench pain or itching increase hyperpigmentation and kill bacteria, therefore having a wide range of indications The initial dose of Uv irradiation is usually below minimal erythema dose(MED), and increased gradually afterwards. Contraind ications of Uv therapy include active tuberculosis, thyroid dysfunction, cardiac dysfunction, hepatic dysfunction, renal dysfunction and photoallergy UVA and UVB can be used separately or in combination for the treatment of pityriasis rosea, psoriasis, alopecia areata, chronic ulcer, acne, folliculitis and herpes zoster etc Recently narrowband UVB (NB-UVB, wavelength 300-311nm)has been used against psoriasis and vitiligo, the results being encouraging 2)Photochemotherapy (PUVA) This is a process with the ad ministration of topical or oral photosensitizer such as 8-methoxypsoralen(8-MOP) before UVA irradiation. The concentration of 8-MOP for topical application is 0. 1-0.5% and oral dose is 0.6mg/kg each time. The initial dose of UVa is usually minimal phototoxic dose(MPD)at approximately 2.5J/cm, and gradually increased. Able to suppress DNa synthesis accord ing to research, PUVA prov effective against psoriasis, MF, vitiligo, alopecia areata and atopic dermatitis(AD)etc Contraindications include cataract, hepatic disease, LE, xeroderma pigmentosum, malignant melanoma, children and pregnant women. Photosensitizing food or drug forbidden during PUVa therapy and regular examination of blood count, hepatic function renal function, eyes and skin is necessary. It is reported that long term PUva will
to be used for infants, face, and skin folds. e.It is recommended that the concentration of the agent be increased gradually, and agents must be changed frequently to prevent drug resistance. Physical Therapy 1. Electro-therapy 1) Electrodessication High-frequency electric power with high voltage and low intensity is used in electrodessication to ablate small warts, solar keratosis and pyogenic granuloma etc. 2) Electrocoagulation As for electrocoagulation, volatage is relatively lower but intensity higher than that used in electrodessication. Relatively larger benign tumors or lesions can be ablated with this method. Patients using pacemaker must not receive either electrodessication or electrocoagulation therapy. 3) Electrocautery Electrocautery is utilized for the ablation of warts, pyogenic granuloma, and small benign tumors. 2. Infrared therapy At a wavelength ranged between 760-1500nm, infrared ray can dilate blood vessels, improve circulation, alleviate inflammation and enhance recovery. The indications of infrared therapy include cutaneous inflammation, chronic ulcer and frostbite. 3. Ultraviolet therapy and photochemotherapy 1) Uitraviolet (UV) therapy Ultraviolet has 3 subtypes: UVA (wavelength 320-400nm), UVB (wavelength 290-320nm) and UVC (wavelength 200-290nm), and the former two are used for medical purposes. UVA and UVB can accelerate blood circulation, quench pain or itching, increase hyperpigmentation and kill bacteria, therefore having a wide range of indications. The initial dose of UV irradiation is usually below minimal erythema dose (MED), and increased gradually afterwards. Contraindications of UV therapy include active tuberculosis, thyroid dysfunction, cardiac dysfunction, hepatic dysfunction, renal dysfunction and photoallergy. UVA and UVB can be used separately or in combination for the treatment of pityriasis rosea, psoriasis, alopecia areata, chronic ulcer, acne, folliculitis and herpes zoster etc. Recently narrowband UVB (NB-UVB, wavelength 300-311nm) has been used against psoriasis and vitiligo, the results being encouraging. 2) Photochemotherapy (PUVA) This is a process with the administration of topical or oral photosensitizer such as 8-methoxypsoralen (8-MOP) before UVA irradiation. The concentration of 8-MOP for topical application is 0.1-0.5% and oral dose is 0.6mg/kg each time. The initial dose of UVA is usually minimal phototoxic dose (MPD) at approximately 2.5J/cm2 , and gradually increased. Able to suppress DNA synthesis according to research, PUVA proves effective against psoriasis, MF, vitiligo, alopecia areata and atopic dermatitis (AD) etc. Contraindications include cataract, hepatic disease, LE, xeroderma pigmentosum, malignant melanoma, children and pregnant women. Photosensitizing food or drug is forbidden during PUVA therapy and regular examination of blood count, hepatic function, renal function, eyes and skin is necessary. It is reported that long term PUVA will
rease the risk of skin cancer, but this is not finally confirmed 4. Laser and intense pulsed light (PL) 1)Continuous-mode co2 laser(10600nm,) Continuous-mode Co2 laser can be used for the ablation of wart, condyloma acuminatum, skin tag, pyogenic granuloma, nevus and benign skin tumor etc 2)He-Ne laser(630nm) Of low intensity, He-Ne laser can be used for the treatment of folliculitis, herpes zoster alopecia areata and skin ulcer etc 3)Q-switched Alexandrite laser (755nm) Based on the principle of selective photothermolysis, Q-switched Alexandrite laser proves effective in treating pigmentary disorder such as nevus of Ota, bilateral nevus of Ota-like macule. tattoo. freckles. seborrhe ic keratosis and cafe au lait etc without scar formation 4)Q-switched Ruby laser(694nm) and Q-switched Nd: YAG laser(1064nm) These 2 lasers have similar ind ications to those of Q-switched Alexandrite laser with similar efficacy 5Pulsed dye laser There are 2 kinds of pulsed dye laser, at wavelengths of 585nm and 595nm respectively They are effective in treating vascular disorder such as portwine stain, telangiectasia pider nevus, angiokeratoma and hypertrophic scar etc 6)Diode laser(810nm) Of long pulse duration, this laser is effective for hair removal, and is also used for the treatment of bromhidrosis 7)Erbium YAG (2940nm)and Ultrapulse co2 laser(10600nm) These 2 laser systems have short pulse durations, therefore minimizing thermal injury during the process of ablation and the risk of scar formation. They can be used for the removal of superficial benign sk in tumours(e.g syringoma), wart, skin tag, seborrheic keratosis, xanthoma and atrophic scar etc. They have also been used for full-face resurfacing abroad, but hyperpigmentation is almost 100% in Asian skin 8)Intense pulsed light (IPL) IPL is a kind of non-coherent light source diiferent from laser with the wavelength sually between 560-1200nm. Different portions of wavelength can be filtered out for different purposes. IPL can be used for various skin or cosmetic purposes, such as superficial pigmentation(e.g freckles, seborrheic keratosis and cafe au lait etc), vascular lesions (e.g portwine stain and telangiectasia), fine wrinkles, hair removal and photorejuvenation. The greatest ad vantage of IPL is minimal injury and thus little downtime 5. Photodynamic therapy (pdt) DT is a process that includes both photosensitizer and activating light source, the latter being either laser or non-coherent light. Usually photosensitizers are administered topically or intravenously, and lesions will be irradiated later. This will initiate photodynamic reaction, generating free radicals and therefore is widely used for various kinds of tumours and skin d iseases )ALA-PDT In this process, 5-ALA is used as a topical sensitizer, and the activating light at a wavekength around 630nm is irrad iated 2-3 hours later. ALA-PDThas proven effective
increase the risk of skin cancer, but this is not finally confirmed. 4. Laser and intense pulsed light (IPL) 1) Continuous-mode CO2 laser (10600nm,) Continuous-mode CO2 laser can be used for the ablation of wart, condyloma acuminatum, skin tag, pyogenic granuloma, nevus and benign skin tumor etc. 2) He-Ne laser (630nm) Of low intensity, He-Ne laser can be used for the treatment of folliculitis, herpes zoster, alopecia areata and skin ulcer etc. 3) Q-switched Alexandrite laser (755nm) Based on the principle of selective photothermolysis, Q-switched Alexandrite laser proves effective in treating pigmentary disorder such as nevus of Ota, bilateral nevus of Ota-like macule, tattoo, freckles, seborrheic keratosis and café au lait etc without scar formation. 4) Q-switched Ruby laser (694nm) and Q-switched Nd:YAG laser (1064nm) These 2 lasers have similar indications to those of Q-switched Alexandrite laser with similar efficacy. 5)Pulsed dye laser There are 2 kinds of pulsed dye laser, at wavelengths of 585nm and 595nm respectively. They are effective in treating vascular disorder such as portwine stain, telangiectasia, spider nevus, angiokeratoma and hypertrophic scar etc. 6) Diode laser (810nm) Of long pulse duration, this laser is effective for hair removal, and is also used for the treatment of bromhidrosis. 7) Erbium YAG (2940nm) and Ultrapulse CO2 laser (10600nm) These 2 laser systems have short pulse durations, therefore minimizing thermal injury during the process of ablation and the risk of scar formation. They can be used for the removal of superficial benign skin tumours (e.g syringoma), wart, skin tag, seborrheic keratosis, xanthoma and atrophic scar etc. They have also been used for full-face resurfacing abroad, but hyperpigmentation is almost 100% in Asian skin. 8) Intense pulsed light (IPL) IPL is a kind of non-coherent light source diiferent from laser, with the wavelength usually between 560-1200nm. Different portions of wavelength can be filtered out for different purposes. IPL can be used for various skin or cosmetic purposes, such as superficial pigmentation (e.g freckles, seborrheic keratosis and café au lait etc), vascular lesions (e.g portwine stain and telangiectasia), fine wrinkles, hair removal and photorejuvenation. The greatest advantage of IPL is minimal injury and thus little downtime. 5. Photodynamic therapy (PDT) PDT is a process that includes both photosensitizer and activating light source, the latter being either laser or non-coherent light. Usually photosensitizers are administered topically or intravenously, and lesions will be irradiated later. This will initiate a photodynamic reaction, generating free radicals and therefore is widely used for various kinds of tumours and skin diseases. 1) ALA-PDT In this process, 5-ALA is used as a topical sensitizer, and the activating light at a wavekength around 630nm is irradiated 2-3 hours later. ALA-PDT has proven effective
Recently, IPL has been used as the light source in ALA-PDT for the purpose of Sis etc in treating superficial basal cell carcinoma(BCC), actinic keratosis, acne and psoria photorejuvenation, and might have better result than IPL alone 2)PDT treatment of portwine stain Hemoporphyrin derivatives are used intravenously as photosensitizers and the wavelengths of the activating light sources are 418nm, 532nm, and 578nm respectively Multiple PDt tretment is required to achieve satisfactory results 6. Cryotherapy Liquid nitrogen(196C)and dry ice(-70oC) are 2 kinds of cryogen in cryotherapy, vith the former more frequently used. They will lead to intracellular ice crystal formation dehydration of cells and degeneration of lipoprotein, eventually causing cellular necrosis The ind ications of cryotherpy include wart, condyloma acuminatum, pyogenic granuloma, prurigo nodularis, keloids and superficial benign tumors. Blister and hypopigmentation may occur after cryotherapy 7. Hydrotherapy Bath in clean water that contain certain med icine at certain temperature has proven effective for psoriasis, pruritus, erythroderma and chronic eczema etc. Starch bath seawater bath, potassium permanganate bath and chinese med icine bath are often utilized in dermatology Dermatologic surgery Dermatologic surgery will probably solve some of the problems on which drug therapy has no effect. The ind ications of dermatologic surgery include skin tumor, biopsy, restoration of normal function, and cosmetic improvement etc 1. Dermabrasion Dermabrasion is used for the treatment of atrophic scar, wrinkles and superficial benign skin tumours. Contraindications include radiodermatitis, xeroderma pigmentosum and inflammatory dermatoses etc 2. Hair transplantation Hair transplantation proves effective for androgenetic alopecia. Minigraft and micrograft are often used in this process. Laser and other methods may be used for the creation of recipient site 3. Skin surgery Skin surgery is used for biopsy, resection of skin tumor, drainage of abscess and nail plucking. Recently Moh's micrographic surgery, which is primarily indicated for difficult basal cell carcinomas(BCC), squamous cell carcinomas(SCC)and other challeng ing neoplasms, has been introduced in this field. With the help of pathologic examination during the operation, lesions will be resected but normal tissue will be preserved as much as possible in Moh's micrographic surgery 4. Liposuction By liposuction, redundant fat tissue can be removed from the body, and therefore this method has been increasingly popular in the field of cosmetic surgery. Ultrasonic wave and laser energy have been used in the treatment (Lu Zhong
in treating superficial basal cell carcinoma (BCC), actinic keratosis, acne and psoriasis etc. Recently, IPL has been used as the light source in ALA-PDT for the purpose of photorejuvenation, and might have better result than IPL alone. 2) PDT treatment of portwine stain Hemoporphyrin derivatives are used intravenously as photosensitizers and the wavelengths of the activating light sources are 418nm, 532nm, and 578nm respectively. Multiple PDT tretment is required to achieve satisfactory results. 6. Cryotherapy Liquid nitrogen (-196oC) and dry ice (-70 oC) are 2 kinds of cryogen in cryotherapy, with the former more frequently used. They will lead to intracellular ice crystal formation, dehydration of cells and degeneration of lipoprotein, eventually causing cellular necrosis. The indications of cryotherpy include wart, condyloma acuminatum, pyogenic granuloma, prurigo nodularis, keloids and superficial benign tumors. Blister and hypopigmentation may occur after cryotherapy. 7. Hydrotherapy Bath in clean water that contain certain medicine at certain temperature has proven effective for psoriasis, pruritus, erythroderma and chronic eczema etc. Starch bath, seawater bath, potassium permanganate bath and Chinese medicine bath are often utilized in dermatology. Dermatologic surgery Dermatologic surgery will probably solve some of the problems on which drug therapy has no effect. The indications of dermatologic surgery include skin tumor, biopsy, restoration of normal function, and cosmetic improvement etc. 1. Dermabrasion Dermabrasion is used for the treatment of atrophic scar, wrinkles and superficial benign skin tumours. Contraindications include radiodermatitis, xeroderma pigmentosum and inflammatory dermatoses etc. 2. Hair transplantation Hair transplantation proves effective for androgenetic alopecia. Minigraft and micrograft are often used in this process. Laser and other methods may be used for the creation of recipient site. 3. Skin surgery Skin surgery is used for biopsy, resection of skin tumor, drainage of abscess and nail plucking. Recently Moh’s micrographic surgery, which is primarily indicated for difficult basal cell carcinomas (BCC), squamous cell carcinomas (SCC) and other challenging neoplasms, has been introduced in this field. With the help of pathologic examination during the operation, lesions will be resected but normal tissue will be preserved as much as possible in Moh’s micrographic surgery. 4. Liposuction By liposuction, redundant fat tissue can be removed from the body, and therefore this method has been increasingly popular in the field of cosmetic surgery. Ultrasonic wave and laser energy have been used in the treatment. (Lu Zhong)