psoriasis(Psoriasis) is a chronic, very common skin disease that has been known since ancient times. The prevalence ranges between 0, 1 and 3% in different countries. However, these numbers only reflect the proportion of psoriasis in patients with other dermatoses or the frequency of its occurrence in patients with internal diseases. Since the disease is often localized and inactive, patients usually do not seek help from medical institutions and therefore are not registered anywhere.
The main pathogenetic link that causes the appearance of skin rashes is increased mitotic activity and accelerated proliferation of epidermal cells, which leads to the cells of the lower layers "pushing out" the cells above, thus preventing their keratinization. This process isCalled parakeratosis and is accompanied by severe peeling. Of great importance for the development of psoriatic lesions in the skin are local immunopathological processes associated with the interaction of various cytokines - tumor necrosis factor, interferons, interleukins, as well as lymphocytes of various subpopulations.
The trigger for the onset of the disease is often severe stress - this factor is present in the anamnesis of most patients. Other triggering factors include skin trauma, medication, alcohol abuse and infections.
Numerous diseases of the epidermis, dermis and all body systems are closely related and cannot individually explain the mechanism of disease development.
There is no generally accepted classification of psoriasis. In addition to ordinary (vulgar) psoriasis, erythrodermic, arthropathic, pustular, exudative, guttate and palmoplantar forms are traditionally distinguished.
Normal psoriasis is clinically manifested by the formation of flat papules that are clearly separated from healthy skin. The papules are pinkish-red in color and covered with loose silvery-white scales. From a diagnostic point of view, an interesting group of symptoms occurs when scraping papules, called the psoriasis triad. First, the phenomenon of "stearin spot" occurs, which is characterized by increased detachment when scratching, as a result of which the surface of the papules resembles a drop of stearin. After removing the scales, the phenomenon of "final film" is observed, which is in the form of a wet, shiny surface of the elements. Subsequently, with further scraping, the phenomenon of "blood dew" is observed - in the form of point-like, non-merging blood droplets.
The rash can appear on any part of the skin, but is mainly localized on the skin of the knee and elbow joints and the scalp, where the disease very often begins. Psoriatic papules are characterized by their tendency to grow peripherally and merge into plaques of varying sizes and shapes. Plaques can be isolated, small or large, and occupy large areas of the skin.
In exudative psoriasis, the type of peeling changes - the scales become yellowish-gray and stick together to form crusts that fit tightly to the skin. The rashes themselves are lighter and more puffy than in normal psoriasis.
Psoriasis of the palms and soles can be seen as an isolated lesion or in combination with lesions elsewhere. It manifests itself in the form of typical papulo-plaque elements and hyperkeratotic, callus-like lesions with painful cracks or pustular rashes.
Psoriasis almost always affects the nail plates. The most pathognomonic is the appearance of point-like impressions on the nail plates, which give the nail plate a resemblance to a thimble. Loosening of the nails, brittle edges, discoloration, transverse and longitudinal grooves, deformation, thickening and subungual hyperkeratosis can also be observed.
Psoriatic erythroderma is one of the most severe forms of psoriasis. It can develop due to the gradual progression of the psoriasis process and the fusion of plaques, but more often it occurs under the influence of irrational treatment. With erythroderma, the entire skin takes on a bright red color, swells, becomes infiltrated, and peels profusely. Patients suffer from severe itching and their general condition worsens.
Radiologically, various changes in the bone and joint system can be observed in most patients without any clinical signs of joint damage. These changes include periarticular osteoporosis, narrowing of the joint space, osteophytes and cystic detachment of bone tissue. The spectrum of clinical manifestations can range from mild arthralgia to the development of disabling ankylosing osteoarthritis. Clinically, swelling of the joints, redness of the skin in the area of the affected joints, pain, limited mobility, joint deformities, ankylosis and mutilation are noted.
Pustular psoriasis manifests itself in the form of generalized or limited rashes, localized mainly on the skin of the palms and soles. Although the main symptom of this form of psoriasis is the appearance of pustules on the skin, which in dermatology are considered a manifestation of a pustular infection, the contents of these blisters are usually sterile.
Guttate psoriasis occurs most often in children and is accompanied by a sudden rash of small papular elements scattered over the skin.
Psoriasis occurs about equally often in men and women. In most patients, the disease begins to develop before the age of 30. In many patients there is a connection between exacerbations and the season: the disease worsens more often in the cold season (winter form), much less often in the summer (summer form). In the future, this dependency may change.
There are three stages of psoriasis: progressive, stationary and regressive. The progressive stage is characterized by growth along the periphery and the appearance of new lesions, especially at the sites of previous lesions (isomorphic Koebner reaction). In the regression stage, there is a decrease or disappearance of infiltration around the perimeter or center of the plaques.
Vulgar psoriasis is differentiated from parapsoriasis, secondary syphilis, lichen planus, discoid lupus erythematosus and seborrheic dermatitis. Difficulties arise in the differential diagnosis of palmoplantar and arthropathic psoriasis.
With vulgar psoriasis, the prognosis for life is favorable. With erythroderma, arthropathic and generalized pustular psoriasis, disability and even death are possible due to exhaustion and the development of severe infections.
The prognosis remains uncertain regarding the duration of the disease, duration of remission and exacerbations. Rashes can persist for a long period of time, for many years, but more often exacerbations alternate with periods of improvement and clinical recovery. Long-term, spontaneous periods of clinical recovery are possible in a significant proportion of patients, particularly those not undergoing intensive systemic treatment.
Irrational treatment, self-medication and turning to "healers" aggravate the course of the disease and lead to the exacerbation and spread of skin rashes. For this reason, the main purpose of this article is to provide a brief description of modern methods of treating this disease.
Today there are a variety of methods for treating psoriasis; Thousands of different medications are used to treat this disease. But this only means that none of the methods give a guaranteed effect and do not completely cure the disease. In addition, the question of cure is not raised - modern therapy is only able to minimize skin manifestations, without affecting many currently unknown pathogenetic factors.
Treatment of psoriasis is carried out taking into account the form, stage, degree of prevalence of the rash and the general condition of the body. Treatment is usually complex and involves a combination of external and systemic medications.
In treatment, the patient's motivation, family circumstances, social status, lifestyle and alcohol abuse are of great importance.
The treatment methods can be divided into the following areas: external therapy, systemic therapy, physiotherapy, climate therapy, alternative and folk methods.
External therapy
In psoriasis, therapy with external medications is of utmost importance. In mild cases, treatment begins with local measures and is limited to these. Medications for topical use generally have fewer side effects, but are inferior in effectiveness to systemic therapy.
In the advanced stage, external treatment is carried out with the greatest care so as not to cause the skin condition to worsen. The more intense the inflammation, the lower the ointment concentration should be. Usually, treatment of psoriasis at this stage is limited to a special cream, 0. 5-2% salicylic ointment and herbal baths.
In the stationary and regressive stages, more active drugs are indicated - 5-10% naphthalane ointment, 2-5% salicylic ointment, 2-5% sulfur-tar ointment, as well as many other methods of therapy.
In modern conditions, when choosing a method of therapy or a specific drug, the doctor must be guided by official protocols and forms developed by the relevant health authorities. The Federal Guide to the Use of Medicines (Edition IV) recommends steroid drugs, salicylic ointments, and tar preparations for the local treatment of patients with psoriasis.
We will focus mainly on the drugs specified in the manuals.
Moisturizing active ingredients.Soften the scaly surface of psoriatic elements, reduce skin tension and improve elasticity. Use lanolin-based creams with vitamins. According to the literature, clinical effects (reduction of itching, erythema and peeling) are achieved in one third of patients even after such mild exposure.
Salicylic acid preparations. Typically, ointments with a concentration of 0. 5 to 5% salicylic acid are used. It has antiseptic, anti-inflammatory, keratoplastic and keratolytic effects and can be used in combination with tar and corticosteroids. Salicylic ointment softens the scaly layers of psoriatic elements, and also enhances the effects of local steroids by increasing their absorption. It is therefore often used in combination with these.
Tar preparations. They have long been used in the form of 5-15% ointments and pastes, often in combination with other local medicines. In our country, ointments with wood tar (usually birch) are used, in some other countries with coal tar. The latter is more active, but, according to our scientists, has carcinogenic properties, although numerous publications and foreign experience do not confirm this. Tar is superior in effectiveness to salicylic acid and has anti-inflammatory, keratoplastic and anti-peeling properties. Its use in psoriasis is also due to its effect on cell proliferation. When prescribing tar preparations, one should take into account their photosensitizing effect and the risk of deterioration in kidney function in people with nephrological diseases.
Shampoos containing tar are used to wash your hair.
Naftalan oil. A mixture of hydrocarbons and resins, contains sulfur, phenol, magnesium and many other substances. Naftalan oil preparations have anti-inflammatory, absorbable, antipruritic, antiseptic, exfoliating and repairing properties. 10-30% naphthalane ointments and pastes are used to treat psoriasis. Naftalan oil is often used in combination with sulfur, ichthyol, boric acid and zinc paste.
Local retinoid therapy. The first effective topical retinoid approved for the treatment of psoriasis. This drug has not yet been registered in our country. It is a water-based gel and is available in concentrations of 0. 05 and 0. 1%. In terms of effectiveness, it is comparable to strong corticosteroids. Side effects include itching and skin irritation. One of the advantages of this drug is its longer remission compared to GCS.
Synthetic hydroxyantrones are currently used.
As an analogue of natural chrysarobin, it has a cytotoxic and cytostatic effect, leading to a reduction in the activity of oxidative and glycolytic processes in the epidermis. This reduces the number of mitoses in the epidermis as well as hyperkeratosis and parakeratosis. Unfortunately, the drug has a pronounced local irritant effect and burns can occur when it comes into contact with healthy skin.
Mustard gas derivatives
They contain blister agents – mustard gas and trichloroethylamine. Treatment with these drugs is carried out with great caution, initially applying low concentration ointments to small lesions once a day. If well tolerated, the concentration, the area of application and the frequency of use increase. Treatment is carried out under strict medical supervision with weekly blood and urine tests. These drugs are now practically no longer used, but are very effective in the stationary stage of the disease.
Zinc pyrithione. Active ingredient, produced in the form of aerosols, creams and shampoos. It has antimicrobial, antifungal and antiproliferative effects – it suppresses the pathological growth of epidermal cells in a state of hyperproliferation. The latter property determines the effectiveness of the drug against psoriasis. The drug relieves inflammation, reduces infiltration and detachment of psoriatic elements. The treatment lasts an average of one month. To treat patients with scalp lesions, aerosol and shampoo are used, and for skin lesions, aerosol and cream are used. The drug is used twice a day, shampoo is used three times a week. In our country, the clinical effectiveness and tolerability of all dosage forms of zinc pyrithionate have been studied since 1995. According to the conclusion of leading dermatological centers, the effectiveness of the drug in the treatment of patients with psoriasis reaches 85-90%. Based on the data published in journals by leading specialists from these and other centers, clinical cure can be achieved after just three to four weeks of treatment. The effect develops gradually, but it is very important that the results of treatment are visible by the end of the first week after starting to take the drug - itching is greatly reduced, scaling is eliminated, and erythema becomes paler. Such a rapid achievement of the clinical effect leads to a rapid improvement in the quality of life of patients. The medication is well tolerated. Approved for ages 3 and up.
Ointments with vitamin D3. A synthetic vitamin D preparation has been used for local treatment since 19873. Numerous experimental studies have shown that calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, affects the skin immune system factors that regulate cell proliferation, and has anti-inflammatory properties. On our market there are 3 drugs of this group from different manufacturers. The medication is applied to the affected skin areas 1-2 times a day. The effectiveness of ointments with D3roughly corresponds to the effect of corticosteroid ointments of classes I, II and, according to J. Koo, even class III. When using these ointments, the majority of patients (up to 95%) experience a pronounced clinical effect. However, to achieve a good effect, it can take quite a long time (from 1 month to 1 year) and the affected area should not exceed 40%. Positive experiences with the substance have been reported in children. The drug was used twice a day, a pronounced effect was observed at the end of the fourth week of treatment. No side effects were noted.
Corticosteroid medications. They have been used in medical practice as external agents since 1952, when the effectiveness of external use of steroids was first demonstrated. To date, around 50 glucocorticosteroid active ingredients for external use have been registered on the pharmaceutical market. This undoubtedly makes it difficult to choose a doctor who must have information about all medications. According to the same survey, the most commonly prescribed corticosteroids for psoriasis also include combination preparations.
The therapeutic effect of external corticosteroids is based on a number of potentially beneficial effects:
- anti-inflammatory effect (vasoconstriction, resolution of the inflammatory infiltrate);
- epidermostatic (antihyperplastic effect on epidermal cells);
- Anti allergic;
- local analgesic effect (elimination of itching, burning, pain, feeling of tension).
Changes in the structure of GCS influenced their properties and activity. This is how a fairly large group of drugs appeared, differing in chemical structure and activity. Hydrocortisone acetate is now practically no longer used for psoriasis; it is used in clinical trials for comparison with newly manufactured drugs. For example, assuming the activity of hydrocortisone to be one, the activity of triamcinolone acetonide is 21 units and that of betamethasone is 24 units. Of the second class drugs for psoriasis, flumethasone pivalate is most commonly used in combination with salicylic acid, and the most modern are non-fluorinated corticosteroids. Due to the minimal risk of side effects, ointments and creams with aclomethasone are approved for use on sensitive areas (face, skin folds), for the treatment of children and the elderly when applied to large areas.
Among the drugs of the third class, a group of fluorinated corticosteroids can be distinguished. According to the data, a pharmacoeconomic analysis of the use of these drugs (although not in psoriasis), which consists of studying the price/safety/efficacy ratio, revealed favorable indicators for betamethasone valerate - rapid development of the therapeutic effect, lower cost treatment.
When treating psoriasis, you should start with lighter medications and, in case of repeated exacerbations and ineffectiveness of the medications used, give stronger medications. However, the following tactic is popular among American dermatologists: first, a strong GCS is used to achieve a quick effect, and then the patient is transferred to a moderate or weak drug for maintenance therapy. In any case, strong medications are used in short doses and only in limited locations because side effects are more likely to occur when prescribed.
In addition to this classification, drugs are divided into fluorinated, difluorinated and non-fluorinated drugs of different generations. First generation non-fluorinated corticosteroids (hydrocortisone acetate) are generally less effective compared to fluorinated ones but are safer in terms of side effects. Now the problem of low effectiveness of non-fluorinated corticosteroids has already been solved - fourth-generation non-fluorinated drugs have been developed, which are comparable in strength to fluorinated ones and in safety to hydrocortisone acetate. The problem of enhancing the effect of the drug is not solved by halogenation, but by esterification. This not only enhances the effect, but also allows you to take esterified medicines once a day. They are the fourth generation non-fluorinated corticosteroids that are currently preferred for topical use in psoriasis.
Standard side effects of local steroid use include the development of skin atrophy, hypertrichosis, telangiectasia, pustular infections, and systemic effects affecting the hypothalamic-pituitary-adrenal system. With the modern, non-fluoridated medications mentioned above, these side effects are reduced to a minimum.
Pharmaceutical companies are trying to diversify the range of dosage forms and produce GCS in the form of ointments, creams and lotions. Fatty ointment, forming a film on the surface of the lesion, causes more effective absorption of the infiltration than other dosage forms. The cream relieves acute inflammation better, moisturizes and cools the skin. The lotion's oil-free base ensures easy distribution on the surface of the scalp without sticking the hair.
According to literature, when using mometasone for 3 weeks, for example, a positive therapeutic effect (reduction in the number of skin rashes by 60-80%) can be achieved in almost 80% of patients. According to V. Yu. Udzhukhu, the most favorable "efficacy/safety" ratio can be achieved when using hydrocortisone butyrate. The pronounced clinical effect when using this drug is accompanied by good tolerability - the authors did not observe any side effects in any of the treated patients, even when used on the face. With prolonged use of other corticosteroids, treatment had to be stopped due to the development of side effects. According to B. Bianchi and N. G. Kochergin, a comparison of the results of the clinical use of mometasone fuorate and methylprednisolone aceponate showed the same effectiveness of these drugs when used externally. A number of authors (E. R. Arabian, E. V. Sokolovsky) propose graded corticosteroid therapy for psoriasis. It is recommended to start external therapy with combination drugs containing corticosteroids (e. g. betamethasone and salicylic acid). The average duration of such treatment is about 3 weeks. This is followed by a transition to pure GCS, preferably of the third class (e. g. hydrocortisone butyrate or mometasone furoate).
Patients are attracted by the ease of use of steroid drugs, the ability to quickly relieve the clinical symptoms of the disease, accessibility and lack of smell. In addition, these medicines do not leave greasy stains on clothing. However, their use should be short-term to avoid worsening the course of the disease. With prolonged use of steroid ointments, addiction develops. Abrupt withdrawal of corticosteroids may result in exacerbation of the skin process. The literature indicates different durations of remission after topical treatment with corticosteroids. Most studies indicate short-term remission - from 1 to 6 months.
For psoriasis, combinations of steroid hormones with salicylic acid are most effective. Salicylic acid complements the dermatotropic action of steroids due to its keratolytic and antimicrobial effects.
It is convenient to apply combination lotions containing corticosteroids and salicylic acid to the scalp. According to the authors, the effectiveness of combined drugs reaches 80 - 100%, while skin cleansing occurs very quickly - within 3 weeks.
In conclusion, in practice the doctor must always decide whether to use exclusively external treatment methods or prescribe them in combination with systemic therapy in order to increase the effectiveness of treatment and prolong remission.