Psoriasis(squamous lichen) is a very common chronic skin disease, known since ancient times. Its prevalence in different countries ranges between 0, 1 and 3%. However, these figures reflect only the proportion of psoriasis in patients with other dermatoses or the frequency of its appearance in patients with internal diseases. Since the disease is usually localized and inactive, patients do not usually seek help in medical institutions and are therefore not registered anywhere.
The main pathogenic link provoking the appearance of skin rashes is increased mitotic activity and accelerated proliferation of epidermal cells, which leads to the fact that the cells of the lower layers "push" the overlying cells, preventing them from they keratinize. This process is called parakeratosis and is accompanied by abundant peeling. Of great importance in the development of psoriatic skin lesions are local immunopathological processes associated with the interaction of various cytokines: tumor necrosis factor, interferons, interleukins and lymphocytes of various subpopulations.
The trigger point for the onset of the disease is usually intense stress; This factor is present in the history of most patients. Other triggers include skin trauma, medication use, alcohol abuse, and infections.
Numerous disorders of the epidermis, dermis and all body systems are closely related and cannot separately explain the mechanism of disease development.
There is no generally accepted classification of psoriasis. Traditionally, along with ordinary (vulgar) psoriasis, erythrodermic, arthropathic, pustular, exudative, guttate and palmoplantar forms are distinguished.
Normal psoriasis is clinically manifested by the formation of flat papules, clearly demarcated from healthy skin. The papules are pinkish red and covered with loose silvery-white scales. From a diagnostic point of view, when the papules are scraped, an interesting group of signs occurs called the psoriatic triad. First, the "stearin spot" phenomenon appears, characterized by increased peeling when scraped, making the surface of the papules look like a drop of stearin. After removing the scales, the phenomenon of "terminal film" is observed, which manifests itself in the form of a wet, shiny surface of the elements. After this, upon further scraping, the "blood spray" phenomenon is observed, in the form of pinpoint blood droplets that do not coalesce.
The rash can be located anywhere on the skin, but is mainly located on the skin of the knee and elbow joints and on the scalp, where the disease most often begins. Psoriatic papules are characterized by a tendency to grow peripherally and merge into plaques of various sizes and shapes. The plaques can be isolated, small or large, occupying large areas of the skin.
With exudative psoriasis, the nature of the peeling changes: the scales become yellowish-gray and stick together, forming crusts that fit tightly to the skin. The rashes themselves are brighter and more swollen than in normal psoriasis.
Psoriasis of the palms and soles can be observed as an isolated lesion or combined with lesions in other locations. It manifests itself in the form of typical papule-plaque elements, as well as hyperkeratotic callus-like lesions with painful cracks or pustular eruptions.
Psoriasis almost always affects the nail plates. The most pathognomonic is the appearance of point 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, deformations, thickening, and subungual hyperkeratosis may also be observed.
Psoriatic erythroderma is one of the most severe forms of psoriasis. It can develop due to the gradual progression of the psoriatic process and the fusion of plaques, but more often it occurs under the influence of irrational treatment. With erythroderma, the entire skin becomes bright red, swells, infiltrates, and profuse peeling occurs. Patients are bothered by intense itching and their general condition worsens.
Radiologically, in most patients various changes in the osteoarticular apparatus are observed without clinical signs of joint damage. Such changes include periarticular osteoporosis, narrowing of joint spaces, osteophytes, and cystic clearing of bone tissue. The range of clinical manifestations can vary from minor arthralgias 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 detected.
Pustular psoriasis manifests itself as generalized or limited rashes, located 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 most often develops in children and is accompanied by a sudden rash of small papular elements scattered throughout the skin.
Psoriasis occurs with approximately the same frequency 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 time of year: most often the disease worsens in the cold season (winter form), and much less often in the summer (summer form). In the future, this dependency may change.
During psoriasis, there are 3 stages: progressive, stationary and regressive. The progressive stage is characterized by growth along the periphery and the appearance of new lesions, especially at sites of previous lesions (isomorphic Koebner reaction). In the regression stage, there is a decrease or disappearance of infiltration around the circumference or in the center of the plaques.
Psoriasis vulgaris is differentiated from parapsoriasis, secondary syphilis, lichen planus, discoid lupus erythematosus, and seborrheic eczema. Difficulties arise in the differential diagnosis of palmoplantar and arthropathic psoriasis.
With psoriasis vulgaris, the prognosis for life is favorable. In erythroderma, generalized arthropathic and pustular psoriasis, disability and even death are possible due to exhaustion and the development of serious infections.
The prognosis remains uncertain in terms of disease duration, duration of remission, and exacerbations. Rashes can exist for a long time, for many years, but more often exacerbations alternate with periods of clinical improvement and recovery. In a significant proportion of patients, especially those not undergoing intensive systemic treatment, periods of spontaneous and prolonged clinical recovery are possible.
Irrational treatment, self-medication and resorting to "healers" worsen the course of the disease and provoke exacerbation and spread of skin rashes. That is why the main objective of this article is to provide a brief overview of modern methods of treating this disease.
Today there are a large number of methods for treating psoriasis, thousands of different medications are used in the treatment of this disease. But this only means that none of the methods gives a guaranteed effect and does not cure the disease completely. Furthermore, the question of cure does not arise: modern therapy is only capable of minimizing skin manifestations, without affecting many currently unknown pathogenic 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. As a rule, treatment is complex and involves a combination of external and systemic medications.
The patient's motivation, family circumstances, social status, lifestyle and alcohol abuse are of great importance in treatment.
Treatment methods can be divided into the following areas: external therapy, systemic therapy, physiotherapy, climatotherapy, alternative and folk methods.
External therapy
External drug therapy is of utmost importance for psoriasis. In mild cases, treatment begins with and is limited to local measures. As a rule, medications for topical use are less likely to have side effects, but their effectiveness is inferior to systemic therapy.
In the advanced phase, external treatment is carried out very carefully so as not to cause a deterioration in the condition of the skin. The more intense the inflammation, the lower the concentration of ointment should be. Usually, at this stage, psoriasis treatment is limited to a special cream, 0. 5-2% salicylic ointment and herbal baths.
In the stationary and regression stage, more active drugs are indicated: 5-10% naphthalene ointment, 2-5% salicylic ointment, 2-5% sulfur tar ointment, as well as many other methods of therapy.
In modern conditions, when choosing a therapeutic method or a specific medication, the doctor must be guided by official protocols and forms drawn up by the current health authorities. The Federal Guide to the Use of Drugs (Number IV) suggests steroid drugs, salicylic ointments and tar preparations for the local treatment of patients with psoriasis.
We will focus mainly on the medications indicated in the manuals.
Moisturizing agents.Softens the scaly surface of psoriatic elements, reduces skin tightness and improves elasticity. Use lanolin-based creams with vitamins. According to the literature, even after such a mild exposure, clinical effects (reduction in itching, erythema and peeling) are achieved in a third of patients.
Salicylic acid preparations.. Ointments with a salicylic acid concentration of 0. 5 to 5% are usually 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 effect of local steroids by improving their absorption, therefore it is often used in combination with them.
tar preparations. They have long been used in the form of 5-15% ointments and pastes, often in combination with other local drugs. In our country, ointments with wood tar (usually birch) are used, in some foreign countries - with coal tar. The latter is more active, but, according to our scientists, it has carcinogenic properties, although numerous foreign publications and experiences do not confirm this. Tar has a higher activity than salicylic acid and has anti-inflammatory, keratoplastic and anti-exfoliation properties. Its use in psoriasis is also due to its effect on cell proliferation. When prescribing tar preparations, their photosensitizing effect and the risk of deterioration of kidney function in people with nephrological diseases should be taken into account.
Shampoos with tar are used to wash hair.
naphthalan oil. A mixture of hydrocarbons and resins, it contains sulfur, phenol, magnesium and many other substances. Naphthalan oil preparations have anti-inflammatory, absorbable, antipruritic, antiseptic, exfoliating and repairing properties. To treat psoriasis, 10-30% naphthalene ointments and pastes are used. Naphthalan oil is often used in combination with sulfur, ichthyol, boric acid and zinc paste.
Local retinoid therapy. The first effective topical retinoid approved for use in the treatment of psoriasis. This medicine has not yet been registered in our country. It is a water-based gelatin 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 hydroxyanthrones are currently used.
Analogue of natural chrysarobin, it has a cytotoxic and cytostatic effect, which leads to a decrease in the activity of oxidative and glycolytic processes in the epidermis. As a result, the number of mitoses in the epidermis decreases, as well as hyperkeratosis and parakeratosis. Unfortunately, the drug has a pronounced local irritant effect, and if it gets on healthy skin, burns may occur.
Mustard gas derivatives
They contain blistering agents: mustard gas and trichloroethylamine. Treatment with these drugs is carried out with great caution, first using ointments with a small concentration on small lesions once a day. Then, if well tolerated, the concentration, area and frequency of use are increased. Treatment is carried out under close medical supervision, with weekly blood and urine tests. Now these drugs are practically not used, but they are very effective in the stationary stage of the disease.
Zinc pyrithione. Active substance produced in the form of sprays, creams and shampoos. It has antimicrobial, antifungal and antiproliferative effects: it suppresses the pathological growth of epidermal cells in a state of hyperproliferation. This last property determines the effectiveness of the drug for psoriasis. The drug relieves inflammation, reduces infiltration and peeling of psoriatic elements. The treatment is carried out on average for a month. For the treatment of patients with scalp lesions, sprays and shampoos are used, for skin lesions - sprays and creams. The medicine is applied 2 times a day, the shampoo is used 3 times a week. In our country, since 1995, the clinical efficacy and tolerability of all pharmaceutical forms of zinc pyrithione have been studied. According to the conclusion of the main dermatological centers, the effectiveness of the drug in the treatment of patients with psoriasis reaches between 85% and 90%. According to data published in journals by leading specialists from these and other centers, clinical cure can be achieved after 3 to 4 weeks of treatment. The effect develops gradually, but it is very important that the results of treatment are evident by the end of the first week from the moment the drug is started: the itching is sharply reduced, the peeling is eliminated, and the erythema pales. Such rapid achievement of the clinical effect consequently leads to a rapid improvement in the quality of life of patients. The drug is well tolerated. Approved for use from 3 years old.
Ointments with vitamin D.3. Since 1987, a synthetic vitamin D preparation has been used for local treatment.3. Numerous experimental studies have shown that calcipotriol inhibits keratinocyte proliferation, accelerates their morphological differentiation, affects skin immune system factors that regulate cell proliferation, and has anti-inflammatory properties. In our market there are 3 drugs from this group from different manufacturers. Medicines are applied to the affected areas of the skin 1-2 times a day. The effectiveness of ointments with D.3It approximately corresponds to the effect of corticosteroid ointments of classes I, II and, according to J. Koo, even class III. When using these ointments, a pronounced clinical effect occurs in most patients (up to 95%). However, to achieve a good effect it may take 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 applied 2 times a day, a pronounced effect was observed at the end of the 4th week of treatment. No side effects were identified.
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, about 50 glucocorticosteroids for external use are 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 include combination medications.
The therapeutic effect of external corticosteroids is due to a number of potentially beneficial effects:
- anti-inflammatory effect (vasoconstriction, resolution of the inflammatory infiltrate);
- epiderstatic (antihyperplastic effect on epidermal cells);
- anti allergic;
- local analgesic effect (elimination of itching, burning, pain, feeling of oppression).
Changes in the structure of GCS affected its properties and activity. Thus, a fairly large group of drugs appeared, which differed in their chemical structure and activity. Hydrocortisone acetate is practically not used today for psoriasis, it is used in clinical studies for comparison with newly produced drugs. For example, it is believed that if the activity of hydrocortisone is taken as one, then the activity of triamcinolone acetonide will be 21 units and that of betamethasone - 24 units. Of the second class drugs for psoriasis, flumetasone pivalate in combination with salicylic acid is most often used, 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 in sensitive areas (face, skin folds), treatment of children and the elderly, when applied to large areas of skin.
Among the third class drugs, a group of fluorinated corticosteroids can be distinguished. A pharmacoeconomic analysis of the use of these drugs (although not for psoriasis), which consists of studying the price/safety/effectiveness relationship, according to the data obtained, revealed favorable indicators for betamethasone valerate: rapid development of the therapeutic effect, lower cost of treatment.
In the treatment of psoriasis, you should start with lighter medications and, in case of repeated exacerbations and ineffectiveness of the medications used, administer stronger ones. However, the following tactics are 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, powerful medications are used in short courses and only in limited areas, since side effects are more likely to develop when prescribed.
In addition to this classification, drugs are divided into fluorinated, difluorinated and non-fluorinated of different generations. First generation non-fluorinated corticosteroids (hydrocortisone acetate) compared to fluorinated ones are usually less effective, but safer in terms of adverse reactions. Now the problem of the low effectiveness of non-fluorinated corticosteroids has been solved: fourth-generation non-fluorinated drugs have been created, comparable in potency to fluorinated ones and in safety, to hydrocortisone acetate. The problem of enhancing the effect of the drug is solved not by halogenation, but by esterification. In addition to enhancing the effect, this allows you to use esterified drugs once a day. It is the fourth generation non-fluorinated corticosteroids that are currently preferred for topical use in psoriasis.
Standard side effects of topical steroid use are the development of skin atrophy, hypertrichosis, telangiectasias, pustular infections, and systemic action affecting the hypothalamic-pituitary-adrenal system. With the modern non-fluorinated medications mentioned above, these side effects are kept 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. The fatty ointment, which creates a film on the surface of the lesion, causes more effective resorption of infiltration than other pharmaceutical forms. The cream best relieves acute inflammation, moisturizes and refreshes the skin. The oil-free base of the lotion ensures its easy distribution over the surface of the scalp without sticking the hair.
According to the literature, when using, for example, mometasone for 3 weeks, a positive therapeutic effect (reduction in the number of rashes by 60% to 80%) can be achieved in almost 80% of patients. According to V. Yu. Udzhukhu, the most favorable "efficacy/safety" ratio can be achieved using hydrocortisone butyrate. The pronounced clinical effect of the use of this drug is combined with good tolerability: the authors did not observe any adverse reactions in any of the patients who underwent treatment, even when applied to the face. With prolonged use of other corticosteroids, it was necessary to discontinue treatment due to the development of side effects. According to B. Bianchi and N. G. Kochergin, a comparison of the results of clinical use of mometasone fuorate and methylprednisolone aceponate showed the same effectiveness of these drugs when used topically. Several authors (E. R. Arabian, E. V. Sokolovsky) propose a staged corticosteroid therapy for psoriasis. It is recommended to start external therapy with combined drugs containing corticosteroids (for example, betamethasone and salicylic acid). The average duration of said treatment is about 3 weeks. It is then converted to pure GCS, preferably third class (for example, hydrocortisone butyrate or mometasone furoate).
Patients are attracted by the ease of use of steroids, the ability to quickly alleviate the clinical symptoms of the disease, accessibility and lack of odor. In addition, these medications do not leave greasy stains on clothing. However, its use should be short-term to prevent the course of the disease from worsening. With prolonged use of steroid ointments, addiction develops. Abrupt withdrawal of corticosteroids can cause an exacerbation of the skin process. The literature indicates different durations of remission after topical corticosteroid treatment. Most studies indicate short-term remission, 1 to 6 months.
For psoriasis, combinations of steroid hormones with salicylic acid are most effective. Salicylic acid, due to its keratolytic and antimicrobial effects, complements the dermatotropic activity of steroids.
It is advisable to apply lotions combined with corticosteroids and salicylic acid to the scalp. According to the authors, the effectiveness of the combined drugs reaches 80 - 100%, while skin cleansing occurs very quickly, within 3 weeks.
In summary, it must be said that in practice, the doctor must always decide whether to use only external treatment methods or prescribe them in combination with any systemic therapy to increase the effectiveness of treatment and prolong remission.