Psoriasis(scaly lichen) is a very common chronic skin disease, known since ancient times. Its prevalence in different countries ranges from 0. 1 to 3%. However, these figures 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 provokes the appearance of rashes is increased mitotic activity and accelerated proliferation of epidermal cells, leading to the fact that the cells of the lower layers "push back" the overlying cells, preventing them from keratinization. This process is called parakeratosis and is accompanied by abundant peeling. Local immunopathological processes associated with the interaction of various cytokines - tumor necrosis factor, interferons, interleukins, as well as lymphocytes of various subpopulations, are of great importance in the development of psoriatic lesions of the skin.
The trigger for the onset of the disease is often severe stress - this factor is present in the anamnesis of most patients. Other triggers include skin trauma, medication use, alcohol abuse and infections.
Many 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, alongside 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 in color and covered with loose silver-white scales. From a diagnostic point of view, an interesting group of signs appears when the papules are scratched and is called the psoriatic triad. First of all, the phenomenon of "stearin stain" appears, characterized by increased desquamation when scratching, which makes the surface of the papules resemble a drop of stearin. After removing the scales, the phenomenon of "terminal film" is observed, which manifests itself in the form of a wet and shiny surface of the elements. Following this, with further scraping, the phenomenon of "blood dew" is observed - in the form of point, unfused droplets of blood.
The rash can be localized 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 a tendency to grow peripherally and coalesce into plaques of different sizes and shapes. 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-grayish, stick together to form crusts that fit tightly to the skin. The rashes themselves are brighter and more swollen than in regular psoriasis.
Psoriasis of the palms and soles may be seen as an isolated lesion or associated with lesions elsewhere. It manifests itself in the form of typical papulo-plaque elements, as well as 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 impressions on the nail plates, giving the nail plate a resemblance to a thimble. Also observed are loosening of the nails, brittle edges, discoloration, transverse and longitudinal furrows, deformities, thickening and subungual hyperkeratosis.
Psoriatic erythroderma is one of the most serious forms of psoriasis. It can develop due to the gradual progression of the psoriatic process and the fusion of plaques, but most often it occurs under the influence of irrational treatment. With erythroderma, the entire skin acquires a bright red color, becomes swollen, infiltrated, and abundant peeling occurs. Patients are bothered by severe itching and their general condition deteriorates.
Radiologically, various changes in the osteoarticular apparatus are observed in most patients without clinical signs of joint damage. These changes include periarticular osteoporosis, narrowing of joint spaces, osteophytes, and cystic disappearance of bone tissue. The spectrum of clinical manifestations can vary from minor arthralgia to the development of disabling ankylosing osteoarthritis. Clinically, swelling of the joints, redness of the skin in the affected joints, pain, limited mobility, joint deformities, ankylosis and mutilation are detected.
Pustular psoriasis manifests itself in the form of generalized or limited skin 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 most often develops in children and is accompanied by a sudden rash of small papular elements scattered all over the skin.
Psoriasis occurs with about 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: the disease worsens more often in the cold season (winter form), much less often in summer (summer form). In the future, this dependence may change.
There are 3 stages of psoriasis: progressive, stationary and regressive. The progressive stage is characterized by growth in the periphery and the appearance of new lesions, particularly at the sites of previous lesions (Koebner isomorphic reaction). In the regressive stage, we observe a reduction or disappearance of infiltrations on 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. With 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 regarding the duration of the disease, the duration of remission and exacerbations. Rashes can exist for many years, but more often exacerbations alternate with periods of improvement and clinical recovery. In a significant proportion of patients, especially those who are not subjected to intensive systemic therapy, spontaneous and long-term periods of clinical recovery are possible.
Irrational treatment, self-medication and resorting to "healers" worsen the course of the disease and lead to the exacerbation and spread of rashes. That is why the main goal of this article is to give a brief description 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 completely cures the disease. Moreover, the question of cure does not arise: modern therapy can only 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. Typically, treatment is complex and involves a combination of external and systemic medications.
The patient's motivation, family situation, social status, lifestyle and alcohol abuse are of great importance in the treatment.
Treatment methods can be divided into the following areas: external therapy, systemic therapy, physiotherapy, climatotherapy, alternative and traditional methods.
External therapy
Treatment with external medications is of utmost importance for psoriasis. In mild cases, treatment begins with local measures and is limited to them. Typically, topical medications are less likely to have side effects, but their effectiveness is lower than systemic treatment.
In the advanced stage, external treatment is carried out with the greatest caution so as not to cause any alteration in the skin condition. The more intense the inflammation, the lower the concentration of ointments should be. Usually, at this stage, treatment of psoriasis is limited to a special cream, 0. 5-2% salicylic ointment and herbal baths.
At the stationary and regressing stage, more active drugs are indicated - 5-10% naphthalan ointment, 2-5% salicylic ointment, 2-5% sulfur tar ointment, as well as many other therapeutic methods.
In modern conditions, when choosing a specific therapeutic method or drug, the doctor should be guided by official protocols and forms developed by the current health authorities. The Federal Guide to the Use of Medicines (Issue IV) suggests steroid drugs, salicylic ointments and tar preparations for the local treatment of patients with psoriasis.
We will mainly focus on medications listed in textbooks.
Moisturizing agents.Softens the scaly surface of psoriatic elements, reduces skin tightness and improves elasticity. Use lanolin creams and vitamins. According to the literature, even after such light exposure, clinical effects (reduction of itching, erythema and scaling) are obtained in a third of patients.
Salicylic acid preparations. Usually ointments with a concentration of 0. 5-5% 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 effect of local steroids by improving their absorption. It is therefore often used in combination with them.
Tar preparations. They have long been used in the form of ointments and pastes at 5 to 15%, often in combination with other local medicines. In our country, ointments with wood (usually birch) tar 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 publications and foreign experiments do not confirm this. Tar has greater activity than salicylic acid and has anti-inflammatory, keratoplastic and anti-exfoliative properties. Its use in psoriasis is also due to its effect on cell proliferation. When prescribing tar preparations, its photosensitizing effect and the risk of deterioration of kidney function in people with nephrological diseases should be taken into account.
Tar shampoos are used to wash 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 restorative properties. To treat psoriasis, ointments and pastes containing 10-30% naphthalan are used. 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 use in the treatment of psoriasis. This medicine is not yet registered in our country. It is a water-based jelly 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 than that of GCS.
Currently, synthetic hydroxyantrones are used.
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. As a result, the number of mitoses in the epidermis, as well as hyperkeratosis and parakeratosis, decreases. Unfortunately, the drug has a pronounced local irritant effect and if it comes into contact with healthy skin, burns may occur.
Mustard gas derivatives
They contain blister agents - mustard gas and trichloroethylamine. Treatment with these drugs is carried out with great caution, first using ointments of low 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. Today, these drugs are practically no longer used, but they are very effective in the stationary stage of the disease.
Zinc pyrithione. Active substance 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. This last property determines the effectiveness of the drug against 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, an aerosol and shampoo are used, for skin lesions - an aerosol and cream. The medicine is applied 2 times a day, shampoo is used 3 times a week. In our country, since 1995, the clinical effectiveness and tolerability of all dosage forms of zinc pyrithionate have been studied. According to the findings of leading dermatological centers, the effectiveness of the drug in the treatment of patients with psoriasis reaches 85-90%. Based on data published in periodicals by leading specialists of these and other centers, clinical cure can be achieved after 3-4 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 start of using the drug: itching is sharply reduced, peeling is eliminated and theerythema pales. Such rapid achievement of a clinical effect therefore leads to a rapid improvement in the quality of life of patients. The drug is well tolerated. Approved for use from 3 years old.
Vitamin D ointments3. Since 1987, a synthetic preparation of vitamin D has been used for local treatment3. Numerous experimental studies have shown that calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, affects factors of the skin immune system that regulate cell proliferation, and has anti-inflammatory properties. There are 3 drugs of this group from different manufacturers on our market. Medicines are applied to the affected areas of the skin 1-2 times a day. The effectiveness of ointments with D3approximately 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 the majority of patients (up to 95%). However, to achieve a good effect, it may take some time (1 month to 1 year) and the affected area should not exceed 40%. Positive experiences with this substance have been reported in children. The drug was applied 2 times a day and a pronounced effect was observed by the end of the fourth week of treatment. No side effects have been 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 glucocorticoid agents for external use are registered on the pharmaceutical market. This undoubtedly makes it difficult to choose a doctor, who must have information on all medications. According to the same survey, the most frequently 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);
- epidermostatic (antihyperplastic effect on epidermal cells);
- Anti allergen;
- local analgesic effect (elimination of itching, burning, aches, feeling of tightness).
Changes in the structure of GCS have affected their properties and activities. This is how a fairly large group of drugs appeared, differing in 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 will be 24 units. Among the second-class drugs for psoriasis, flumethasone 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, aclometasone ointments and creams are approved for use on sensitive areas (face, skin folds), treatment of children and elderly people, when applied tolarge areas of skin.
Among the drugs of the third class, a group of fluorinated corticosteroids can be distinguished. A pharmacoeconomic analysis of the use of these drugs (but not for psoriasis), which consists of studying the ratio of price/safety/effectiveness, according to the data, revealed favorable indicators for betamethasone valerate - rapid development oftherapeutic effect, lower cost of treatment.
When treating psoriasis, you should start with lighter medications, and in case of repeated exacerbations and ineffectiveness of the drugs used, administer stronger ones. However, the following tactics are popular among American dermatologists: first, a strong GCS is used to achieve a quick effect, then the patient is transferred to a moderate or weak drug for maintenance therapy. In any case, strong drugs are used in short courses and only on limited areas, because side effects are more likely to develop 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) compared to fluorinated corticosteroids are generally less effective, but safer in terms of adverse effects. Now the problem of low effectiveness of non-fluorinated corticosteroids has already been solved - fourth generation non-fluorinated drugs have been created, comparable in strength to fluorinated drugs and in safety - to hydrocortisone acetate. The problem of improving 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. These are the fourth generation non-fluorinated corticosteroids currently preferred for topical use in psoriasis.
Standard side effects when using local steroids are the development of skin atrophy, hypertrichosis, telangiectasias, pustular infections, systemic action having an effect on 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. Fatty ointment, creating a film on the surface of the lesion, causes more effective resorption of the infiltration than other dosage forms. The cream better relieves acute inflammation, moisturizes and refreshes the skin. The non-greasy base of the lotion ensures its easy distribution over the surface of the scalp without sticking to the hair.
According to literature data, when using, for example, mometasone for 3 weeks, a positive therapeutic effect (reduction in the number of rashes by 60-80%) can be achieved in almost 80% of patients. According to V. Yu. Udzhukhu, the most favorable "effectiveness/safety" ratio can be obtained using hydrocortisone butyrate. The pronounced clinical effect when using this drug is associated 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 long-term 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 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 staged corticosteroid therapy for psoriasis. It is recommended to start external treatment with combination drugs containing corticosteroids (for example, betamethasone and salicylic acid). The average duration of such treatment is approximately 3 weeks. Subsequently, we move on 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 relieve clinical symptoms of the disease, accessibility and lack of odor. In addition, these drugs do not leave greasy stains on clothes. However, their use should be short-term to avoid worsening the course of the disease. With prolonged use of steroid ointments, addiction develops. Abrupt discontinuation of corticosteroids may cause 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 and salicylic acid are most effective. Salicylic acid, through its keratolytic and antimicrobial effects, complements the dermatotropic activity of steroids.
It is convenient to apply combined lotions containing corticosteroids and salicylic acid to the scalp. According to the authors, the effectiveness of combined drugs reaches 80-100%, while cleansing the skin occurs very quickly - within 3 weeks.
Summing up, it must be said that in practice the doctor must always decide whether to use only external methods of treatment or prescribe them in combination with systemic therapy in order to increase the effectiveness of treatment and prolong remission.