Psoriasis(scaly lichen) is a chronic, very common skin disease, known since ancient times. Its prevalence in different countries varies 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 causes the appearance of skin rashes is the 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 keratinizing. This process is called parakeratosis and is accompanied by abundant peeling. Of great importance in the development of psoriatic lesions of the skin 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 often severe stress: this factor is present in the medical history of most patients. Other triggers include skin trauma, drug use, alcohol abuse, and infections.
Numerous disorders in 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, palmoplantar forms are distinguished.
Normal psoriasis manifests clinically with the formation of flat papules, clearly demarcated from healthy skin. The papules are pinkish-red and covered with silvery-white loose scales. From a diagnostic point of view, an interesting group of signs occurs when the papules are scraped and is called the psoriatic triad. First of all, the phenomenon of "stearin stain" appears, characterized by increased flaking when scraped, which causes the surface of the papules to resemble a drop of stearin. After removing the scales, the phenomenon of "terminal film" is observed, which manifests itself in the form of a shiny, wet surface of the elements. Subsequently, with further curettage, the phenomenon of "blood dew" is observed - in the form of point-like, non-united droplets of blood.
The rash can be localized on any part of the skin, but is localized mainly on the skin of the knee and elbow joints and on the scalp, where most often the disease begins. Psoriatic papules are characterized by the tendency to grow peripherally and coalesce into plaques of various sizes and shapes. Plaques can be isolated, small or large, occupying large areas of the skin.
With exudative psoriasis, the nature of peeling changes: the scales become yellowish-grayish, come together to form crusts that adhere tightly to the skin. The rashes themselves are brighter and more swollen than in normal psoriasis.
Psoriasis of the palms and soles may be seen as an isolated lesion or combined with lesions elsewhere. It manifests itself in the form of typical papulo-plaque elements, as well as callus-like hyperkeratotic lesions with painful cracks or pustular eruptions.
Psoriasis almost always affects the nails. The most pathognomonic is the appearance of punctate imprints 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 serious 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 acquires a bright red color, becomes swollen, infiltrated, and abundant peeling is observed. Patients are disturbed by severe itching, and their general condition worsens.
Radiologically, various changes in the osteoarticular system are observed in most patients without clinical signs of joint damage. Such changes include periarticular osteoporosis, narrowing of joint spaces, osteophytes, and cystic removal of bone tissue. The range of clinical manifestations can vary from minor arthralgia to the development of disabling ankylosing arthritis. Clinically, swelling of the joints, redness of the skin in the area of the affected joints, pain, limited mobility, joint deformities, ankylosis and mutilations are noted.
Pustular psoriasis manifests itself in the form of generalized or limited skin rashes, localized mainly on the skin of the palms of the hands and soles of the feet. 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 develops most often in children and is accompanied by a sudden rash of small papular elements scattered all over the skin.
Psoriasis occurs with approximately equal 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: more often the disease worsens in the cold season (winter form), much less often in summer (summer form). In the future, this dependence may change.
There are 3 stages in 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 phase, a decrease or disappearance of infiltrations is observed around the circumference or center of the plaques.
Psoriasis vulgaris differs 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, arthropathic and generalized 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 flare-ups. Rashes can exist for a long time, for many years, but more often flare-ups 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 long-term clinical recovery are possible.
Irrational treatments, self-medication and resort to "healers" worsen the course of the disease and lead to exacerbation and spread of skin rashes. That is why the main purpose of this article is to provide a brief description of modern methods of treating this disease.
Today, there are numerous methods for treating psoriasis; Thousands of different drugs are used to treat 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 treatment is not raised: modern therapy is only capable of minimizing skin manifestations, without influencing 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. As a rule, treatment is complex and involves a combination of external and systemic drugs.
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 local measures and is limited to them. As a rule, topical drugs are less likely to have side effects, but are less effective than systemic therapy.
In the advanced phase, external treatment is carried out with the utmost care so as not to cause a worsening of the skin condition. The more intense the inflammation, the lower the concentration of the ointments should be. Usually at this stage, the treatment of psoriasis is limited to a special cream, 0. 5–2% salicylic ointment and herbal baths.
In the stationary and regression phase, 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 therapeutic method or a specific drug, the doctor must be guided by official protocols and formularies developed by government health authorities. The Federal Guide to the Use of Drugs (Edition IV) suggests steroid drugs, salicylic ointments, and tar preparations for the local treatment of patients with psoriasis.
We will focus mainly on the drugs indicated in the manuals.
Moisturizing agents.It softens the scaly surface of psoriatic elements, reduces skin tension and improves elasticity. Use lanolin-based creams with vitamins. According to the literature, even after such mild exposure, clinical effects (reduction of itching, erythema and desquamation) are achieved in a third of patients.
Salicylic acid preparations. Ointments with a concentration of 0. 5 to 5% salicylic acid are typically 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, so it is often used in combination with them.
Tar preparations. They have been used for a long time 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, 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-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 renal function in people with nephrological diseases should be taken into account.
Shampoos with tar are used to wash hair.
Naftalan oil. Mixture of hydrocarbons and resins, contains sulphur, phenol, magnesium and many other substances. Naftalan oil preparations have anti-inflammatory, absorbable, antipruritic, antiseptic, exfoliating and repairing properties. For the treatment of psoriasis, 10-30% naphthalane 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 drug 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 powerful 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 chrysarobine, 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, 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 trichlorethylamine. Treatment with these drugs is carried out with great caution, initially 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 strict medical supervision, with weekly blood and urine tests. Now these drugs are practically not used, but they are very effective in the stationary phase 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 desquamation of psoriatic elements. Treatment is carried out on average for a month. For the treatment of patients with scalp lesions, aerosol and shampoo are used, for skin lesions: aerosol and cream. The drug 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 conclusion 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 by the end of 3-4 weeks of treatment. The effect develops gradually, but it is very important that the results of treatment are noticeable by the end of the first week from the moment of starting use of the drug: itching decreases sharply, peeling is eliminated, and erythema becomes pale . 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 of age.
Ointments with vitamin D3. Since 1987, a synthetic vitamin D preparation has been used for local treatment3. Numerous experimental studies have shown that calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, acts on the factors of the skin immune system that regulate cell proliferation and has anti-inflammatory properties. In this group there are 3 drugs from different manufacturers on our market. The drugs are applied to the affected areas of the skin 1-2 times a day. The effectiveness of ointments with D3corresponds approximately to the effect of corticosteroid ointments of classes I, II and, according to J. Koo, also 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 by the end of the fourth week of treatment. No side effects have been identified.
Corticosteroid drugs. 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, approximately 50 glucocorticosteroid agents for external use are registered on the pharmaceutical market. This undoubtedly makes the choice of doctor difficult, who must have information on all drugs. According to the same survey, the most frequently prescribed corticosteroids for psoriasis include combination drugs.
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 allergic;
- local analgesic effect (elimination of itching, burning, soreness, feeling of tightness).
Changes in the structure of GCSs 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 trials for comparison with newly produced drugs. For example, it is believed that if the activity of hydrocortisone is taken as one, the activity of triamcinolone acetonide will be 21 units, and betamethasone - 24 units. Among second-class drugs for psoriasis, flumethasone pivalate in combination with salicylic acid is 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 on sensitive areas (face, skin folds), for the treatment of children and the elderly, when applied to large areas of the skin.
Among the drugs of the third class we can distinguish the group of fluorinated corticosteroids. A pharmacoeconomic analysis of the use of these drugs (although not for psoriasis), which consists in the study of the price/safety/effectiveness ratio, according to the data, revealed favorable indicators for betamethasone valerate: rapid development of the therapeutic effect , lower treatment cost.
When treating psoriasis, you should start with lighter drugs, and in case of repeated exacerbations and ineffectiveness of the drugs used, give 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, since 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) are usually less effective than fluorinated ones, but safer in terms of adverse reactions. Now the problem of the low effectiveness of non-fluorinated corticosteroids has already been solved: fourth generation non-fluorinated drugs have been created, 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, in addition to enhancing the effect, allows you to use thesterified drugs once a day. Fourth generation non-fluorinated corticosteroids are currently preferred for topical use in psoriasis.
Standard side effects when using local steroids are the development of skin atrophy, hypertrichosis, telangiectasia, pustular infections, systemic action with an effect on the hypothalamic-pituitary-adrenal system. With the modern non-fluorinated drugs mentioned above, these side effects are minimized.
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 cools the skin. The grease-free base of the lotion ensures easy distribution on 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 achieved using hydrocortisone butyrate. The pronounced clinical effect when using this drug is combined with good tolerability: the authors did not observe any adverse reactions in any of the patients undergoing 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. Numerous authors (E. R. Arabian, E. V. Sokolovsky) propose gradual 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 such treatment is approximately 3 weeks. Subsequently we move on to pure GCS, preferably of the third class (for example 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 odor. Furthermore, these medicines 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 withdrawal of corticosteroids can cause an exacerbation of the skin process. The literature indicates different durations of remission after topical treatment with corticosteroids. Most studies indicate short-term remission, 1 to 6 months.
For psoriasis, combinations of steroid hormones with salicylic acid are most effective. Salicylic acid, thanks to its keratolytic and antimicrobial effects, complements the dermatotropic activity of steroids.
It is convenient to apply combined lotions with corticosteroids and salicylic acid to the scalp. According to the authors, the effectiveness of combined drugs reaches 80-100%, while cleansing of the skin occurs very quickly, within 3 weeks.
In summary, it should 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 in order to increase the effectiveness of treatment and prolong remission.