Psoriasis(scaly lichen) is a very common, chronic skin disease known since ancient times. Its prevalence in different countries varies from 0. 1 to 3%. 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 often 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 increase in mitotic activity and accelerated proliferation of epidermal cells, causing cells in the lower layers to "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 on 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 point for the onset of the disease is usually severe stress - a factor that is present in the anamnesis of most patients. Other triggers include skin trauma, medication 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 common (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 silvery-white scales. From a diagnostic point of view, an interesting group of signs occurs when papules are scraped and is called the psoriatic triad. Firstly, 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 moist, shiny surface of the elements. Then, with more scraping, the phenomenon of "blood dew" is observed - in the form of punctual blood droplets that do not merge.
The rash can be located on any part of the skin, but is mainly located on the skin of the knee and elbow joints and on the scalp, where the disease often begins. Psoriatic papules are characterized by a tendency to grow peripherally and merge 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 the peeling changes - the scales become yellowish-grayish, stick together to form crusts that fit snugly against the skin. The rashes are brighter and swollen than in normal psoriasis.
Psoriasis of the palms and soles can be seen 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 lesions similar to calluses with painful fissures or pustular eruptions.
Psoriasis almost always affects the nail plates. The most pathognomonic is the appearance of pinpoint impressions on the nail plates, giving the nail plate a similarity 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. In erythroderma, the entire skin acquires a bright red color, becomes swollen, infiltrated and there is abundant desquamation. Patients are bothered by severe itching and their general condition worsens.
Radiologically, several 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 clearing of bone tissue. The range of clinical manifestations can vary 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, difficulty in mobility, joint deformities, ankylosis and mutilation are detected.
Pustular psoriasis manifests itself in the form of 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 pustular infection, the contents of these blisters are usually sterile.
Guttate psoriasis most often develops in children and is accompanied by a sudden eruption of small papular elements scattered across 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.
During psoriasis, there are 3 stages: progressive, stationary and regressive. The progressive phase is characterized by growth in the periphery and the appearance of new lesions, mainly at the sites of previous lesions (Koebner's isomorphic reaction). In the regressive phase, infiltration decreases or disappears 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.
In 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, duration of remission and exacerbations. Skin 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 who have not undergone intensive systemic treatment, periods of spontaneous and long-term clinical recovery are possible.
Irrational treatment, self-medication and turning to "healers" worsen the course of the disease and lead to the exacerbation and spread of 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 a huge number of methods of treating psoriasis, thousands of different medicines are used to treat this disease. But this only means that none of the methods have a guaranteed effect and do not completely cure the disease. Furthermore, the question of cure is not raised - 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. As a rule, treatment is complex, involving 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
Therapy with external medications is extremely important 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 they are inferior in effectiveness to systemic therapy.
In the advanced stage, external treatment is carried out very carefully so as not to worsen the condition of the skin. The more intense the inflammation, the lower the concentration of the ointment should be. Typically, at this stage, psoriasis treatment is limited to a special cream, salicylic ointment 0. 5–2% and herbal baths.
In the stationary and regressive stage, more active drugs are indicated - naphthalene ointment 5-10%, salicylic ointment 2-5%, sulfur tar ointment 2-5%, as well as many other methods of therapy.
In modern conditions, when choosing a therapeutic method or a specific medicine, a doctor must be guided by official protocols and forms developed by health authorities. The Federal Guide to Drug Use (Edition IV) suggests steroid medications, salicylic ointment, and tar preparations for the local treatment of patients with psoriasis.
We will focus mainly on the medicines indicated in the manuals.
Moisturizing agents.Soften the scaly surface of psoriatic elements, reduce skin tightness and improve elasticity. Use lanolin-based creams with vitamins. According to the literature, even after such mild exposure, clinical effects (reduction in itching, erythema and scaling) are achieved in a third of patients.
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 effect of local steroids, increasing 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 medicines. 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 experiments do not confirm this. Tar has 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, 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. Naftalan oil preparations have anti-inflammatory, absorbable, antipruritic, antiseptic, exfoliating and repairing properties. To treat psoriasis, 10 to 30% naphthalan ointments and pastes 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 has not yet been 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 potent corticosteroids. Side effects include itching and skin irritation. One of the advantages of this drug is its longer remission compared to GCS.
Currently, synthetic hydroxyanthrones are used.
An analogue of natural chrysarobin, it has a cytotoxic and cytostatic effect, leading 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, decrease. Unfortunately, the medicine has a pronounced local irritating effect, and if it comes into contact with healthy skin, burns may occur.
Mustard gas derivatives
They contain blistering agents - mustard gas and trichlorethylamine. Treatment with these medications is carried out with great caution, first applying low-concentration ointments to small lesions once a day. So, if well tolerated, the concentration, area and frequency of use increase. 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 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. The 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 for an average of one month. For the treatment of patients with scalp injuries, aerosol and shampoo are used, for skin injuries - 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 efficacy and tolerability of all pharmaceutical forms of zinc pyrithione 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 journals by leading experts from 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 moment you start using the drug - the itching decreases dramatically, the peeling is eliminated and the erythema becomes pale. Such rapid achievement of clinical effect consequently leads to a rapid improvement in patients' quality of life. The drug is well tolerated. Approved for use from 3 years of age.
Vitamin D ointments3. Since 1987, a synthetic vitamin D preparation has been used for local treatment3. Numerous experimental studies have demonstrated that calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, affects skin immune system factors that regulate cell proliferation, and has anti-inflammatory properties. There are 3 drugs in this group from different manufacturers on our market. Medicines are applied to affected areas of the skin 1 to 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, it can take a long time to achieve a good effect (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 medicine was applied twice a day, with a pronounced effect observed at the end of the fourth 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 research, 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 inflammatory infiltrate);
- epidermostatic (antihyperplastic effect on epidermal cells);
- anti-allergic;
- local analgesic effect (elimination of itching, burning, pain, feeling of tightness).
Changes in the structure of the GCS have affected its properties and activities. This is how a fairly large group of medicines appeared, differing 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 betamethasone - 24 units. Of the second-class medications for psoriasis, flumethasone pivalate in combination with salicylic acid is the most 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), treatment of children and the elderly, when applied to large areas of the 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 (although not for psoriasis), which consists of studying the price/safety/efficacy relationship, 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 milder 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, strong medications are used in short courses and only in limited areas, as side effects are more likely to develop when they are prescribed.
In addition to this classification, medicines are divided into fluorinated, difluorinated and non-fluorinated medicines of different generations. First generation non-fluorinated corticosteroids (hydrocortisone acetate) compared to fluorinated ones are generally less effective, but safer in terms of adverse reactions. Now the problem of low effectiveness of non-fluorinated corticosteroids has already been resolved - 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 solved not by halogenation, but by esterification. In addition to enhancing the effect, it allows the use of esterified medications once a day. The fourth generation non-fluorinated corticosteroids are currently preferred for topical use in psoriasis.
Standard side effects from the use of 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-fluoridated medicines 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. The fatty ointment, which creates a film on the surface of the lesion, causes more effective resorption of the infiltration than other pharmaceutical forms. The cream better relieves acute inflammation, moisturizes and cools the skin. The fat-free base of the lotion ensures that it is easily distributed 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 "efficacy/safety" ratio can be achieved when using hydrocortisone butyrate. The pronounced clinical effect of using this medication is combined with good tolerability - the authors did not observe adverse reactions in any of the patients undergoing treatment, even when applied to the face. With prolonged use of other corticosteroids, it was necessary to interrupt 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 furorate and methylprednisolone aceponate showed the same effectiveness of these drugs when used externally. Several authors (E. R. Arabian, E. V. Sokolovsky) propose stepwise 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 this treatment is around 3 weeks. Subsequently, the transition to pure GCS occurs, preferably of the 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, their accessibility, and their lack of odor. In addition, these medicines do not leave greasy stains on clothes. However, its use should be short-term to avoid worsening the course of the disease. With prolonged use of steroid ointments, dependence develops. Abrupt withdrawal of corticosteroids may cause an exacerbation of the cutaneous 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, due to its keratolytic and antimicrobial effects, complements the dermatotropic activity of steroids.
It is convenient to apply lotions combined with 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.
Summing up, it must be said that in practice, the doctor always needs to decide whether to use only external methods of treatment or prescribe them in combination with any systemic therapy in order to increase the effectiveness of treatment and prolong remission.