Psoriasis(scaly lichen) is a chronic, very common skin disease, known since ancient times. Its prevalence in different countries ranges from 0. 1 to 3%. However, these numbers only reflect the prevalence of psoriasis in patients with other dermatological diseases or the frequency of occurrence in patients with medical diseases. Since the disease is often localized and inactive, patients often do not seek help from medical facilities and are therefore not registered anywhere.
The main pathogenic link that causes the appearance of rashes on the skin is increased mitotic activity and rapid proliferation of epidermal cells, which leads to the fact that the cells of the underlying layers "pushes the cells above out, preventing them from becoming keratinized. This process is called parakeratosis and is accompanied by extensive peeling. Of great importance in the development of psoriatic skin lesions are local immunopathological processes involving the interaction of various cytokines - tumor necrosis factor, interferon, interleukins, as well asas lymphocytes of different populations.
The onset of the disease is often severe stress - this factor is present in the history of most patients. Other triggers include skin trauma, drug use, alcohol abuse, and infections.
Numerous disorders of the epidermis, dermis and entire body systems are closely related to each other and the mechanism of disease development cannot be explained individually.
There is no universally accepted classification of psoriasis. Traditionally, along with ordinary (vulgar) psoriasis, erythrodermic, arthritis, pustular, exudative, guttate, palmoplantar forms are distinguished.
Normal psoriasis is clinically manifested by the formation of flat papules with clear boundaries from healthy skin. The papules are pinkish red and covered with loose silvery-white scales. From a diagnostic standpoint, an interesting group of signs occurs when the papules slough off and is known as the psoriasis triad. First, the phenomenon of "stearin spots" appears, characterized by increased peeling when scraping, causing 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 as a wet shiny surface of the particles. Then, when scraping further, the phenomenon of "blood mist" is observed - in the form of small, unmixed drops of blood.
The rash can be located on any area of the skin, but is mainly localized to the skin of the knees, elbow joints and scalp, where the disease often begins. Psoriatic papules are characterized by their tendency to grow peripherally and merge into plaques of various sizes and shapes. The patches can be individual, small or large, covering a large area of the skin.
With exudative psoriasis, the peeling properties change - the scales become grayish-yellow, stick together, forming a scab that adheres tightly to the skin. The rash itself is brighter and more inflamed than typical psoriasis.
Psoriasis on the palms and soles of the feet may be observed as solitary lesions or in combination with lesions at other sites. It presents as typical papular plaque components, as well as hyperkeratotic, scar tissue-like lesions with painful fissures or pustular rashes.
Psoriasis almost always affects the nail plates. The most characteristic sign is the appearance of small pins on the nail plate, making the nail plate look like a thimble. Loose nails, brittle edges, discoloration, horizontal and vertical grooves, deformation, thickening, and subungual hyperkeratosis may also be observed.
Psoriatic erythrodermatitis is one of the most severe forms of psoriasis. It can develop due to the gradual progression of the psoriasis process and the aggregation of plaques, but more often it occurs under the influence of unreasonable treatment. With generalized erythroderma, the entire skin turns bright red, becomes swollen, infiltrated, and peels a lot. Patients feel uncomfortable because of intense itching and their general condition worsens.
Radiologically, various changes in the bone and joint apparatus are observed in most patients without clinical signs of joint damage. Such changes include periarticular osteoporosis, joint space narrowing, bone spurs, and clearing of bone tissue cysts. The range of clinical manifestations can vary, from mild joint pain to the development of disabling ankylosing spondylitis. Clinically, joint swelling, redness of the skin in the affected joint area, pain, limited movement, joint deformity, stiffness and mutilation are detected.
Pustular psoriasis presents as a generalized or limited rash, localized mainly on the skin of the palms of the hands and soles of the feet. Although the leading symptom of this form of psoriasis is the appearance of pustules on the skin, which in dermatology is considered a manifestation of pustular infection, the insides of these blisters are usually sterile.
Guttate psoriasis often develops in children and is accompanied by a sudden rash with small bumps scattered throughout 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: the disease is often worse in the cold season (winter form), less oftenmore frequent in the summer (summer form). In the future, this dependence may change.
In psoriasis, there are 3 stages: progressive, stable and regressive. The advanced stage is characterized by growth along the periphery and the appearance of new lesions, especially at the sites of previous lesions (isomorphic Koebner reaction). During the regression phase, there is a decrease or disappearance of the infiltrate around the perimeter or in the center of the plaque.
Psoriasis vulgaris is distinguished from parapsoriasis, secondary syphilis, lichen planus, discoid lupus erythematosus, and seborrheic eczema. Difficulties arise in the differential diagnosis of palmar psoriasis and joint psoriasis.
With vulgar psoriasis, the prognosis of life is favorable. With generalized erythroderma, psoriatic arthritis, and generalized pustules, disability and even death can occur due to exhaustion and the development of severe infections.
Prognosis remains uncertain regarding disease duration, remission, and exacerbation. The rash may persist for a long time, for many years, but acute exacerbations are often interspersed with periods of clinical improvement and recovery. In a significant proportion of patients, especially those who do not receive aggressive systemic therapy, a long period of spontaneous clinical recovery is possible.
Improper treatment, self-medication and seeking "healers" will make the disease worse and lead to more severe and widespread skin rashes. That is why the main purpose of this article is a brief description of modern methods of treating this disease.
Today, there are many treatments for psoriasis, thousands of different drugs are used to treat this disease. But this only means that there is no method that provides guaranteed effectiveness and does not cure the disease completely. Moreover, the question of how to cure the disease does not arise - modern therapy can only minimize skin manifestations without affecting many currently unknown causative factors.
Treatment of psoriasis is carried out taking into account the form, stage, prevalence of the rash and the general condition of the body. In principle, treatment is very complex, including a combination of topical and systemic drugs.
Patient motivation, family situation, social status, lifestyle and alcohol abuse are very important factors in treatment.
Treatment methods can be divided into the following areas: external therapy, systemic therapy, physiotherapy, climate therapy, alternative and folk methods.
External therapy
Topical treatment is extremely important for psoriasis. In mild cases, treatment begins with topical measures and is limited to those. As a rule, topical medications have fewer side effects but are less effective than systemic therapy.
In severe stages, external treatment is carried out very carefully so as not to worsen the skin condition. The more intense the inflammation, the lower the ointment concentration. Usually at this stage, the treatment of psoriasis is limited to a special cream, 0. 5–2% salicylic ointment and herbal baths.
At the stage of stabilization and regression, more active drugs are prescribed - naphthalan ointment 5-10%, salicylic ointment 2-5%, sulfur-tar ointment 2-5%, as well as manyother treatment methods.
In modern conditions, when choosing a treatment method or a specific drug, the doctor must be guided by official protocols and formulas developed by regulatory health authorities. The Federal Drug Guide (No. IV) recommends steroids, salicylic ointments, and tar preparations for topical treatment of patients with psoriasis.
We will focus mainly on the drugs listed in the instructions for use.
Moisturizers.Softens the peeling surface of psoriatic elements, reduces skin tightness and improves elasticity. Use a cream that contains lanolin with vitamins. According to the literature, even after such mild exposure, a clinical effect (reduction of itching, erythema and peeling) is achieved in 1/3 of patients.
Salicylic acid preparations. Typically, ointments with a salicylic acid concentration of 0. 5 to 5% are used. It has antiseptic, anti-inflammatory, hyperkeratotic and keratolytic effects and can be used in combination with tarragon and corticosteroids. Salicylic ointment softens the peeling layers of psoriasis elements, and also enhances the effect of topical steroids by enhancing 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 made from wood tar (usually birch) are used, in some foreign countries - from coal tar. The second type is more active, but according to our scientists, it has carcinogenic properties, although many foreign publications and experiences do not confirm this. Tar is more active than salicylic acid and has anti-inflammatory, stratum corneating and anti-exfoliation properties. Its use in psoriasis is also due to its effects on cell proliferation. When prescribing tar preparations, one must take into account the photosensitizing effect and the risk of impaired kidney function in people with kidney disease.
Shampoo containing tar is used to wash hair.
naftalan oil. Mixture of hydrocarbons and resins, containing sulfur, phenol, magnesium and many other substances. Naftalan oil preparations have anti-inflammatory, absorbent, antipruritic, antiseptic, exfoliating and restorative properties. To treat psoriasis, 10–30% naphthalan ointments and pastes are used. Naftalan oil is often used in combination with sulfur, ichthyol, boric acid and zinc powder.
Topical retinoid therapy. First effective topical retinoid approved for use in the treatment of psoriasis. This medicine has not been registered in our country. It is a water-based jelly and comes 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 period compared to GCS.
Currently, synthetic hydroxyantrones are being used.
An analogue of natural chrysarobin, it has cytotoxic and cytostatic effects, 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, is reduced. Unfortunately, the drug has a pronounced local irritant effect and if it comes into contact with healthy skin, burns are possible.
Mustard gas derivative
They contain blistering agents - mustard gas and trichlorethylamine. Treatment with these drugs is carried out with extreme caution, first using the ointment in small concentrations on small lesions once a day. Then, if well tolerated, the concentration, area and frequency of use will increase. Treatment is carried out under close medical supervision, with weekly blood and urine tests. Currently these drugs are practically not used, but they are very effective in the stable phase of the disease.
zinc pyrithione. Active ingredients are produced in the form of sprays, creams and shampoos. It has antibacterial, antifungal and antiproliferative effects - it prevents the pathological development of epidermal cells in a proliferative state. The second characteristic determines the effectiveness of psoriasis treatment drugs. The drug reduces inflammation, reduces the infiltration and peeling of psoriatic elements. Treatment is carried out on average for one month. To treat patients with lesions on the scalp, sprays and shampoos are used, for lesions on the skin - aerosols and creams. 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 pyrithioneate have been studied. According to the conclusions of leading dermatology centers, the effectiveness of the drug in treating psoriasis patients reaches 85–90%. Based on data published in periodicals 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 will be clearly visible by the end of the first week from the moment of starting to use the drug - itching decreases sharply, peeling is eliminated, and the erythema turns dark. bland. Accordingly, achieving such a rapid clinical effect leads to a rapid improvement in the patient's quality of life. The drug is well tolerated. Allowed for use from 3 years old.
Ointment with vitamin D3. Since 1987, synthetic vitamin D preparations have been used for topical treatment.3. Many experimental studies have shown that calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, and affects factors of the skin immune system that regulate cell proliferation. and has anti-inflammatory properties. There are 3 drugs in this group from different manufacturers on our market. The medicine is applied to the affected skin area 1-2 times a day. The effectiveness of the ointment against D3approximately corresponds to the effect of corticosteroid ointments of types I, II, and according to J. Koo - even type III. When using these ointments, a pronounced clinical effect occurs in the majority of patients (up to 95%). However, to achieve good results it may take quite a long time (from 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 is applied 2 times a day, a noticeable effect is observed by 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 steroid use was first demonstrated. To date, about 50 topical glucocorticosteroid drugs are registered on the pharmaceutical market. This certainly makes it difficult to choose a doctor, who must have information about all medications. According to the same survey, the most frequently prescribed corticosteroids for psoriasis included combination medications.
The therapeutic effectiveness of topical corticosteroids is due to the following beneficial effects:
- anti-inflammatory effect (vasoconstriction, resolution of inflammatory infiltrates);
- epidermal (anti-hyperplastic effect on epidermal cells);
- anti-allergy;
- Local analgesic effect (eliminates itching, burning, pain, feeling of tightness).
Changes in the structure of GCS affect their properties and activity. This is how a rather 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 developed drugs. For example, it is believed that if the activity of hydrocortisone is considered one, then the activity of triamcinolone acetonide will be 21 units, and betamethasone - 24 units. Among second-line psoriasis medications, flumethasone pivalate combined with salicylic acid is the most commonly used and the most modern non-fluoridated corticosteroid. Due to the minimal risk of side effects, ointments and creams with aclomethasone are approved for use on sensitive skin 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 group, a group of fluorinated corticosteroids can be distinguished. According to the data, a pharmacoeconomic analysis of the use of these drugs (although not for psoriasis), including a price/safety/effectiveness ratio study, revealed indicatorsAdvantages for betamethasone valerate - rapid development of therapeutic effects, lower treatment costs. treatment.
When treating psoriasis, you should start with milder medications. In case the disease recurs many times and the medication is ineffective, stronger medications should be used. However, the following tactics are favored by American dermatologists: first, use strong GCS to achieve quick results, then the patient is switched to a moderate or weak drug for maintenance treatment. maintain. In all cases, strong medications should be used only for short periods of time and only on limited areas, as side effects are more likely to develop when they are prescribed.
In addition to this classification, drugs are divided into fluoride drugs, fluoride-containing and fluoride-free drugs of different generations. First generation corticosteroids that do not contain fluoride (hydrocortisone acetate) compared to those that contain fluoride are generally less effective but safer in terms of side effects. Now the problem of low effectiveness of fluoride-free corticosteroids has been solved - fluoride-free drugs of the fourth generation have been created, which are comparable in strength to fluoride-containing drugs and in safety. - with 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 the esterified drug once a day. This is a fourth generation non-fluoridated corticosteroid that is currently preferred for topical use in psoriasis.
Standard side effects of topical steroid use are the development of skin atrophy, hirsutism, telangiectasia, pustular infections, systemic effects on the hypothalamic-pituitary-adrenal system. With the modern fluoride-free medications mentioned above, these side effects are kept to a minimum.
Pharmaceutical companies are trying to diversify 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 infiltrates than other dosage forms. The cream reduces acute inflammation better, moisturizes and cools the skin. The lotion's fat-free base ensures easy distribution over the scalp surface without sticking to the hair.
According to literature data, when using mometasone for 3 weeks, for example, a positive therapeutic effect (reducing 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 of using this drug is combined with good tolerability - the authors did not observe any adverse reactions in any patient who underwent treatment, even whenApply on face. With long-term use of other corticosteroids, treatment may need to be discontinued due to the development of side effects. According to B. Bianchi and N. G. Kochergin, comparison of the results of clinical use of mometasone fuorate and methylprednisolone aceponate shows similar effectiveness of these drugs when used externally. Some authors (E. R. Arabian, E. V. Sokolovsky) recommend episodic corticosteroid therapy for psoriasis. External treatment should be started with combination drugs containing corticosteroids (e. g. betamethasone and salicylic acid). The average duration of such treatment is about 3 weeks. There is then a transition to pure GCS, preferably a third grade (eg, hydrocortisone butyrate or mometasone furoate).
Patients are attracted by the ease of use of steroid drugs, their ability to quickly relieve the clinical symptoms of the disease, their accessibility and lack of odor. In addition, these drugs do not leave greasy stains on clothes. However, their use should only be short-term to avoid aggravating the course of the disease. With prolonged use of steroid ointments, addiction develops. Abrupt discontinuation of corticosteroids may worsen skin conditions. The literature indicates variable duration of remission after topical treatment with corticosteroids. Most studies indicate short-term remission - from 1 to 6 months.
For psoriasis, a combination of steroid hormones with salicylic acid is most effective. Salicylic acid, due to its keratolytic and antibacterial effects, complements the dermatotropic activity of steroids.
It is very convenient to apply combined creams with corticosteroids and salicylic acid to the scalp. According to the authors, the effectiveness of the combined drug reaches 80-100%, and the skin cleansing process occurs very quickly - within 3 weeks.
In conclusion, it must be said that in practice, the doctor always needs to decide whether to use external treatment methods only or to prescribe them in combination with any systemic therapy to increase the effectiveness of treatment and prolong the duration of treatment. period of remission.