The main pathogenetic link that causes 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 "displace" the covering cells, preventing their keratinization. This process is called parakeratosis and is accompanied by abundant peeling. The skinlocal immunopathological processes related to the interaction of different cytokines - tumor necrosis factor, interferons, interleukins, and lymphocytes of different subpopulations - are of great importance in the development of psoriatic lesions.
The trigger point for the development of the disease is often severe stress - this factor is present in the anamnesis of most patients. Other triggers include skin trauma, medication, alcohol consumption, and infections.
Many disorders in the epidermis, dermis, and all body systems are closely related, and the mechanism of disease development cannot be explained separately.
There is no universally accepted classification of psoriasis. Traditionally, in addition to common (vulgar) psoriasis, erythrodermic, arthropathic, pustular, exudative, guttate, and palmoplantar forms are distinguished.
Normal psoriasis is clinically manifested by the formation of flat papules that are 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 occurs when the papules are scraped and is called the psoriatic triad. First, the "stearin spot" phenomenon appears, characterized by increased exfoliation when scraping, which makes the surface of the papules resemble a drop of stearin. After the scales are removed, the "terminal film" phenomenon is observed, which manifests itself in the form of a wet, shiny surface of the elements. After that, with further scraping, the phenomenon of "blood dew" can be observed - in the form of pin-point, non-merging drops of blood.
The rash can be localized on any part of the skin, but it is mainly localized on the skin of the knee and elbow joints, as well as on the scalp, where the disease very often begins. Psoriatic papules are characterized by a 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.
In case of exudative psoriasis, the nature of exfoliation changes - the scales become yellowish-gray, stick together and form crusts that fit closely to the skin. The rashes themselves are lighter and more swollen than regular psoriasis.
Psoriasis of the palms and soles can be observed as an isolated lesion or in combination with lesions appearing in other places. It manifests itself in the form of characteristic papulo-plaque elements as well as hyperkeratotic, callus-like lesions, painful fissures or pustular rashes.
Psoriasis almost always affects the nail plates. The most pathognomonic is the appearance of pin-point impressions on the nail plates, which makes the nail plate look like a thimble. Loosening of the nails, brittle edges, discoloration, transverse and longitudinal grooves, deformations, thickening and subungual hyperkeratosis can also be observed.
Psoriatic erythroderma is one of the most severe forms of psoriasis. It can develop as a result of the gradual progression of the psoriasis process and the fusion of plaques, but more often as a result of irrational treatment. With erythroderma, the entire skin becomes bright red, swells, infiltrates, and profuse peeling occurs. Patients are disturbed by severe itching, and their general condition worsens.
Radiologically, various changes in the osteoarticular apparatus are observed in most patients without clinical symptoms 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 joint pain to the development of ankylopoetica arthrosis, which causes disability. Clinically, swelling of the joints, redness of the skin in the area of the affected joints, pain, limited movement, joint deformities, ankylosis and mutilation can be observed.
Pustular psoriasis manifests itself in the form of generalized or limited rashes, mainly on the skin of the palms and soles. 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 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 on 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 correlation between exacerbations and the season: the disease worsens more often in the cold season (winter form), much less often in summer (summer form). This dependency may change in the future.
Psoriasis has 3 stages: progressive, stationary and regressive. The progressive stage is characterized by growth along the periphery and the appearance of new lesions, especially at the site of previous lesions (isomorphic Koebner reaction). In the regression stage, the infiltration on the periphery or center of the plaques decreases or disappears.
Psoriasis vulgaris can be distinguished 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 the case of erythroderma, arthropathic and generalized pustular psoriasis, disability and even death are possible due to exhaustion and the development of serious infections.
Prognosis remains uncertain regarding disease duration, duration of remission, and exacerbations. Rashes can persist for a long time, many years, but more often exacerbation alternates with periods of improvement and clinical recovery. Long-term, spontaneous periods of clinical recovery are possible in a significant proportion of patients, especially those not receiving intensive systemic treatment.
Irrational treatment, self-medication, turning to "healers" worsens the course of the disease, leads to the worsening and spread of skin rashes. That is why the main goal of this article is to briefly describe the modern methods of treating the disease.
Today, there are many ways to treat psoriasis, thousands of different drugs are used to treat the disease. But this only means that none of the methods gives a guaranteed effect and does not completely cure the disease. Moreover, the question of cure does not arise - modern therapy can only minimize the skin manifestations, without influencing many currently unknown pathogenetic factors.
Psoriasis treatment is carried out taking into account the form, stage, degree of occurrence of the skin rash and the general condition of the body. Treatment usually involves a complex combination of external and systemic drugs.
The patient's motivation, family circumstances, social situation, lifestyle and alcoholism are of great importance in the 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 drugs is extremely important in psoriasis. In mild cases, treatment begins with and is limited to local measures. As a general rule, topical medications are less likely to cause any side effects, but they are less effective than systemic therapy.
In an advanced stage, the external treatment is carried out with great care so as not to cause the skin condition to deteriorate. The more intense the inflammation, the lower the concentration of ointments should be. Usually, treatment of psoriasis at this stage is limited to a special cream, 0. 5-2% salicylic ointment and herbal baths.
In stationary and regression stages, more active drugs are indicated - 5-10% naphthalene ointment, 2-5% salicylic ointment, 2-5% sulfur-tar ointment, as well as many other therapeutic methods.
In modern conditions, when choosing a therapeutic method or a specific drug, the doctor must act on the basis of official protocols and formulas developed by the governing health authorities. The Federal Guidelines for the Use of Medications (IV Edition) recommends steroid medications, salicylic ointment, and tar preparations for topical treatment of patients with psoriasis.
We mainly focus on the medicines listed in the manuals.
Moisturizers.It softens the scaly surface of psoriatic elements, reduces skin tightness and improves its elasticity. Use creams containing lanolin-based vitamins. According to the literature, even after such mild exposure, clinical effects (reduction of itching, redness and scaling) can be achieved in a third of patients.
Salicylic acid preparations. As a rule, 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 elements caused by psoriasis, and also enhances the effect of topical steroids by increasing their absorption, which is why it is often used together with them.
Tar preparations. It has 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, wood tar (usually birch) ointments 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 experiences do not confirm this. Tar is more effective than salicylic acid and has anti-inflammatory, keratoplastic and anti-exfoliation properties. Its use in psoriasis is also due to its effect on cell reproduction. When prescribing tar preparations, its photosensitizing effect and the risk of deterioration of kidney function in people with nephrological diseases must be taken into account.
Tar shampoos are used to wash hair.
Naphthalene oil. A mixture of hydrocarbons and resins, it contains sulfur, phenol, magnesium and many other substances. Naftalan oil products have anti-inflammatory, absorbent, anti-itching, disinfecting, exfoliating and restorative properties. 10-30% naphthalene ointments and pastes are used to treat psoriasis. Naphthalene oil is often used in combination with sulfur, ichthyol, boric acid and zinc paste.
Topical retinoid therapy. The first effective topical retinoid approved for the treatment of psoriasis. This medicine has not yet been registered in our country. It is a water-based gel and is available in concentrations of 0. 05 and 0. 1%. In terms of its effectiveness, it can be compared to strong corticosteroids. Side effects include itching and skin irritation. One of the advantages of this drug is a longer remission compared to GCS.
Currently, synthetic hydroxyanthrones are used.
An 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 can cause burns if it comes into contact with healthy skin.
Mustard gas derivatives
They contain blisters - mustard gas and trichloroethylamine. Treatment with these drugs is carried out with great care, first we use low-concentration ointments for small injuries once a day. Then, if well tolerated, the concentration, area and frequency of use are increased. The 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 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 abnormal growth of epidermal cells in a hyperproliferative state. This last feature determines the effectiveness of the drug for psoriasis. The drug relieves inflammation, reduces the infiltration and peeling of psoriatic elements. The treatment lasts an average of one month. Aerosol and shampoo are used to treat patients with scalp lesions, and aerosol and cream are used for skin lesions. The medicine is used twice a day, shampoo three times a week. In Hungary, the clinical effectiveness and tolerability of all dosage forms of zinc pyrithionate have been investigated since 1995. According to the conclusions of the leading dermatological centers, the effectiveness of the drug in the treatment of patients with psoriasis reaches 85-90%. Based on the data published in journals by the leading specialists of these and other centers, clinical recovery 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 the treatment are evident by the end of the first week from the moment of starting to use the drug - the itching decreases sharply, the peeling stops, and the erythema turns pale. Achieving such a rapid clinical effect accordingly leads to a rapid improvement in the patients' quality of life. The drug is well tolerated. It can be used from the age of 3.
Ointments with vitamin D3. Since 1987, a synthetic vitamin D preparation has been used for topical treatment3. Numerous experimental studies have proven that calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, affects the factors regulating cell proliferation of the skin's immune system, and has anti-inflammatory properties. In this group, there are 3 drugs on the market from different manufacturers. The drugs are applied 1-2 times a day to the affected areas of the skin. The effectiveness of ointments with D3roughly corresponds to I. , II. class III corticosteroid ointments, and according to J. Koo, III. class. When using these ointments, a pronounced clinical effect occurs in the majority of patients (up to 95%). However, achieving a good effect can take quite 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 used twice a day, and a pronounced effect was observed by the end of the fourth week of treatment. No side effects were identified.
Corticosteroid drugs. They have been used in medical practice as external agents since 1952, when the effectiveness of the external use of steroids was first demonstrated. So far, about 50 glucocorticosteroid drugs intended for external use are registered on the pharmaceutical market. This undoubtedly makes it difficult to choose a doctor who must have information about each drug. According to the same survey, the most frequently prescribed corticosteroids for the treatment of psoriasis include combination drugs.
The therapeutic effect of topical corticosteroids is due to several potentially beneficial effects:
- anti-inflammatory effect (vasoconstriction, cessation of inflammatory infiltrate);
- epidermostatic (antihyperplastic effect on epidermal cells);
- antiallergenic;
- local analgesic effect (elimination of itching, burning, pain, tightness).
Changes in the structure of GCS affected their properties and activity. This is how a fairly large group of drugs appeared, which differed in their chemical structure and activity. Today, hydrocortisone acetate is practically not used to treat psoriasis, it is used in clinical trials for comparison with newly produced drugs. For example, if the activity of hydrocortisone is considered to be one, it is believed that the activity of triamcinolone acetonide is 21 units and that of betamethasone is 24 units. Among the second-class drugs for psoriasis, flumetasone pivalate is most often used in combination with salicylic acid, and the most modern are non-fluorinated corticosteroids. Owing to the minimal risk of side effects, the use of ointments and creams containing aclometasone is permitted in sensitive areas (face, skin folds), for the treatment of children and the elderly, when applied to large skin areas.
Among the drugs belonging to the third class, the group of fluorinated corticosteroids can be distinguished. The pharmacoeconomic analysis of the use of these drugs (although not for psoriasis), which consists of studying the price/safety/effectiveness ratio, according to the data, revealed favorable indicators in the case of betamethasone valerate - the rapid development of the therapeutic effect, the lower cost of the drug. treatment.
When treating psoriasis, you should start with lighter medications, and stronger ones should be given in case of repeated exacerbations and the ineffectiveness of the medications used. 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 medium or weak drug for maintenance therapy. In any case, strong drugs 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 drugs of different generations. Non-fluorinated first-generation corticosteroids (hydrocortisone acetate) are generally less effective than fluorinated ones, but safer in terms of side effects. Now the problem of low effectiveness of non-fluorinated corticosteroids has been solved - the fourth-generation non-fluorinated drugs have been created, which are comparable in strength to fluorinated ones and, in terms of safety, to hydrocortisone acetate. The problem of increasing the effect of the drug is not solved by halogenation, but by esterification. In addition to enhancing the effect, this allows esterified drugs to be used once a day. It is the fourth-generation non-fluorinated corticosteroid currently preferred for topical use in psoriasis.
The usual side effects of topical steroids are skin atrophy, hypertrichosis, telangiectasia, the development of pustular infections, systemic effects affecting 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, which creates a film on the surface of the lesion, absorbs the infiltration more effectively than other dosage forms. The cream relieves acute inflammation better, moisturizes and cools the skin. The cream's fat-free base ensures easy distribution on the surface of the scalp without the hair sticking together.
According to literature data, for example, a positive therapeutic effect can be achieved in almost 80% of patients with the use of mometasone for 3 weeks (a 60-80% reduction in the number of rashes). According to V. Yu. Udzhukhu, the most favorable "efficacy/safety" ratio can be achieved with the use of hydrocortisone butyrate. The pronounced clinical effect during the use of the drug is combined with good tolerability - the authors did not observe any side effects in the patients who underwent treatment, even ifapplied to the face. In case of long-term use of other corticosteroids, the treatment had to be stopped 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 furoate and methylprednisolone aceponate showed the same effectiveness of these drugs when applied externally. Severalauthor (E. R. Arabian, E. V. Sokolovsky) recommends intermittent corticosteroid therapy for the treatment of 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 about 3 weeks. After that, they switch to pure GCS-re, preferably in the third class (eg hydrocortisone butyrate or mometasone furoate).
Patients are attracted by the ease of use of steroid drugs, rapid relief of clinical symptoms of the disease, accessibility and odorlessness. In addition, these drugs do not leave greasy stains on clothes. However, their use should be short-term to avoid aggravating the course of the disease. Addiction develops in case of long-term use of steroid ointments. Abrupt withdrawal of corticosteroids may cause worsening of the skin process. The literature indicates different durations of remission after topical corticosteroid treatment. Most studies indicate short-term remission - for 1-6 months.
In the case of psoriasis, the combination of steroid hormones with salicylic acid is the most effective. Due to its keratolytic and antimicrobial effect, salicylic acid complements the dermatotropic effect of steroids.
It is convenient to apply combined lotions containing corticosteroids and salicylic acid to the scalp. According to the authors, the effectiveness of the combined drugs reaches 80-100%, while the skin cleansing happens very quickly - within 3 weeks.
In conclusion, it must be said that in practice the doctor must always decide whether to use only external treatment methods or to prescribe them in combination with any systemic therapy in order to increase the effectiveness of the treatment and prolong the remission.