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 layer "push out" the cells above it, preventing them from becoming keratin. This process is called parakeratosis and is accompanied by extensive peeling. Very important in the development of psoriatic lesions on the skin is the local immunopathological process related to the interaction of various cytokines - tumor necrosis factor, interferon, interleukin, as well as lymphocytes of various subpopulations.
The trigger point for the onset of the disease is often severe stress - this factor is present in the anamnesis of most patients. Other triggering factors include skin trauma, medication use, alcohol abuse and infection.
Many disorders in the epidermis, dermis and all body systems are closely related and cannot separately explain the mechanisms of disease development.
There is no generally accepted classification of psoriasis. Traditionally, along with common (abusive) psoriasis, erythrodermic, arthropathic, pustular, exudative, guttate, palmoplantar forms are distinguished.
Common psoriasis is clinically manifested by the formation of flat papules, clearly marked by 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. First, the "stearin spot" phenomenon appears, characterized by increased exfoliation when scraped, which makes the surface of the papule resemble a drop of stearin. After removing the scale, the phenomenon of "terminal film" is observed, which manifests itself in the form of a wet shiny surface of the elements. Following this, with further scraping, the phenomenon of "blood dew" is observed - in the form of blood droplets that do not merge.
The rash can be located on any part of the skin, but is mainly localized on the skin of the knees 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 various sizes and shapes. Plaques can be isolated, small or large, occupying large areas of the skin.
With exudative psoriasis, the nature of exfoliation changes - the scales become yellowish-gray, stick together to form a crust that fits the skin. The rash itself is brighter and more swollen than normal psoriasis.
Psoriasis of the palms and soles can be observed as isolated lesions or combined with lesions in other locations. It manifests itself in the form of typical papulo-plaque elements, as well as hyperkeratotic lesions, such as calluses with painful cracks or pustular rashes.
Psoriasis almost always affects the nail plate. The most pathognomonic is the appearance of an exact impression on the nail plate, giving the nail plate a resemblance to a thimble. Nail loosening, brittle edges, discoloration, transverse and longitudinal furrows, deformation, thickening, and subungual hyperkeratosis may also be observed.
Psoriatic erythroderma is one of the most severe forms of psoriasis. It can develop due to the gradual development of the psoriatic process and the combination 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 there is a lot of peeling. 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 signs of joint damage. Such changes include periarticular osteoporosis, joint space narrowing, osteophytes, and cystic clearing of bone tissue. The range of clinical manifestations can vary from minor arthralgia to the development of crippling ankylosing arthrosis. Clinically, joint swelling, redness of the skin in the affected joint area, pain, limited mobility, joint deformity, ankylosis, and deformity are detected.
Pustular psoriasis manifests itself in the form of a generalized or limited rash, 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 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 spread over the entire 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 most patients, there is a relationship between the aggravation and the time of year: more often the disease worsens in the winter (winter form), less often in the summer (summer form). In the future, this dependency may change.
During psoriasis, there are 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 the previous lesion (isomorphic Koebner reaction). In the regressing stage, there is a decrease or loss of infiltration around the circumference 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 palmoplantar and arthropathic psoriasis.
With abusive psoriasis, the prognosis for life is good. With erythroderma, arthropathic and generalized pustular psoriasis, disability and even death may result from fatigue and the development of severe infections.
The prognosis is still uncertain regarding the duration of the disease, the period of remission and exacerbation. The rash can exist for a long time, for years, but more often exacerbations alternate with periods of improvement and clinical recovery. In the majority of patients, especially those who do not undergo intensive systemic treatment, a long-term and spontaneous period of clinical recovery is possible.
Irrational treatment, self-medication, and turning to "healers" worsen the course of the disease and lead to worsening and spreading of skin rashes. That is why the main purpose of this article is to give a brief description of modern methods of treating this disease.
Today, there are a large number of methods to treat psoriasis; thousands of different drugs are used in the treatment of this disease. But this only means that no method gives a guaranteed effect and does not cure the disease completely. Moreover, the question of a cure is not raised - modern therapy is only able to minimize skin manifestations, without affecting many unknown pathogenetic factors.
Psoriasis treatment is carried out taking into account the form, stage, prevalence of the rash, and the general condition of the body. As a rule, treatment is complex, involving a combination of external and systemic drugs.
Patient motivation, family situation, social status, lifestyle, and alcohol abuse are very important 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 drugs is very important for psoriasis. In mild cases, treatment begins with local measures and is limited to them. As a rule, drugs for topical use are less likely to have any side effects, but their effectiveness is lower than systemic therapy.
At an advanced stage, external treatment is done very carefully so as not to cause deterioration of the skin condition. The more intense the inflammation, the lower the concentration of the ointment should be. Usually at this stage, psoriasis treatment is limited to special creams, salicylic ointment 0. 5-2%, and herbal baths.
At the stage of stagnation and regression, 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 method of therapy or medicine, doctors must be guided by official protocols and formularies developed by the governing health authority. The Federal Guide to Drug Use (Issue IV) recommends steroid drugs, salicylic ointment, and tar preparations for the local treatment of psoriasis patients.
We will focus mainly on the drugs indicated in the manual.
Hydrating agent.Softens the exfoliating surface of psoriatic elements, reduces skin tension, and improves elasticity. Use a lanolin-based cream with vitamins. According to the literature, even after such light exposure, clinical effects (reduction of itching, erythema and peeling) are achieved in one third of patients.
Preparation of salicylic acid. Usually, ointment with a concentration of 0. 5 to 5% salicylic acid is used. It has antiseptic, anti-inflammatory, keratoplasty and keratolytic effects and can be used in combination with tar and corticosteroids. Salicylic ointment softens the layer of debris of psoriatic elements, and also enhances the effect of local steroids by increasing their absorption, therefore it is often used in combination with them.
Preparation of tar. They have been used for a long time in the form of ointments and pastes 5-15%, often combined with other local medicines. In our country, ointment with wood tar (usually birch) is used, in some foreign countries - with coal tar. The latter is more active, but, according to our scientists, it has carcinogenic properties, although many foreign publications and experiences do not confirm this. Tar is higher than salicylic acid in activity and has anti-inflammatory, keratoplasty and anti-exfoliation properties. Its use in psoriasis is also due to its effect on cell proliferation. When prescribing tar preparations, one should take into account their photosensitizing effect and the risk of deterioration of kidney function in people with nephrological diseases.
Shampoo with tar is used to wash your hair.
Naphthalan oil. A mixture of hydrocarbons and resins, containing sulfur, phenol, magnesium and many other substances. Naftalan oil preparations have anti-inflammatory, absorbable, antipruritic, antiseptic, exfoliating and reparative properties. To treat psoriasis, 10-30% naphthalan ointment and paste are used. Naphthalan oil is often used in combination with sulfur, ichthyol, boric acid, and zinc paste.
Topical 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 strong corticosteroids. Side effects include itching and skin irritation. One of the advantages of this drug is that its remission is longer than GCS.
Currently, synthetic hydroxyanthrones are used.
A natural analogue of 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, as well as hyperkeratosis and parakeratosis, decreases. Unfortunately, the drug has a significant local irritant 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 drugs is carried out very carefully, first using ointment with a small concentration on small lesions once a day. Then, if well tolerated, the concentration, area and frequency of use increase. 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 stage of the disease.
Zinc pyrithione. Active ingredients produced in the form of aerosols, creams and shampoos. It has antimicrobial, antifungal, and antiproliferative effects - it blocks the pathological growth of epidermal cells in hyperproliferative conditions. The last property determines the effectiveness of the drug for psoriasis. This medicine relieves inflammation, reduces infiltration and exfoliates psoriatic elements. Treatment is carried out on average for a month. For the treatment of patients with scalp lesions, aerosols and shampoos are used, for skin lesions - aerosols and creams. This medicine is used 2 times a day, shampoo is used 3 times a week. In our country, since 1995, the clinical effectiveness and tolerance of all dosage forms of zinc pyrithioneate have been studied. According to the conclusion of a leading dermatology center, the effectiveness of the drug in the treatment of psoriasis patients reaches 85-90%. Based on data published in periodicals by leading experts from this center and others, clinical healing can be achieved at the end of 3-4 weeks of treatment. The effect develops gradually, but it is very important that the results of the treatment are clear at the end of the first week from the moment of starting to use the drug - itching is dramatically reduced, peeling is eliminated, and the erythema becomes pale. The achievement of such a rapid clinical effect leads, therefore, to a rapid improvement in the patient's quality of life. The drug is well tolerated. Approved for use from 3 years of age.
Ointment with vitamin D3. Since 1987, synthetic vitamin D preparations have been used for local treatment3. Many experimental studies have shown that calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, affects skin immune system factors that control cell proliferation, and has anti-inflammatory properties. There are 3 drugs in this group from different manufacturers on our market. Medicines are applied to the affected skin area 1-2 times a day. The effectiveness of ointment with D3approximately corresponds to the effect of corticosteroid ointment class I, II, and according to J. Koo - even class III. When using this ointment, a significant clinical effect occurs in the majority of patients (up to 95%). However, to achieve a good effect 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. This medicine is used 2 times a day, a clear effect is observed at 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. To date, about 50 glucocorticosteroid agents for external use are registered on the pharmaceutical market. This undoubtedly makes it difficult to choose a doctor, who must have information about 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 several potentially beneficial effects:
- anti-inflammatory effect (vasoconstriction, resolution of inflammatory infiltrates);
- epidermostatic (antihyperplastic effect on epidermal cells);
- antiallergic;
- local analgesic effect (elimination of itching, burning, stinging, tightness).
Changes in the structure of GCS affect its properties and activity. This is how a relatively large group of drugs 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 developed 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 drugs for psoriasis, flumethasone pivalate in combination with salicylic acid is most often used, and the most modern is a non-fluorinated corticosteroid. 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 used on large areas of skin.
Among the drugs of the third class, a 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, reveals favorable indications for betamethasone valerate - rapid development of the therapeutic effect, lower cost of treatment.
When treating psoriasis, you should start with a milder drug, and in the case of repeated exacerbations and ineffectiveness of the drug used, give a stronger one. 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 drugs are used in short courses and only in limited areas, because side effects are more likely to develop when they are 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 usually less effective, but safer in terms of adverse reactions. Now the problem of low effectiveness of non-fluorinated corticosteroids has already been solved - a fourth-generation non-fluorinated drug has been created, comparable in strength to fluorinated ones, and in safety - to hydrocortisone acetate. The problem of increasing the effect of the drug is solved not by halogenation, but by esterification. In addition to increasing the effect, this allows you to use the esterified drug once a day. It is a fourth-generation non-fluorinated corticosteroid that is now 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 effects on the hypothalamic-pituitary-adrenal system. With the modern non-fluoridated drugs 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 absorption of the infiltration than other dosage forms. The cream better relieves acute inflammation, moisturizes, and cools the skin. The fat-free lotion base ensures 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 "efficacy/safety" ratio can be achieved when using hydrocortisone butyrate. A significant clinical effect when using this drug is combined with good tolerance - the author did not see any adverse reactions in any of the patients undergoing treatment, even when used on the face. With long-term use of other corticosteroids, it is necessary to stop 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 shows the same effectiveness of these drugs when used externally. A number of authors (E. R. Arabian, E. V. Sokolovsky) suggest staged 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 about 3 weeks. After that, there is a transition 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 the lack of odor. In addition, these drugs do not leave greasy marks on clothes. However, its use should be short-term to avoid worsening the course of the disease. With prolonged use of steroid ointment, addiction develops. Abrupt withdrawal of corticosteroids may cause exacerbation of the skin process. The literature shows different periods of remission after topical treatment with corticosteroids. Most studies show short-term remission - from 1 to 6 months.
For psoriasis, the combination of steroid hormones with salicylic acid is most effective. Salicylic acid, due to its keratolytic and antimicrobial effects, complements the dermatotropic activity of steroids.
It is easy to use a combination lotion with corticosteroids and salicylic acid on the scalp. According to the author, the effectiveness of the combined drug reaches 80 - 100%, while skin cleansing occurs very quickly - within 3 weeks.
To summarize, it should be said that in practice, doctors always have to decide whether to use only external treatment methods or prescribe them in combination with any systemic therapy to increase the effectiveness of treatment and prolong remission.