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 out" the upper cells, preventing their keratinization. This process is called parakeratosis and is accompanied by abundant peeling. Of great importance for the development of psoriatic lesions in the skin are the local immunopathological processes associated with the interaction of various cytokines - tumor necrosis factor, interferons, interleukins, as well as lymphocytes from different 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 triggers include skin trauma, drug use, alcohol abuse, and infections.
Numerous disorders in the epidermis, dermis and all systems of the body 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 by healthy skin. The papules are pink-red in color and covered with loose silvery-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 stain" phenomenon appears, characterized by increased peeling when scraping, which makes the surface of the papules look like a drop of stearin. After removing the scales, the phenomenon of "terminal film" is observed, which manifests itself in the form of a wet, shiny surface of the elements. Then, with further scraping, the phenomenon of "blood dew" is observed - in the form of point-like, non-cohesive droplets of blood.
The rash can be localized on any part of the skin, but it is localized mainly on the skin of the knee and elbow joints and the scalp, where the disease often begins. Psoriatic papules are characterized by a tendency to grow peripherally and coalesce into plaques of different sizes and shapes. Plaques can be isolated, small or large, occupying large areas of the skin.
In exudative psoriasis, the nature of peeling changes - the scales become yellowish-gray, stick together to form crusts that fit tightly to the skin. The rashes themselves are brighter and more swollen than in ordinary psoriasis.
Psoriasis of the palms and soles may occur as an isolated lesion or in combination with lesions elsewhere. It manifests itself in the form of typical papulo-plaque elements, as well as hyperkeratotic, callus-like lesions with painful fissures or a pustular rash.
Psoriasis almost always affects the nail plates. The most pathognomonic is the appearance of dot prints on the nail plates, giving the nail plate the appearance of a thimble. Nail loosening, brittle edges, discoloration, transverse and longitudinal furrows, deformities, 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 progression of the psoriatic process and the fusion of plaques, but more often it appears under the influence of irrational treatment. In erythroderma, the entire skin acquires a bright red color, swells, infiltrates and has abundant peeling. Patients are worried about severe itching and their general condition worsens.
Radiologically, various changes in the bone-joint apparatus are observed in most patients without clinical signs of joint damage. Such changes include periarticular osteoporosis, narrowing of joint spaces, osteophytes, and cystic bone clearing. The range of clinical manifestations can vary from mild arthralgia to the development of debilitating ankylosing arthrosis. Clinically, swelling of the joints, redness of the skin in the area of the affected joints, pain, limited mobility, joint deformities, ankylosis, mutilation are detected.
Pustular psoriasis manifests itself in the form of generalized or limited rashes, localized 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 are considered a manifestation of purulent infection, the contents of these bubbles are usually sterile.
Guttate psoriasis most often develops in children and is accompanied by a sudden rash of small papular elements scattered 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 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 peripheral growth and the appearance of new lesions, especially at the sites of previous lesions (Koebner's isomorphic reaction). In the regression stage, there is a decrease or disappearance of infiltration 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. In erythroderma, arthropathic and generalized pustular psoriasis, disability and even death are possible due to exhaustion and the development of severe infections.
The prognosis remains uncertain regarding the duration of the disease, duration of remission and exacerbations. Rashes can exist for a long time, for many years, but more often exacerbations alternate with periods of improvement and clinical recovery. Prolonged spontaneous periods of clinical recovery are possible in a significant proportion of patients, especially those not undergoing intensive systemic treatment.
Irrational treatment, self-medication and turning to "healers" worsen the course of the disease and lead to exacerbation and spread of skin rashes. Therefore, the main purpose of this article is to give a brief description of modern methods of treatment of this disease.
Today, there are a huge number of methods for the treatment of 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 completely cure the disease. In addition, the question of cure is not raised - modern therapy is only able to minimize skin manifestations, without affecting many currently unknown pathogenetic factors.
Psoriasis treatment is carried out taking into account the form, stage, degree of spread of the rash and the general condition of the body. As a rule, the treatment is complex, including 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, climate therapy, alternative and folk methods.
External therapy
Therapy with external drugs is extremely important in psoriasis. In mild cases, treatment begins with local measures and is limited to them. As a rule, topical medications are less likely to have side effects, but are less effective than systemic therapy.
In an advanced stage, external treatment is carried out very carefully, so as not to cause deterioration of the skin condition. The more intense the inflammation, the lower the concentration of 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 regressing stage, more active drugs are indicated - 5-10% naphthalan ointment, 2-5% salicylic ointment, 2-5% sulfur-tar ointment, as well as many other methods of treatment.
In modern conditions, when choosing a method of treatment or a specific drug, the doctor must be guided by official protocols and forms developed by the governing health authorities. The Federal Drug Administration Guide (Edition IV) recommends steroid drugs, salicylic ointment, and tar preparations for topical treatment of patients with psoriasis.
We will focus mainly on the drugs mentioned in the manuals.
Hydrating agents.Softens the scaly surface of psoriatic elements, reduces skin tightness 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 scaling) are achieved in one third of patients.
Preparations with salicylic acid. Ointments with a concentration of 0. 5 to 5% salicylic acid are usually used. It has antiseptic, anti-inflammatory, keratoplasty 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, which is why 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. Ointments with wood tar (usually birch) are used in our country, 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 experience do not confirm this. Tar surpasses salicylic acid in activity and has anti-inflammatory, keratoplasty 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 kidney function in people with nephrological diseases should be taken into account.
Shampoos with tar are used to wash the hair.
Naphthalene oil. A mixture of hydrocarbons and resins, contains sulfur, phenol, magnesium and many other substances. Preparations with naphthalene oil have anti-inflammatory, resorbable, antipruritic, antiseptic, exfoliating and reparative properties. For the treatment of psoriasis, 10-30% naphthalene ointments and pastes are used. 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 use in the treatment of psoriasis. This medicine is not yet 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 powerful 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 decreases, as well as hyperkeratosis and parakeratosis. Unfortunately, the drug has a pronounced local irritant effect, and if it comes into contact with healthy skin, a burn may occur.
Derivatives of mustard
They contain blisters - mustard and trichloroethylamine. Treatment with these drugs is carried out with great care, first using ointments with a small concentration on small lesions once a day. Then, if it is well tolerated, the concentration, area and frequency of use are increased. The 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 stage of the disease.
Zinc pyrithione. The active substance is produced in the form of aerosols, creams and shampoos. It has an antimicrobial, antifungal and antiproliferative effect - suppresses the pathological growth of epidermal cells in a state of hyperproliferation. The latter 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. Aerosol and shampoo are used to treat patients with scalp lesions, aerosol and cream for skin lesions. The medicine is applied 2 times a day, the shampoo is used 3 times a week. In our country, since 1995, the clinical effectiveness and tolerability of all medicinal 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 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 the treatment are evident by the end of the first week from the moment of using the drug - the itching decreases sharply, the peeling is eliminated and the erythema becomes pale. Such a rapid achievement of a clinical effect 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 preparation with vitamin D has been used for topical treatment3. Numerous experimental studies have shown that calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, affects the factors of the skin immune system that regulate cell proliferation and has anti-inflammatory properties. In our market, there are 3 drugs from different manufacturers in this group. Medicines are applied to the affected areas of the skin 1-2 times a day. The effectiveness of ointments with D3approximately corresponds to the effect of corticosteroid ointments of class I, II, and according to J. Koo - even class III. When using these ointments, a pronounced clinical effect is observed in most patients (up to 95%). However, it may take a long time (from 1 month to 1 year) to achieve a good effect, and the affected area should not exceed 40%. There have been reports of positive experience with the substance in children. The drug is applied 2 times a day, a pronounced effect is 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 means since 1952, when the effectiveness of the external use of steroids was first shown. To date, about 50 glucocorticosteroid agents for external use have been 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 study, the most commonly prescribed corticosteroids for psoriasis include combination drugs.
The therapeutic effect of topical corticosteroids is due to a number of potentially beneficial effects:
- anti-inflammatory effect (vasoconstriction, separation of inflammatory infiltrate);
- epidermostatic (anti-hyperplastic effect on epidermal cells);
- anti-allergic;
- local analgesic effect (elimination of itching, burning, soreness, tightness).
Changes in the structure of GCS affected their properties and activity. Thus, a rather large group of drugs appeared, different in their chemical structure and activity. Hydrocortisone acetate is practically not used today for psoriasis, it is used in clinical trials 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 of drugs for psoriasis, flumethasone pivalate in combination with salicylic acid is most often used, and non-fluorinated corticosteroids are the most modern. Due to the minimal risk of side effects, aclomethasone ointments and creams are approved for use on sensitive areas (face, skin folds), treatment of children and the elderly when applied to 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 (but not for psoriasis), which consists of a study of the price/safety/efficacy ratio, according to the data, revealed favorable indicators for betamethasone valerate - rapid development of the therapeutic effect, lower cost of treatment.
In the treatment of psoriasis, you should start with milder drugs, and in case of repeated exacerbations and ineffectiveness of the drugs used, stronger ones should be given. 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, 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) compared to fluorinated ones are generally less effective but safer in terms of side effects. Now the problem of low effectiveness of non-fluorinated corticosteroids has already been solved - non-fluorinated drugs of the fourth generation have been created, comparable in strength to fluorinated ones, and in terms of 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, this allows you to use esterified drugs once a day. It is the fourth generation of non-fluorinated corticosteroids that 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 compared to other drug forms. The cream better relieves acute inflammation, moisturizes and cools the skin. The oil-free base of the lotion ensures its easy distribution on the surface of the scalp without sticking the hair together.
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. Ujuhu, the most favorable "efficacy / safety" ratio can be achieved when using hydrocortisone butyrate. The pronounced clinical effect with the use of this drug is combined with good tolerability - the authors did not observe any adverse reactions in any of the patients undergoing treatment, even when they were applied to the face. With long-term use of other corticosteroids, it is necessary to stop the treatment due to the development of side effects. According to B. Bianchi and N. G. Kochergin, the comparison of the results of the clinical use of mometasone furate and methylprednisolone aceponate shows the same effectiveness of these drugs when used externally. A number of authors (E. R. Arabian, E. V. Sokolovsky) propose staged corticosteroid therapy in psoriasis. It is recommended to start external therapy with combined drugs containing corticosteroids (eg betamethasone and salicylic acid). The average duration of such treatment is about 3 weeks. Subsequently, there is a transition to a 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 alleviate the clinical symptoms of the disease, accessibility and lack of smell. In addition, these drugs do not leave greasy stains on clothes. However, their use should be short-term to avoid worsening the course of the disease. With long-term use of steroid ointments, addiction develops. Abrupt discontinuation of corticosteroids may cause exacerbation of the skin process. The literature reports varying duration of remission after topical corticosteroid treatment. Most studies show short-term remission - from 1 to 6 months.
In 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 combined corticosteroid and salicylic acid lotions to the scalp. According to the authors, the effectiveness of the combined drugs reaches 80 - 100%, while the cleansing of the skin occurs very quickly - within 3 weeks.
Summarizing, it must be said that in practice the doctor must always decide whether to use only external methods of treatment or to prescribe them in combination with any systemic therapy in order to increase the effectiveness of the treatment and prolong the remission.