The main pathogenetic link leading to the formation of skin rashes is increased mitotic activity and rapid proliferation of epidermal cells, which causes "pushing" of cells that prevent the keratinization of the cells of the lower layers. This process is called parakeratosis and is accompanied by abundant peeling. In the development of psoriatic lesions on the skin, local immunopathological processes associated with the interaction of various cytokines - tumor necrosis factor, interferons, interleukins, as well as lymphocytes of various subpopulations are of great importance.
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, drug use, alcohol abuse, and infections.
Multiple disorders in the epidermis, dermis, and all body systems are closely related and cannot explain the mechanism of disease development separately.
There is no generally accepted classification of psoriasis. Traditionally, along with common (vulgar) psoriasis, erythrodermic, arthropathic, pustular, exudative, guttate, palmoplantar forms are distinguished.
Normal psoriasis is clinically manifested by the formation of flat papules clearly separated from healthy skin. The papules are pinkish-red and covered with loose silvery-white scales. From a diagnostic point of view, an interesting group of symptoms occurs when the papules are scraped off 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 "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" is observed - in the form of precise, non-combining drops of blood.
The rash can be located on any part of the skin, but it is mainly localized on the skin of the knee and elbow joints and on the scalp, where the disease begins very often. 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, covering large areas of the skin.
With exudative psoriasis, the nature of peeling changes - the scales become yellowish-gray, stick together to form crusts that fit closely to the skin. The rashes themselves are brighter and more swollen than regular psoriasis.
Psoriasis of the palms and soles may appear as an isolated lesion or may be combined with lesions elsewhere. It manifests as typical papulo-plaque elements, as well as hyperkeratotic, callus-like painful fissures or pustular rashes.
Psoriasis almost always affects the nail plates. The most pathognomonic is the appearance of precise impressions on the nail plates that resemble a raised nail plate. Loosening of the nail, fragility of the 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 due to the gradual progression 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, swells, infiltrates and exfoliates profusely. 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, narrowing of joint spaces, osteophytes, and cystic clearing of bone tissue. The range of clinical manifestations can vary from minor arthralgia to the development of ankylosing arthrosis. Clinically, swelling of the joints, reddening of the skin in the area of the affected joints, pain, limitation of mobility, joint deformations, ankylosis and paralysis are revealed.
Pustular psoriasis manifests itself in the form of localized 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, in dermatology pustules are considered a manifestation of 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 throughout the skin.
Psoriasis occurs with approximately the same 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 exacerbation and the time of year: the disease worsens more often in the cold season (winter form), less often in the summer (summer form). This dependency may change in the future.
During psoriasis, 3 stages are distinguished: progressive, stationary and regressive. The progressive stage is characterized by growth along the periphery and the appearance of new lesions, especially at the sites of previous lesions (isomorphic Koebner reaction). In the regression phase, there is a decrease or disappearance of infiltration around the periphery or in the center of the plaques.
Psoriasis vulgaris differs from parapsoriasis, secondary syphilis, lichen planus, discoid erythema, and seborrheic eczema. Difficulties arise in the differential diagnosis of palmoplantar and arthropathic psoriasis.
The prognosis for life with psoriasis vulgaris is favorable. With erythroderma, arthropathic and generalized pustular psoriasis, disability and even death are possible due to the development of exhaustion and severe infections.
The prognosis regarding the duration of the disease, the duration of remission and exacerbations remains uncertain. Rashes can be present for a long time, for many years, but more often exacerbations are replaced by periods of improvement and clinical recovery. Long periods of spontaneous clinical recovery are possible in a significant proportion of patients, especially those not undergoing intensive systemic treatment.
Irrational treatment, self-medication, recourse to "healers" worsen the course of the disease and cause exacerbation and spread of skin rashes. Therefore, the main goal of this article is to give a brief description of modern methods of treatment of this disease.
Today, there are many ways to treat 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. Moreover, the question of treatment 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, extent of the rash and the general condition of the body. As a rule, the treatment is complex, includes a combination of external and systemic drugs.
The patient's motivation, family circumstances, social status, lifestyle and alcohol abuse are of great importance in the treatment.
Treatment methods can be divided into the following directions: 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 cause any side effects, but are less effective than systemic therapy.
External treatment is carried out very carefully in order not to worsen the condition of the skin in the advanced stage. The stronger the inflammation, the lower the concentration of ointments should be. Usually, psoriasis treatment at this stage is limited to special cream, 0. 5-2% salicylic ointment and herbal baths.
In the stationary and regression phase, more active drugs are indicated - 5-10% naphthalene ointment, 2-5% salicylic ointment, 2-5% sulfur-tar ointment, as well as many other therapy methods.
In modern conditions, when choosing a therapy method or a certain drug, the doctor should be guided by the official protocols and formulas developed by the governing bodies of health care. The Federal Guide to the Use of Medicines (number IV) recommends steroid drugs, salicylic ointment, and tar preparations for the topical treatment of psoriasis patients.
We will mainly focus on the drugs specified in the instructions.
Moisturizers.It softens the crusty surface of psoriatic elements, reduces the density of the skin and increases its elasticity. Use lanolin-based creams with vitamins. According to the literature, clinical effects (pruritus, erythema and reduction of crusts) are obtained in one third of patients even after such mild exposure.
Salicylic acid preparations. Typically, ointments with a concentration of 0. 5-5% salicylic acid are used. It has antiseptic, anti-inflammatory, keratoplasty and keratolytic effects and can be used together with tar and corticosteroids. Salicylic ointment softens the crusty layers of psoriatic elements, and also increases the effect of local steroids by increasing their absorption, so it is often used together with them.
Tar preparations. They have long been used as 5-15% ointments and pastes, often in combination with other topical medications. In our country, ointments are used with wood resin (usually birch), and in some foreign countries, ointments with coal resin. The latter is more active, but according to our scientists, it has carcinogenic properties, although numerous publications and foreign experience do not confirm this. The resin is superior in activity to salicylic acid and has anti-inflammatory, keratoplastic and exfoliative properties. Its use in psoriasis is also related to its effect on cell proliferation. When prescribing tar preparations, it is necessary to take into account its photosensitizing effect and the risk of deterioration of kidney function in people with nephrological diseases.
Resin shampoos are used to wash your hair.
Naphthalan oil. A mixture of hydrocarbons and resins, it contains sulfur, phenol, magnesium and many other substances. Naphthalan oil preparations have anti-inflammatory, absorbent, anti-itching, antiseptic, abrasive and restorative properties. 10-30% naphthalene ointments and pastes are used to treat psoriasis. 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 is not yet registered in our country. It is a water-based gel 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 a longer remission compared to GCS.
Currently, synthetic hydroxyanthrones are used.
Natural chryzarobin analogue has a cytotoxic and cytostatic effect, which causes 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 burns can occur if it comes into contact with healthy skin.
Mustard gas derivatives
They contain blister agents - mustard gas and trichloroethylamine. Treatment with these drugs is carried out with great care, first, small concentrations of ointments are used on small lesions once a day. Then, if well tolerated, the concentration, area and frequency of use are increased. Treatment is carried out under the close supervision of a doctor, 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 antimicrobial, antifungal and antiproliferative effects - it suppresses the pathological growth of epidermal cells in the case of hyperproliferation. The last feature determines the effectiveness of the drug for psoriasis. The drug eliminates inflammation, reduces infiltration and peeling of psoriatic elements. Treatment is carried out on average for one month. Aerosol and shampoo are used to treat patients with scalp damage, and aerosol and cream are used for skin lesions. The medicine is applied 2 times a day, the shampoo is used 3 times a week. Clinical effectiveness and tolerability of all dosage forms of zinc pyrithionate have been studied in our country since 1995. According to the opinion of leading dermatological centers, the effectiveness of the drug in the treatment of psoriasis patients reaches 85-90%. According to the information published in periodicals by the leading specialists of this and other centers, clinical recovery 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 from the moment of starting to use the drug until the end of the first week - the itching decreases sharply, peeling is eliminated and the erythema fades. Such a rapid achievement of the clinical effect, accordingly, leads to a rapid improvement of 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 vitamin D preparation has been used for local 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. There are 3 drugs in this group from different manufacturers in our market. 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 classes I, II, and according to J. Koo - even class III. When using these ointments, a clear clinical effect occurs in the majority of patients (up to 95%). However, it may take quite 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 drug was applied 2 times a day, a clear effect was observed at the end of the fourth week of treatment. No side effects were identified.
Corticosteroid drugs. They have been used as external agents in medical practice since 1952, when the effectiveness of the external use of steroids was first shown. To date, approximately 50 glucocorticosteroid agents have been registered on the pharmaceutical market for external use. This certainly makes it difficult to choose a doctor who must be knowledgeable about all medications. According to the same survey, the most frequently prescribed corticosteroids for psoriasis include combination drugs.
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);
- antiallergic;
- local analgesic effect (relieves itching, burning, pain, tightness).
Changes in the structure of GCS affected their properties and activity. A fairly large group of drugs, differing in chemical structure and activity, appeared. Hydrocortisone acetate is not used in practice for psoriasis today, it is used in clinical studies to compare with newly developed drugs. For example, it is considered that if the activity of hydrocortisone is taken as one, then the activity of triamcinolone acetonide will be 21 units, and betamethasone will be 24 units. Of the second-class drugs for psoriasis, flumethasone pivalate with salicylic acid is most commonly used, and the most modern are non-fluorine corticosteroids. Due to the minimal risk of side effects, ointments and creams with aclomethasone are approved for use in sensitive areas (face, skin folds), in the 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. According to the data, a pharmacoeconomic analysis of the use of these drugs (although not for psoriasis), consisting of a study of the price/safety/effectiveness ratio, revealed favorable indicators for betamethasone valerate - rapid development of the therapeutic effect, low cost of the drug. treatment.
When treating psoriasis, it is necessary to start with milder drugs, and in case of repeated exacerbations and ineffectiveness of the used drugs, give stronger ones. However, the following tactics are popular among American dermatologists: first, a strong GCS is used to achieve a quick effect, 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, because when they are prescribed, side effects develop more.
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) are usually less effective than fluorinated ones, but are safer in terms of adverse reactions. Now, the problem of low effectiveness of non-fluorinated corticosteroids has already been solved - the fourth generation of non-fluorinated drugs has been created, which is comparable in strength to fluorides and in terms of safety to hydrocortisone acetate. The problem of increasing 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 drugs once a day. Fourth-generation non-fluorinated corticosteroids are currently preferred for topical use in psoriasis.
Standard side effects when using local steroids are skin atrophy, hypertrichosis, telangiectasia, development of pustular infections, and systemic effects with effects on the hypothalamo-pituitary-adrenal system. These side effects are minimized with the modern non-fluoride drugs mentioned above.
Pharmaceutical companies are trying to diversify the range of dosage forms and produce GCS in the form of ointments, creams and lotions. Oily ointment, which creates a film on the surface of the lesion, leads to more effective resorption of infiltration than other dosage forms. The cream better relieves acute inflammation, moisturizes and cools the skin. The oil-free base of the lotion ensures that it is easily spread over the surface of the scalp without sticking to the hair.
According to literature data, for example, when mometasone is used for 3 weeks, a positive therapeutic effect (60-80% reduction in the number of rashes) can be achieved in almost 80% of patients. V. Yu. According to Udzhukh, the most favorable "efficacy / safety" ratio can be achieved when using hydrocortisone butyrate. A noticeable clinical effect when using this drug is combined with good tolerance - the authors did not observe any adverse reactions in any of the treated patients, even when applied to the face. With long-term use of other corticosteroids, treatment should be discontinued 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 when these drugs were 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. Later, 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 eliminate the clinical symptoms of the disease, availability and lack of odor. In addition, these drugs do not leave greasy stains on clothes. However, their use should be short-term in order not to worsen the course of the disease. Addiction develops with long-term use of steroid ointments. Acute withdrawal of corticosteroids can lead to exacerbation of the skin process. The literature shows different durations of remission after local treatment with corticosteroids. Most studies show short-term remission - from 1 to 6 months.
Combinations of steroid hormones with salicylic acid are most effective for psoriasis. Salicylic acid complements the dermatotropic activity of steroids due to its keratolytic and antimicrobial effects.
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%, and the skin is cleared very quickly - within 3 weeks.
To summarize, it should be said that in practice, the doctor should always decide whether to use only external treatment methods or to prescribe them together with any systemic therapy in order to increase the effectiveness of the treatment and prolong the remission.