The main pathogenic link that causes the appearance of skin rashes is increased mitotic activity and accelerated proliferation of epidermal cells, leading to the fact that the cells of the lower layers "push" the upper cells, preventing them from keratinizing. This process is called parakeratosis and is accompanied by abundant peeling. Of great importance in the development of psoriatic skin lesions are local immunopathological processes associated with the interaction of various cytokines - tumor necrosis factor, interferons, interleukins, as well as lymphocytes of 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 precipitating factors include skin trauma, medication use, alcohol abuse, and infections.
Multiple disorders in the epidermis, dermis and all body systems are closely related and cannot separately explain the mechanism of disease development.
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 defined 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 appears when the papules itch and is called the psoriatic triad. First, the phenomenon of "stearin spots" appears, characterized by increased peeling during scratching, which makes the surface of the papules resemble 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. After that, with further scratching, the phenomenon of "blood dew" is observed - in the form of drops of blood with dots, not united.
The rash can be located on any part of the skin, but it is mainly located on the skin of the knee and elbow joints and on the scalp, where the disease 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 the peeling changes - the scales become yellow-gray, stick together to form crusts that fit tightly to the skin. The rashes themselves are brighter and more swollen than with regular psoriasis.
Psoriasis of the palms and soles can be observed as an isolated lesion or combined with lesions in other places. It appears in the form of typical papulo-plaque elements, as well as hyperkeratotic, callus-like lesions with painful cracks or pustular rash.
Psoriasis almost always affects the nail plates. More pathognomonic is the appearance of precise impressions on the nail plates, giving the nail plate a resemblance to a case. Nail loosening, edge brittleness, spotting, 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 progress of the psoriatic process and melting of plaques, but more often it occurs under the influence of irrational treatment. With erythroderma, the entire skin takes on a bright red color, swells, infiltrates, and has abundant skin. 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 disabling ankylosing arthrosis. Clinically, swelling of the joints, redness of the skin in the area of the affected joints, pain, limited mobility, deformities of the joints, ankylosis and 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 main symptom of this form of psoriasis is the appearance of pustules on the skin, which in dermatology are considered a manifestation of a pustular infection, the contents of these blisters are usually sterile.
Guttate psoriasis develops more often in children and is accompanied by a sudden rash of small papular elements 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: more often the disease worsens in the cold season (winter form), much less often in summer (summer form). In the future, this dependence may change.
During psoriasis, there are 3 phases: progressive, stationary and regressive. The progressive phase 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 perimeter or in the center of the plates.
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.
With vulgar psoriasis, the prognosis for life is favorable. With erythroderma, arthropathic and generalized pustular psoriasis, disability and even death are possible due to exhaustion and the development of severe infections.
The prognosis remains unclear in terms of the duration of the disease, duration of remission and exacerbations. Rashes can exist for a long time, for many years, but more often irritations alternate with periods of improvement and clinical recovery. In a significant proportion of patients, especially those not undergoing intensive systemic treatment, long, spontaneous periods of clinical recovery are 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 treatment of this disease.
Today, there are a large number of methods for treating psoriasis; thousands of different drugs are used in the treatment of 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 healing is not raised - modern therapy is only able to minimize skin manifestations, without affecting many currently unknown pathogenic 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.
Patient 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, climatotherapy, alternative and popular methods.
External therapy
External drug therapy is of great importance 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 are inferior in effectiveness to systemic therapy.
In the advanced stage, the external treatment is carried out very carefully in order 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, salicylic ointment 0. 5-2% and herbal baths.
In the stationary and regressive phase, more active drugs are indicated - 5-10% naphthalene ointment, 2-5% salicylic ointment, 2-5% sulfur-tar oil, as well as many other methods of therapy.
In modern conditions, when choosing a therapy method or a specific drug, the doctor must be guided by official protocols and forms drawn up by the governing health authorities. The Federal Drug Use Guideline (Issue IV) suggests steroid medications, salicylic ointment, and tar preparations for topical treatment of patients with psoriasis.
We will focus mainly on the drugs indicated in the manuals.
Moisturizing agents.Soften the smooth surface of psoriatic elements, reduce skin tightness and improve elasticity. Use lanolin-based creams with vitamins. According to the literature, even after such a light exposure, clinical effects (reduction of itching, erythema and peeling) are achieved in one third of patients.
Salicylic acid preparations. Typically, ointments with a concentration of 0. 5 to 5% of salicylic acid are used. It has antiseptic, anti-inflammatory, keratoplasty and keratolytic effects and can be used in combination with tar and corticosteroids. Salicylic ointment softens the wrinkled layers of psoriatic elements and also increases the effect of local steroids by increasing their absorption, therefore it is often used in combination with them.
Tar preparations. They have been used for a long time in the form of ointments and pastes 5–15%, often in combination with other local drugs. In our country, ointments are used with wood tar (usually birch), 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 is superior to 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.
Tar shampoos are used to wash hair.
Naphthalan oil. A mixture of hydrocarbons and resins, it contains sulphur, phenol, magnesium and many other substances. Naftalan oil preparations have anti-inflammatory, absorbent, antipruritic, antiseptic, exfoliating and repairing properties. For the treatment of psoriasis, 10-30% naphthalene ointments and pastes 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 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 analog of natural chrysarobin, 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, as well as hyperkeratosis and parakeratosis, decreases. Unfortunately, the drug has a pronounced local irritant effect and if it comes into contact with healthy skin, burns may occur.
Mustard gas derivatives
They contain blowing agents - mustard gas and trichloroethylamine. Treatment with these drugs is carried out very carefully, initially using ointments with a small concentration on small lesions once a day. Then, if well tolerated, increase the concentration, area and frequency of use. 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. 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 a state of hyperproliferation. The last property determines the effectiveness of the medicine for psoriasis. The drug relieves inflammation, reduces the infiltration and skin of psoriatic elements. Treatment is carried out on average for one month. For the treatment of patients with head lesions, aerosol and shampoo are used, for skin lesions - aerosol and cream. 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 dosage forms of zinc pyrithionate have been studied. According to the conclusion of the main 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 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 visible by the end of the first week from the moment of starting to use the drug - the itching is significantly reduced, the crust is eliminated and the erythema fades. Such rapid achievement of the clinical effect leads, accordingly, to a rapid improvement in the quality of life of patients. The drug is well tolerated. It is approved for use from the age of 3 years.
Ointment with vitamin D3. Since 1987, a synthetic vitamin D preparation has been used for topical treatment3. Numerous experimental studies have shown that calcipotriol inhibits keratinocyte proliferation, accelerates their morphological differentiation, affects skin immune system factors that regulate cell proliferation, and has anti-inflammatory properties. In our market there are 3 drugs in this group from different manufacturers. Medicines are applied to the affected areas of the skin 1-2 times a day. The effectiveness of ointments with D3roughly corresponds to the effect of corticosteroid ointments of classes I, II, and according to J. Koo - even class III. When using these ointments, a pronounced clinical effect appears in most patients (up to 95%). However, to achieve a good effect it may take 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 pronounced effect was 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 first appeared. 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 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 a number of potentially beneficial effects:
- anti-inflammatory effect (vasoconstriction, resolution of inflammatory infiltrate);
- epidermostatic (antihyperplastic effect on epidermal cells);
- antiallergic;
- local analgesic effect (elimination of itching, burning, stinging, tightness).
Changes in the structure of GCS affected their properties and activity. Thus appeared a rather large group of drugs, different in their chemical structure and activity. Hydrocortisone acetate is practically not used today for psoriasis; 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 are non-fluorinated corticosteroids. Due to the minimal risk of side effects, aclomethasone ointments and creams are approved for use in sensitive areas (face, skin folds), for the 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. A pharmacoeconomic analysis of the use of these drugs (although not for psoriasis), which consists in the study of the price/safety/efficiency ratio, according to the data, revealed favorable indicators for betamethasone valerate - rapid development of the therapeutic effect, cost andlow and treatment.
When treating psoriasis, you should start with lighter drugs, and in case of repeated irritations and ineffectiveness of the drugs used, give stronger ones. 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 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 ones 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 - non-fluorinated drugs of the fourth generation have been created, comparable in strength to fluorinated ones, and in safety - with hydrocortisone acetate. The problem of increasing the effect of the drug is not solved by halogenation, but by esterification. In addition to increasing the effect, this allows you to use esterified drugs once a day. It is the fourth-generation fluoride-free corticosteroids that are currently preferred for topical use in psoriasis.
Standard side effects during the use of 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-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 layer on the surface of the lesion, causes more effective resorption of the infiltration than other dosage forms. The cream better relieves acute inflammation, moisturizes and cools the skin. The non-greasy base of the lotion ensures its easy distribution on the surface of the head without sticking to the hair.
According to literature data, when using, for example, mometasone for 3 weeks, a positive therapeutic effect (decrease 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 hydrocortisone butyrate is used. The pronounced clinical effect during the use of this medication is combined with good tolerability - the authors did not observe any negative reaction in any of the patients who underwent treatment, even when applied to the face. With the long-term use of other corticosteroids, it was necessary to stop the treatment due to the development of side effects. According to B. Bianchi and N. G. Kochergin, a comparison of the results of clinical use of mometasone fuorate and methylprednisolone aceponate showed the same effectiveness of these drugs when used externally. A number of authors (E. R. Arabian, E. V. Sokolovsky) propose topical 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. Then 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 absence of odor. 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 prolonged use of steroid ointments, addiction develops. Immediate withdrawal of corticosteroids may cause a worsening of the skin process. The literature shows varying durations of remission after topical corticosteroid treatment. Most studies show short-term remission - from 1 to 6 months.
For 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 suitable for applying lotions combined with corticosteroids and salicylic acid on the scalp. According to the authors, the effectiveness of combined drugs reaches 80 - 100%, while skin cleansing occurs very quickly - within 3 weeks.
To summarize, it should 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 some systemic therapy in order to increase the effectiveness of the treatment and prolong the remission.