The main pathogenetic link that causes rashes on the skin is increased mitotic activity and accelerated proliferation of epidermal cells, which leads to the fact that the cells of the lower layers "throw out" the cells above, preventing them from becoming keratinized. This process is called parakeratosis and is accompanied by abundant peeling. Of great importance in the development of psoriatic lesions on the skin are local immunopathological processes associated with the interaction of various cytokines - tumor necrosis factor, interferon, interleukin, as well as lymphocytes of different subpopulations.
The trigger 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 body systems are closely related and cannot separately explain the mechanism of disease development.
There is no universally accepted classification of psoriasis. Traditionally, along with ordinary (vulgar) psoriasis, erythrodermic, arthropathic, pustular, exudative, guttate, palmoplantar forms are distinguished.
Normal psoriasis is clinically manifested by the formation of flat papules, clearly demarcated from 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 the papules are scraped off and is called the psoriatic triad. First, the "stearin stain" phenomenon appears, characterized by increased peeling during scraping, which makes the surface of the papule 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 scraping, the phenomenon of "blood dew" is observed - in the form of pointed, unconnected drops of blood.
The rash can be found on any part of the skin, but it is mainly localized on the skin of the knee and elbow joints and the scalp, where the disease often begins. Psoriatic papules are characterized by a tendency for peripheral growth and merging into plaques of various 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-grayish, stick together and form crusts that adhere tightly to the skin. The rashes themselves are brighter and more swollen than in ordinary psoriasis.
Psoriasis of the palms and soles can be observed as an isolated lesion or in combination with lesions in other locations. It manifests itself in the form of typical papulo-plaque elements, as well as hyperkeratotic, callous lesions with painful cracks or pustular rash.
Psoriasis almost always affects the nail plates. The most pathognomonic is the appearance of precise impressions on the nail plates, giving the nail plate a resemblance to thimbles. Nail loosening, brittle edges, discoloration, transverse and longitudinal furrows, deformations, 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 it occurs more often under the influence of irrational treatment. In erythroderma, the entire skin takes on a bright red color, becomes swollen, infiltrated and abundant peeling occurs. Patients suffer from severe itching and their general condition worsens.
Radiologically, in most patients, various changes in the osteoarticular apparatus are observed 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 leading symptom of this form of psoriasis is the appearance of pustules on the skin, which in dermatology are 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 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 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 reduction or disappearance of infiltration around the perimeter or in the center of the plaques.
Vulgar psoriasis is different from parapsoriasis, secondary syphilis, lichen planus, discoid lupus erythematosus, and seborrheic eczema. Difficulties arise in the differential diagnosis of palmoplantar and arthropathic psoriasis.
In 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 uncertain regarding the duration of the disease, duration of remission and exacerbations. The rash can persist for many, 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 worsening and spreading of skin rashes. That is why the main purpose of this article is to briefly describe the modern methods of treating this disease.
Today, there are a huge number of methods for the treatment of 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 cure does not arise - 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 prevalence of the rash and the general condition of the body. As a rule, treatment is complex and includes 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 folk methods.
External therapy
External drug therapy is of utmost importance for psoriasis. In mild cases, treatment begins with local measures and is limited to them. As a rule, drugs for local administration are less likely to have any side effects, but they are inferior in effectiveness compared to systemic therapy.
In the advanced stage, external treatment is carried out with great care in order not to worsen the condition of the skin. The more intense the inflammation, the lower the fat concentration 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 regressive phase, 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 therapy.
In modern conditions, when choosing a method of therapy or a certain drug, the doctor must be guided by official protocols and forms prepared by the competent health authorities. The Federal Drug Use Guideline (Issue IV) suggests steroid drugs, salicylic ointment, and tar preparations for topical treatment of patients with psoriasis.
We will mainly focus on the drugs listed in the manuals.
Hydration products.They soften the scaly surface of psoriatic elements, reduce skin tightening and improve elasticity. Use creams based on lanolin with vitamins. According to the literature, even after such mild exposure, clinical effects (reduction of itching, erythema and peeling) are achieved in a third of patients.
Salicylic acid preparations. 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 action of local steroids by improving their absorption, so it is often used in combination with them.
Tar preparations. They have been used for a long time in the form of 5-15% ointments and pastes, often in combination with other local drugs. We use greases with 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 experiences do not confirm this. Tar is superior to salicylic acid in its action and has anti-inflammatory, keratoplastic and anti-exfoliating properties. Its use in psoriasis is also due to its effect on cell proliferation. When prescribing tar preparations, one should take into account its photosensitizing effect and the risk of deterioration of kidney function in people with nephrological diseases.
Shampoos with tar are used to wash the hair.
Naphthalan oil. A mixture of hydrocarbons and resins, it contains sulfur, phenol, magnesium and many other substances. Naphthalene oil preparations have anti-inflammatory, absorbent, 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 therapy with retinoids. 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 strong corticosteroids. Side effects include itching and skin irritation. One of the advantages of this drug is its longer remission compared to GCS.
Synthetic hydroxyanthrones are currently 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 if it comes into contact with healthy skin, it can cause burns.
Mustard derivatives
They contain blister agents - mustard gas and trichlorethylamine. Treatment with these drugs is carried out with great caution, at first ointments with a low concentration are used on small lesions once a day. Then, if it is well tolerated, increase the concentration, area and frequency of use. Treatment is carried out under strict medical supervision, with weekly blood and urine analyses. 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. This last property determines the effectiveness of the drug for psoriasis. The drug relieves inflammation, reduces infiltration and peeling of psoriatic elements. Treatment is carried out for an average of one month. Aerosol and shampoo are used for treating patients with scalp lesions, and 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, the clinical effectiveness and tolerability of all dosage forms of zinc pyrithionate have been studied 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 data published in journals by leading specialists of these and other centers, clinical cure 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 is eliminated, and the erythema fades. Achieving a clinical effect so quickly leads, accordingly, to a rapid improvement in the quality of life of patients. The drug is well tolerated. Approved for use from 3 years of age.
Fats with vitamin D3. Since 1987, a synthetic preparation of vitamin D has been used for local treatment3. Numerous experimental studies have shown that calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, influences the factors of the immune system of the skin that regulate cell proliferation and has anti-inflammatory properties. There are 3 drugs from this group of different manufacturers on 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 class I, II, and according to J. Koo - even class III. When using these ointments, most patients (up to 95%) have a pronounced clinical effect. 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%. Positive experiences with the substance in children have been reported. The drug was applied twice a day, and the 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 means since 1952, when the effectiveness of the external use of steroids was first demonstrated. 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 research, the most commonly 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, removal of inflammatory infiltrate);
- epidermostatic (antihyperplastic effect on epidermal cells);
- antiallergic;
- local analgesic effect (elimination of itching, burning, pain, tightness).
Changes in the structure of GCS affected their properties and activity. Thus, a rather large group of drugs appeared that differ in their chemical structure and activity. Hydrocortisone acetate is not currently used in practice for psoriasis, but is used in clinical studies to compare it 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 drugs of the second class for psoriasis, flumetasone pivalate is most often used in combination with salicylic acid, and the most modern are non-fluorinated corticosteroids. Due to the minimal risk of side effects, ointments and creams with aclometasone 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, the group of fluorinated corticosteroids can be singled out. The pharmacoeconomic analysis of the use of these drugs (although not for psoriasis), which consists of the study of the price/safety/effectiveness relationship, according to the data, revealed favorable indicators for betamethasone valerate - rapid development of the therapeutic effect, lower cost treatment.
When treating psoriasis, you should start with lighter drugs, and in case of repeated exacerbations and ineffectiveness of the drugs used, stronger ones should be given. However, the following tactic is popular among American dermatologists: first, a strong GCS is used to achieve a quick effect, and then the patient is switched 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 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 side effects. Now the problem of low efficiency 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 increasing the effect of the drug is not solved 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 effects with effects on the hypothalamic-pituitary-adrenal system. With the above-mentioned modern non-fluorinated drugs, 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 fat, creating a film on the surface of the lesion, causes more effective resorption of the infiltration than other forms of dosage. The cream relieves acute inflammation better, moisturizes and cools the skin. The non-greasy base of the lotion ensures its easy distribution over the surface of the scalp without sticking to the hair.
According to literature data, 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. Udzhukhuu, the most favorable "efficacy/safety" ratio can be achieved with the use of hydrocortisone butyrate. Pronounced clinical effect when using this drug combined with good tolerability - the authors did not observe any side effects in any of the patients who underwent treatment, even when applied to the face. With 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 the 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) suggest graded therapy with corticosteroids 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 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, affordability and lack 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 long-term use of steroid ointments, addiction develops. Abrupt discontinuation 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 - from 1 to 6 months.
In psoriasis, combinations of steroid hormones with salicylic acid are the most effective. Salicylic acid, due to its keratolytic and antimicrobial action, complements the dermatotropic activity of steroids.
It is convenient to apply combined lotions with corticosteroids and salicylic acid to 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 should 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 treatment and prolong remission.