Psoriasis and its modern treatments

psoriasis(lichen scaly) is a chronic, very common skin disease known since ancient times. Its prevalence in different countries ranges from 0. 1% to 3%. However, these figures only reflect the proportion of psoriasis in patients with other skin diseases or the frequency of psoriasis in patients with medical diseases. Since the disease is usually localized and inactive, patients usually do not seek help from medical institutions and therefore are not registered anywhere.The main pathogenic link that causes rashes is the enhanced mitotic activity and accelerated proliferation of epidermal cells, which causes the lower cells to "push out" the upper cells and prevent their keratinization. This process is called parakeratosis and is accompanied by extensive peeling. Of great importance in the development of cutaneous psoriatic lesions are local immunopathological processes related to the interaction with various cytokines (tumor necrosis factor, interferons, interleukins, and various subpopulations of lymphocytes).The trigger for the onset of the disease is often severe stress—a factor present in most patients' medical histories. Other triggers include skin trauma, drug use, alcohol abuse and infections.Many diseases of the epidermis, dermis and various systems of the body are closely related, and the mechanism of disease occurrence cannot be explained alone.There is no universally accepted classification of psoriasis. Traditionally, in addition to ordinary (vulgar) psoriasis, erythrodermic, arthrotic, pustular, exudative, guttate, palmoplantar types are distinguished.The clinical manifestations of normal psoriasis are the formation of flat papules that are clearly demarcated from healthy skin. The papules are pink and covered with loose silvery white scales. From a diagnostic standpoint, there is an interesting set of symptoms that appear when a pimple is scratched, called the psoriasis triad. First, the phenomenon of "stearin spots" appears, which is characterized by increased peeling when scratched, making the surface of the papule look like a drop of stearin. After removing the scales, a "final film" phenomenon can be observed, which is characterized by a moist and shiny component surface. Later, with further scraping, the phenomenon of "blood dew" can be observed - in the form of needle-shaped, unmerged droplets of blood.The rash can appear on any part of the skin, but is mainly concentrated on the skin of the knees, elbows, and scalp, where the disease most commonly occurs. 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 skin.With exudative psoriasis, the nature of the peeling changes - the scales turn yellow-grey, stick together to form scabs that adhere tightly to the skin. The rash itself is brighter and more swollen than regular psoriasis.Psoriasis on the palms and soles of the feet may be observed as isolated lesions or in association with lesions elsewhere. It presents with a typical papulopuclear component, as well as hyperkeratotic, callus-like lesions with painful fissures or pustular rashes.Psoriasis almost always affects the nail plate. The most characteristic are pinpoint indentations that appear on the nail plate, making it look like a thimble. Nail loosening, brittle edges, discoloration, transverse and longitudinal grooves, deformation, thickening, and subungual hyperkeratosis may also be observed.Psoriatic erythroderma is one of the most severe forms of psoriasis. It can occur due to the gradual progression of the course of psoriasis and the fusion of plaques, but more often it occurs under the influence of inappropriate treatment. When suffering from erythroderma, the entire skin is bright red, swollen, infiltrated, and has a large amount of peeling. Patients suffer from severe itching and worsening of their general condition.Radiographically, various changes in the bony joint apparatus are observed in most patients, but there are no clinical symptoms of joint damage. These changes include periarticular osteoporosis, joint space narrowing, osteophytes, and cystic clearance of bone tissue. Clinical manifestations can range from mild arthralgia to progression to disabling ankylosing arthropathy. Clinical findings include joint swelling, redness of the skin in the affected joint area, pain, limited movement, joint deformity, ankylosis, and mutilation.Pustular psoriasis presents as a generalized or localized rash, mainly on the skin of the palms and soles of the feet. Although the main symptom of this form of psoriasis is the appearance of pustules on the skin, considered in dermatology to be a sign of pustular infection, the contents of these blisters are usually sterile.Guttate psoriasis occurs most often in children and is associated with a sudden appearance of a rash of small papules scattered throughout the skin.Psoriasis occurs about equally in men and women. Most patients develop the disease before age 30. In many patients, the exacerbation of the disease is related to the time of year: the disease worsens more often in the cold seasons (winter type) and much less often in the summer (summer type). In the future, this reliance may change.Psoriasis has 3 stages: progressive, quiescent and regressive. The progressive stage is characterized by peripheral growth and appearance of new lesions, especially at the site of previous lesions (isomorphic Kobner reaction). During the regression phase, the infiltrate around or in the center of the plaque decreases or disappears. Psoriasis vulgaris is different from parapsoriasis, secondary syphilis, lichen planus, discoid lupus erythematosus, and seborrheic eczema. The differential diagnosis of palmoplantar psoriasis and arthropathic psoriasis is difficult.For psoriasis vulgaris, the life prognosis is good. In the case of erythroderma, arthropathy, and generalized pustular psoriasis, disability and even death may occur due to exhaustion and the development of severe infection.Prognosis regarding disease duration, duration of remission and exacerbation remains uncertain. The rash can persist for long periods of time, even for many years, but more commonly worsening alternates with periods of improvement and clinical recovery. In a substantial proportion of patients, particularly those who do not receive intensive systemic therapy, a prolonged, spontaneous period of clinical recovery is possible.Unreasonable treatment, self-medication, and seeking help from "doctors" will worsen the course of the disease and cause the rash to worsen and spread. That is why the main purpose of this article is to briefly describe modern methods of treating this disease.Today, there are many ways to treat psoriasis; there are thousands of different medications used to treat the disease. But this just means that none of these methods are guaranteed to work, nor can they completely cure the disease. Furthermore, the question of cure has not been raised - modern treatments can only minimize the cutaneous manifestations without affecting many currently unknown causative factors.Treatment of psoriasis takes into account the form, stage, and prevalence of the rash, as well as the general condition of the body. Generally, treatment is complex and involves a combination of external and systemic medications.The patient's motivations, family situation, social status, lifestyle, and alcoholism are very important in treatment.Treatment methods can be divided into the following aspects: external therapy, systemic therapy, physiotherapy, climatic therapy, alternative therapies and folk remedies.

external treatment

Topical medication is crucial for psoriasis. In mild cases, treatment begins with and is limited to local measures. In general, topical medications are less likely to cause any side effects, but are not as effective as systemic treatments.In advanced stages, external treatments need to be done very carefully to avoid worsening the skin condition. The more severe the inflammation, the less concentrated the ointment should be. Usually at this stage, psoriasis treatment is limited to special creams, 0. 5-2% salicylic acid ointments and herbal baths.During the resting and resolving phases, it is necessary to use more active drugs - 5-10% naphthalene ointment, 2-5% salicylic acid ointment, 2-5% sulfur tar ointment, and many other treatments.In modern conditions, when choosing a treatment or a specific drug, doctors must follow the guidance of official protocols and formularies established by the health authorities. The Federal Guidelines for the Use of Drugs (Issue IV) recommend the use of steroid medications, salicylic acid ointments, and tar preparations for topical treatment of patients with psoriasis.We will focus mainly on the drugs labeled in the manual.moisturizer.Softens the flaky surface of psoriasis ingredients, reduces skin tightness and improves elasticity. Use lanolin cream that contains vitamins. According to the literature, clinical results (reduced itching, erythema, and peeling) are achieved in one-third of patients even after such mild exposure.Salicylic acid preparations. An ointment with a concentration of 0. 5 to 5% salicylic acid is usually used. It has antiseptic, anti-inflammatory, keratogenic and keratolytic effects and can be used in combination with tar and corticosteroids. Salicylic acid ointments can soften the flaky layer of psoriasis components and can also enhance the effects of topical steroids by promoting their absorption, so they are 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 topical medications. In our country, an ointment containing wood tar (usually birch) is used, in some foreign countries - coal tar is used. 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 more active than salicylic acid and has anti-inflammatory, keratinogenic and anti-flaking properties. Its use in psoriasis also lies in its effect on cell proliferation. When prescribing tar preparations, its photosensitizing effects and the risk of worsening renal function in patients with renal disease should be considered.Shampoos containing tar are used to wash hair.naphtal 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 restorative properties. When treating psoriasis, 10-30% naphthalene ointments and pastes can be used. Naftalan oil is often used in combination with sulfur, Ichthyol, boric acid, and zinc paste. Topical Retinoic Acid Treatment. The first effective topical retinoid approved for the treatment of psoriasis. This drug has not yet been registered in my country. It is a water-based jelly available in concentrations of 0. 05 and 0. 1%. In terms of effectiveness, it is comparable to potent corticosteroids. Side effects include itching and skin irritation. One of the advantages of this drug is its longer duration of relief compared with GCS.Currently, synthetic hydroxyanthrones are used.Analog of natural rhubarb Robin, with cytotoxic and cytostatic effects, leading to a reduction in the activity of epidermal oxidative and glycolytic processes. As a result, the number of mitoses in the epidermis as well as hyperkeratosis and parakeratosis are reduced. Unfortunately, this drug has significant local irritation effects and burns may occur if it comes into contact with healthy skin.

mustard gas derivatives

They contain the foaming agents - mustard gas and trichloroethylamine. Use extreme caution when treating with these medications, starting by applying a small concentration of ointment to small lesions once a day. Then, if well tolerated, application concentration, area, and frequency can be increased. Treatment is carried out under close medical supervision, with weekly blood and urine tests. These drugs are virtually no longer used today, but they were very effective in the stable stages of the disease.zinc pyrithione. Active substances produced in the form of aerosols, creams and shampoos. It has antibacterial, antifungal and antiproliferative effects - it inhibits the pathological growth of epidermal cells in a state of hyperproliferation. This latter property determines the effectiveness of the drug in treating psoriasis. The drug relieves inflammation and reduces the infiltration and flaking of psoriatic components. Treatment lasts an average of one month. For the treatment of patients with scalp lesions, aerosols and shampoos are used, for skin lesions - aerosols and creams. The drug is used 2 times a day and the shampoo 3 times a week. my country has conducted research on the clinical effectiveness and tolerability of various dosage forms of zinc pyrithione since 1995. According to leading dermatology centers, the drug is 85-90% effective in treating psoriasis patients. According to data published in journals by leading experts from these and other centers, clinical cure is achieved by the end of 3-4 weeks of treatment. The effects appear gradually, but it is very important that by the end of the first week, from the moment you start using the drug, the results of the treatment are noticeable - the itching is sharply reduced, peeling disappears, and red spots become pale. Achieving clinical results so quickly results in a corresponding rapid improvement in patients' quality of life. The drug was well tolerated. Approved for use from 3 years of age.Ointment with vitamin D₃. Synthetic vitamin D preparations have been used in topical treatments since 1987₃. A large number of experimental studies have shown that calcipotriol can inhibit the proliferation of keratinocytes, accelerate their morphological differentiation, affect the factors of the skin immune system that regulate cell proliferation, and has anti-inflammatory properties. We have 3 medicines on the market from different manufacturers. Apply the medication to the affected skin area 1-2 times daily. Effectiveness of D ointment₃Approximately equivalent to the effectiveness of Class I, Class II corticosteroid ointments, and even Class III according to J. Koo. Most patients (up to 95%) experience significant clinical results when using these ointments. However, it may take quite a long time (1 month to 1 year) to achieve good results, and the affected area should not exceed 40%. Children have been reported to have positive experiences with the substance. The drug is used 2 times a day and significant effects are observed at the end of the fourth week of treatment. No side effects were found.corticosteroid drugs. Since topical steroids were first shown to be effective in 1952, they have been used in medical practice as topical medications. To date, approximately 50 topical glucocorticoid drugs have been registered on the pharmaceutical market. This undoubtedly makes it difficult to choose a doctor because the doctor must have information about all the drugs. According to the same survey, the most commonly used corticosteroids to treat psoriasis include combination medications.The therapeutic efficacy of topical corticosteroids is attributed to a number of potentially beneficial effects:

• Anti-inflammatory effect (vasoconstriction, reduction of inflammatory infiltration);
• Epidermal stabilization (anti-proliferative effect on epidermal cells);
• anti-allergy;
• Local analgesic effect (relieve itching, burning, soreness, tightness).

Changes in the structure of GCS affect their properties and activity. This is how a rather large group of drugs emerged, varying in chemical structure and activity. Currently, hydrocortisone acetate is actually no longer used to treat psoriasis; it is used in clinical studies to compare it with newly produced drugs. For example, it is believed that if the activity of hydrocortisone was taken as 1, the activity of triamcinolone acetonide would be 21 units and the activity of betamethasone would be 24 units. Among the second class of drugs used to treat psoriasis, the most commonly used is the combination of flumetasone pivalate and salicylic acid, and the most modern are non-fluorinated corticosteroids. Due to the minimal risk of side effects, ointments and creams containing aclomethasone are approved for the treatment of large areas of skin in sensitive areas (face, skin folds), children and the elderly. In the third class of drugs, 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), including a study of price/safety/efficacy ratios, revealed favorable indicators for betamethasone valerate - rapid development of therapeutic effects and lower cost of treatmenttreat.When treating psoriasis, you should start with lighter medications and then give stronger medications if the condition gets worse repeatedly and the medications you are using are ineffective. However, the following strategy is popular among U. S. dermatologists: first use stronger GCS to achieve rapid results and then switch patients to moderate or weaker drugs for maintenance treatment. In any case, powerful medications should only be used for short periods of time and in limited areas because side effects are more likely to occur when prescribed.In addition to this classification, drugs are also divided into fluorinated, difluorinated and non-fluorinated drugs of different generations. Non-fluorinated first-generation corticosteroids (hydrocortisone acetate) are generally less effective but safer with respect to adverse effects than fluorinated corticosteroids. Now, the problem of low effectiveness of non-fluorinated corticosteroids has been solved - a fourth generation of non-fluorinated drugs has emerged that are as strong as fluorinated drugs and as safe as hydrocortisone acetate. The problem of enhancing drug efficacy is not solved by halogenation, but by esterification. In addition to enhancing the effects, this also allows you to use your esterified medication once a day. It is currently the fourth generation non-fluorinated corticosteroid of choice for topical treatment of psoriasis.Standard side effects when using topical steroids are skin atrophy, hirsutism, telangiectasia, pustular infection, systemic effects affecting the hypothalamic-pituitary-adrenal system. These side effects can be kept to a minimum with the modern non-fluorinated medications mentioned above.Pharmaceutical companies are trying to diversify the dosage form range, producing GCS in the form of ointments, creams and lotions. Fatty ointments form a thin film on the surface of the lesion and absorb infiltration more effectively than other formulations. The cream better relieves acute inflammation, moisturizes and cools the skin. The lotion's fat-free base ensures that it distributes easily over the scalp surface without clinging to hair.According to literature data, for example, after 3 weeks of using mometasone, a positive therapeutic effect (60-80% reduction in the number of rashes) can be achieved in almost 80% of patients. According to V. Yu. Udzhukhu, the most favorable "efficacy/safety" ratio is achieved with hydrocortisone butyrate. The significant clinical effects when using this drug are combined with good tolerability - the authors did not observe any adverse effects in any of the patients treated, even when applied to the face. With long-term use of other corticosteroids, it is necessary to discontinue treatment due to the development of side effects. B. Bianchi and N. G. Kochergin believed that by comparing the results of clinical use of mometasone fluate and methylprednisolone acetate propionate, they found that these drugs have the same effect when applied externally. Many authors (E. R. Arabian, E. V. Sokolovsky) recommend staged corticosteroid treatment of psoriasis. It is recommended to start external treatment with a combination drug containing corticosteroids (such as betamethasone and salicylic acid). The average duration of this treatment is about 3 weeks. Subsequently, transition to pure GCS, preferably the third category (e. g. hydrocortisone butyrate or mometasone furoate).Patients are attracted to steroid drugs by their ease of use, ability to quickly relieve clinical symptoms of disease, accessibility, and lack of odor. Additionally, these medications do not leave oily stains on clothes. However, their use should be short-term to avoid worsening of the condition. Long-term use of steroid ointments can lead to addiction. Abrupt discontinuation of corticosteroids may result in exacerbation of skin disease. The literature suggests that the duration of response after topical corticosteroid treatment varies. Most studies show short-term relief - 1 to 6 months.For psoriasis, a combination of steroid hormones and salicylic acid is most effective. Salicylic acid complements the skin-loving activity of steroids due to its keratolytic and antibacterial effects.A combination corticosteroid and salicylic acid lotion is conveniently applied to the scalp. According to the authors, the effectiveness of the combination drug reaches 80 - 100%, while the skin is cleared very quickly - within 3 weeks.In summary, it should be said that in practice, the doctor always needs to decide whether to use only external treatments or combine them with any systemic treatment in order to increase the therapeutic effect and prolong the remission.