Psoriasis is an autoimmune disease with an adverse combination of genesis factors with a recurrent course, various phenotypes, clinical varieties and the possible detection of various simultaneously subjected to chronic diseases.According to literature, the spread of psoriasis in the world is 4-7%.
According to K. Reich, mild forms of the disease, which affect less than 3-5% of the body area and do not give significant changes in the patient's immune status, require only topical treatment.Psoriasis of the moderate and severe course is a systemic, inflammatory process that leads to the development of concomitant pathologies or worsening of them and they themselves have a huge impact on the health and quality of life of the patient.
The problem with the treatment of psoriasis does not lose its relevance, and despite the emergence of new modern methods of treatment, it remains a difficult task that requires a personified approach.
For the treatment of psoriasis, there is a wide selection of topical and systemic drugs, most of which model the immune system.When choosing personalized therapy, the spread and severity of psoriasis, the stage of the process, its clinical form, and the attitude to the patient's disease is taken into account.So, with the location of rashes in the open areas of the skin - the face, the hairy part of the head and the brush, the disease has a significant effect on the quality of life and causes severe psycho -emotional experiences.According to the study of G. Krueger et al.(2001), 40% of patients with psoriasis were disappointed with the ineffectiveness of the treatment received, and 32% considered treatment insufficient.
Systemic therapy of psoriasis
System glucocorticoids in tablet form are extremely rare in connection with multiple side effects.However, such as the drug "ambulance" to stabilize the psoriatic process with a progressive stage, erythroderma is advisable to use prolonged systemic glucocorticoids for intramuscular administration in the form of short courses.Such an approach to therapy avoids adverse side effects.
Metotrexate has been used in the treatment of psoriasis for more than 40 years in the treatment of psoriasis.The mechanism of its action is associated with the inhibition of dihydrofolateradese, which converts the acid dihydrophole into tetrahydropholic and is a donor of simple carbon groups into the synthesis of Purin nucleotides and thymidilate required for DNA synthesis.In this regard, the simultaneous purpose of folic acid helps to avoid metabolic anemia.
Cyclosporine, an acyclic polypeptide, isolated from the fungus of the fat inflatum GAMS, has an immunosuppressive effect by suppressing the activity of T cells and a decrease in their antigenic sensitivity due to the immune system.The drug is highly effective in the treatment of a common slow flowing psoriasis, psoriatic erythroderma.
Since 1997, second -generation aromatic retinoids have been used to treat refractory forms of psoriasis, the basis of the chemical formula of which is acithretin.The drug inhibits the proliferation of the cells of the epidermis, normalizes the process of keratinization, has an immunomodulatory effect.The effectiveness of the product depends on the dose: the higher doses lead to the faster resolution of psoriatic rashes.
A new group of medicines has recently emerged - biological drugs that include recombinant protein substances synthesized by biotechnological from living cells of animals, plants and microorganisms.Indications for prescribing biological drugs are severe forms of psoriasis resistant to other systemic drugs.
Treatment of moderate and severe forms of psoriasis (more than 10% of the body surface) is performed taking into account the conditions in which the patient has several chronic diseases such as metabolic syndrome, cardiovascular disease, diabetes mellitus, non-alcoholic fatty liver and lipid metabolic disorders.According to statistical studies, such conditions for psoriasis are observed more frequently than in a general population.Thus, in the treatment of psoriasis, it is necessary to take into account the risk of the side effects of current systemic therapy, respectively, the conditions in which the patient has several chronic diseases that are detected separately in each patient.In fact, some pharmacological drugs can adversely affect cardiovascular and metabolic concomitant diseases.The relationship between psoriasis and cardiovascular disorders has important clinical effects.First, systemic therapy of psoriasis can adversely affect metabolic concomitant diseases, especially in the case of continuous and prolonged treatment.In particular, methotrexate should be prescribed with caution in obesity, diabetes mellitus, not alcohol fatty liver disease due to the increase in the risk of liver fibrosis.Cyclosporin can either cause the appearance or worsen the course of arterial hypertension, enhance insulin resistance and affect the metabolism of fatty acids, has a toxic effect.
Acytotin also promotes hypertriglyceridemia and/or hypercholesterolemia.Thus, when conducting patients with psoriasis, it is necessary to take into account all the data.
Phototherapy is given a special place in the treatment of psoriasis.The positive effect of ultraviolet radiation on the skin is associated with the selective inhibition of T cells of immunity.According to the literature, the following areas of phototherapy are distinguished: anti -inflammatory, artificial inhibition of immunity and anti -mass.The effect of ultraviolet rays on immunity is associated with penetration depth.UFB rays affect epidermal keratinocytes and Langean cells, UFA rays penetrate the deeper layers of the skin and have an effect on dermal fibroblasts, dendritic cells and cells of the immune system.The positive effect of ultraviolet radiation is due to the apoptosis of T cells, a decrease in the number of cells of langengans, change in cytokines, growth factors (EGF, VEGF), adhesion and neuropeptides.The purpose of phototherapy is recommended for a common skin process.
Photochimotherapy (bullet therapy) is used in the treatment of psoriasis-the combined use of long waves (UFA) (320-400 nm) and photosensitizer (8-methoxyorale).PUVA therapy is one of the most effective methods of treating psoriasis, its recipe is recommended with ordinary vulgar and exudative psoriasis, stubborn course of the disease, severe infiltration.Treatment is performed according to the methodology of 3- or 4-range irradiation per week, the average course is 20-30 procedures.
Currently, selective phototherapy, a combination of wave radiation (280-320 nm) has lost its position and is prescribed less to treat psoriasis.The indication of its purpose is psoriasis, characterized by low -inflamed cell formations.
Tight -lane UFB therapy with a 311 Nm emissions peak at high therapeutic efficiency is comparable to the bullet therapy, but in contrast it does not require the use of a photosniostelizer.It is performed according to the radiation methodology of 3-5 rockets per week with a course of 20-30 procedures.
For the treatment of restricted vulgar psoriasis in a stationary stage, the highly effective therapeutic technique is an exiration laser that allows to deliver monochromatic light with a high intensity of a wavelength of 308 nm only to the affected area of the skin.
Local therapy
Quite a large selection of local psoriasis treatment products includes, in particular, traditional ointments containing tar, naphthalan, ichthyol and salicylic acid.
When choosing local therapy, an individual approach is an important approach on which the patient with psoriasis will depend.So, due to cosmetic inability to treat, 40% of patients do not respond to the destination.
The effectiveness of topical corticosteroid drugs in the treatment of psoriasis is based on their pronounced effects on the modulation of immunity and the reduction of inflammation of the tissues.The action is related to the mechanism of the complex of hormones and receptors, which penetrates the core of the target cell and increases the expression of genes encoding the synthesis of peptides inhibiting the activity of phospholipase.This mechanism leads to a decrease in the formation of mediators of inflammation by phospholipids.Combined corticosteroid ointments and salicylic acid creams are particularly preferred.Local corticosteroid preparations are not indicated for prolonged continuous treatment and suggest combined and rotary regimens, as prolonged use can lead to the development of side effects such as skin atrophy, hypertrichosis, telangiectasia, steroid acne and adrenal protection.
Synthetic analogues of vitamin D3 have established themselves well as highly effective remedies for psoriasis.The most famous of this group are calcipotriol.The principle of action of the drug is based on the effect of softening keratinized skin with vitamin D3: it inhibits keratinocyte proliferation and modeled skin differentiation, and also has an immunomodulatory effect, in particular reduces the expression of IL-2 and information.Calcipotriol has a cumulative effect and therefore the therapeutic effect is observed after 1-2 weeks.From the beginning of treatment.
Unlike local steroids, long -term use of this group of medicines is possible.In order to achieve maximum therapeutic effect, the combined purpose of calcipotriol and topical steroids is possible.
The action of local calcineurin inhibitors (Takrolimus and PimeCrolimus) is associated with the blockage of T-lymphocyte signal transduction by inhibition of calcineurine.It is most advisable to prescribe this group of medicines in case of localization of face rashes as they do not have such side effects as local steroids.
The value of using mitigating agents in the treatment of psoriasis is of no doubt: they soften the skin, reduce peels and dryness, enhance its hydration, especially after ultraviolet exposure;contribute to reducing itching.The largest effect is achieved by applying wet skin after contact with water (bath, shower).The use of mitigating agents in complex therapy of psoriasis reduces the total cost of treatment as a result of the stabilization of the disease and the onset of remission in shorter periods, which helps to reduce patients in the hospital.
Thus, the problem of treating psoriasis retains its relevance and remains a complete task, aimed primarily at a personalized approach to therapy, on which the patient with psoriasis and prospective patients will depend, taking into account the coordinity.