Psoriasis is an autoimmune disease with an adverse combination of genesis factors with a recurring course, a variety of phenotypes, clinical varieties and the possible detection of various chronic diseases later.According to literature, the prevalence of world psoriasis is 4-7%.
According to K. Reich, the slight forms of the disease that affect less than 3-5% of the body area and do not give significant changes in the patient's immune state, require only local treatment.The psoriasis of the moderate and serious course is a systemic and inflammatory process, which leads to the development of concomitant or worsening pathologies, and themselves have a huge impact on the patient's health and quality of life.
The problem of psoriasis treatment does not lose its relevance and, despite the emergence of new modern treatment methods, it remains a difficult task that requires a personified approach.
For the treatment of psoriasis, there is a wide selection of local and systemic drugs, most of which model the immune system.When choosing personified therapy, the prevalence and severity of psoriasis, the stage of the process, its clinical form and the attitude towards the patient's disease are taken into consideration.Therefore, with the location of rashes in the open areas of the skin: the face, the hairy part of the head and brush, the disease has a significant effect on the quality of life and causes serious psycho -emotional experiences.According to the study of G. Krueger et al.(2001), 40% of patients with psoriasis were disappointed by the ineffectiveness of the resulting treatment and 32% considered insufficient treatment.
Psoriasis system therapy
Systemic glucocorticoids in the form of tablets are extremely rare in relation to numerous side effects.However, since the "ambulance" of the drug to stabilize the psoriatic process with a progressive phase, the erythroderma is advisable to use prolonged systemic glucocorticoids for intramuscular administration in the form of short courses.An approach similar to therapy avoids adverse side effects.
More than 40 years in the treatment of psoriasis, Methotrexate is used.The mechanism of its action is associated with the inhibition of dihydrofolatedustase, which transforms dihydrofolic acidum into tetrahydrofolic and is a donor of simple carbon groups in the synthesis of purine and timidized nucleotides necessary for the synthesis of the DNA.In this regard, the simultaneous purpose of folic acid helps to avoid metabolic anemia.
Cyclosporine, a-cyclic polypeptide, isolated by the Games of Mushroom Talypocladium swelling, has an immunosuppressive effect by suppressing the activity of the T cells and reducing their antigenic sensitivity due to the immune system.The drug has a high effectiveness in the treatment of psoriasis that flows slowly common, psoriatic erythroderm.
Since 1997, the aromatic retinoids of the second generation have been used to treat the refractory forms of psoriasis, the basis of whose chemical formula is Aciiretine.The drug inhibits the proliferation of epidermis cells, normalizes the keratinization process, has an immunomodulating effect.The effectiveness of the product depends on the dose: higher doses lead to a faster resolution of psorial eruptions.
Relatively recently, a new group of drugs has appeared: biological drugs, which include recombinant protein substances, synthesized by biotechnology by living cells of animals, plants and microorganisms.The indications for the prescription of biological drugs are serious forms of psoriasis resistant to other system drugs.
The treatment of moderate and serious forms of psoriasis (over 10% of the body surface) is carried out taking into account the conditions in which the patient has various chronic diseases such as metabolic syndrome, cardiovascular diseases, diabetes mellitus, non -alcoholic fat liver and lipid metal disorder.According to statistical studies, these conditions for psoriasis are observed more often than in a general population.Therefore, in the treatment of psoriasis, it is necessary to take into account the risk of side effects of the systemic therapy in progress, respectively, the conditions in which the patient has several chronic diseases that are detected individually in each patient.In fact, some drug drugs may negatively influence concomitant cardiovascular and metabolic diseases.The connection between psoriasis and cardiac-metabolic disorders has important clinical consequences.First, the systemic psoriasis therapy can negatively influence metabolic concomitant diseases, especially in the case of continuous and prolonged treatment.In particular, the Methotrexate should be prescribed with caution in obesity, diabetes mellitus, not alcoholic oily hepatic disease due to an increased risk of liver fibrosis.Cyclosporine, or can cause the appearance or aggravate the course of arterial hypertension, improve insulin resistance and influence the metabolism of fatty acids, has a toxic effect.
Acitrotine also promotes hypertriglyceridemia and/or hypercholesterolemia.Therefore, when patients with psoriasis are conducted, it is necessary to take into account all data.
A special place in the treatment of psoriasis is given phototherapy.The positive effect of ultraviolet radiation on the skin is associated with the selective inhibition of the T cell of immunity.According to literature, the following areas of the action of phototherapy are distinguished: anti -inflammatory, artificial inhibition of immunity and anti -caulifier.The effect of ultraviolet rays on immunity is associated with a depth of penetration.UFB rays influence epidermal keratinocytes and Langgan cells, UFA rays penetrate the deepest layers of the skin and have an effect on dermal fibroblasts, on dendritic cells and on the cells of the immune system.The positive effect of ultraviolet radiation is due to the apoptosis of the T cells, a decrease in the number of Langorganes cells, a change in cytokines, growth factors (EGF, Vegf), the adhesion and molecules of neuropeptids.The purpose of phototherapy is recommended for a common skin process.
In the treatment of psoriasis, photochemotherapy is used (project therapy), the combined use of long wave ultraviolet rays (UFA) (320–400 Nm) and photosensitizer (8-MetossyPsorallen).Puva therapy is one of the most effective methods for the treatment of psoriasis, its prescription is recommended with a common vulgar and exudative psoriasis, the stubborn course of the disease, severe infiltration.The treatment is carried out according to the 3 or 4 rack irradiation method per week, on average, the course is 20-30 procedures.
Currently, selective phototherapy, a combination of wave radiation (280–320 Nm) have lost its position and is prescribed less and less for the treatment of psoriasis.The indication for its purpose is psoriasis, characterized by formations with a low content of inflamed cells.
UFB therapy with a narrow lane with the peak of emissions at a wavelength of 311 Nm in high therapeutic efficiency is comparable to the bullet therapy, but unlike does not require the use of a photosensitizer.It is performed according to the 3-5-Rack irradiation method per week with a course of 20-30 procedures.
For the treatment of limited vulgar psoriasis in a stationary phase, a highly effective therapeutic technique is a laser eximmary, which allows you to provide high intensity monochromatic light of the wavelength of 308 Nm only in the affected area of the skin.
Local therapy
A fairly large selection of local products for the treatment of psoriasis includes, in particular, traditional ointments containing tar, NAFTANS, IQHHHYOL and salicylic acid.
When choosing topical therapy, an individual approach is important, on which the compliance of the patient will depend on psoriasis.Therefore, due to the cosmetic impossibility of treatment, 40% of patients are not compliant with the destination.
The effectiveness of topical corticosteroid drugs in the treatment of psoriasis is based on their effects pronounced on the modulation of immunity and on a decrease in the inflammation of the tissues.The action is associated with the mechanism of the hormones and receptors complex, which penetrates the nucleus of the target cell and increases the expression of the genes that encode the synthesis of peptides that inhibit the activity of phospholipase.This mechanism leads to a decrease in the formation of inflammation mediators from phospholipids.Combined corticosteroid ointments and salicylic acid creams are particularly preferred.The preparations of local corticosteroids are not shown for prolonged continuous treatment and suggest combinations and rotation patterns, since prolonged use can lead to the development of side effects, such as skin atrophy, hypertrichosis, telangectasia, steroid acne and oppression of adrenal function.
The synthetic analogues of vitamin D3 have established themselves well as highly effective means against psoriasis.The most famous in this group are calcipotorol.The principle of action of the drug is based on the effect of the softening of keratinized skin with vitamin D3: it inhibits the proliferation of keratinocytes and model the differentiation of the skin and also has an immunomodulating effect, in particular, reducing 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 the treatment.
Unlike topical steroids, long -term use of this group of drugs is possible.To obtain the maximum therapeutic effect, the combined purpose of calcipotorol and topical steroids is possible.
The action of the local calcineurin inhibitors (Takrolimus and Pimecrolimus) is associated with the blocking of the transduction of the signal of T lymphocytes by inhibiting the calcineurin.It is advisable to prescribe this group of drugs in case of location of rashes on the face, because they have no side effects such as topical steroids.
The value of the use of mitigating agents, in the treatment of psoriasis, is not in doubt: they soften the skin, reduce peeling and dryness, increase its hydration, especially after ultraviolet exposure;contribute to a decrease in itching.The major effect is obtained when applying to wet skin after contact with water (bathroom, shower).The use of mitigating agents in the complex psoriasis therapy reduces the total cost of treatment due to the achievement of the stabilization of the disease and the beginning of remission in shorter periods, which helps to reduce the stay of patients in the hospital.
Therefore, the problem of the treatment of psoriasis maintains its relevance and remains a global task, aimed mainly at a personified approach to therapy, on which the compliance of the patient with psoriasis and prospective patients will depend, taking into account coordinities.