Psoriasis

What is Psoriasis?

Lime scab – chronic dermatosis, characterized by frequent relapses, the characteristics of which are skin rashes in the form of scaly papules. This is one of the most common skin diseases that can begin at any age. The course of psoriasis is long and persistent. With remissions of several months or years, the disease continues until the end of life. In exceptional cases, there is a spontaneous cure.

Pathogenesis during psoriasis

Psoriasis is a systemic process that is formed in patients not only with immune disorders, but also with pronounced morphological and functional changes in various organs and systems. Psoriasis is one of the most studied dermatoses. However, none of the existing hypotheses of psoriasis does not fully reveal the essence of the disease. However, the problems of treatment and prevention of this dermatosis face dermatologists as acutely as many years ago. At various times, various theories of the origin of psoriasis have been proposed. The following forms were highlighted:

  • hereditary
  • parasitic
  • allergic
  • infectious-allergic
  • exchange
  • autoimmune
  • infectious (including viral)
  • neurogenic
  • endocrine

Each of these theories is based on relevant clinical observations and the results of some laboratory tests. Infectious theory is one of the oldest theories of the origin of scaly lichen. At the end of the XIX century. there were known cases of extensive psoriatic lesions after acute febrile conditions such as influenza, scarlet fever. The systemic nature of the lesion, a long relapsing course, the connection of exacerbations with fluctuations of meteorological and heliophysical factors, some features of the evolution of psoriatic lesions, testified in favor of the infectious nature of the disease. Often, researchers have found a link between the relapse of the disease and the exacerbation of foci of focal infection.

It was assumed the relationship of psoriasis with syphilitic and tuberculosis infection. Some researchers believed that the microorganisms found by them in patients with psoriasis are the causative agents of this dermatosis. However, none of these theories could not withstand criticism. At the present time, the participation of various microorganisms in the development of psoriasis as inducers and modifiers of cellular and humoral reactions in the body is being actively discussed.

  • The hereditary theory is psoriasis in representatives of 2-5-6 generations, family cases of the disease.
  • The exchange theory is a violation of fat (cholesterol) metabolism, an elevated content of phosphorus, DNA and RNA in psoriatic scales, enzymopathies, a decrease in the incidence of disease during famine.
  • Viral Theory. The concept of the role of viral infection in the etiology of psoriasis arose on the basis of clinical observations. As far back as 1940, in a number of studies, scientists discovered peculiar acidophilic bodies called “elementary bodies”, which were located intra and extracellularly in the tissue fluid of psoriatic papules. In an experiment on guinea pigs and rabbits after they were “infected” with psoriatic material, the researchers managed to reproduce the morphological changes in the visceral organs in the form of fibrosis, degenerative changes and atrophy of parenchymal cellular elements. Currently, the search continues for viral agents capable of causing the development of the psoriatic process. When examining children with psoriasis using the polymerase chain reaction method, they found human papillomaviruses (HPV5 and HPV36b) in them. Thus, despite the complexity of the problem and the inconsistency of experimental data, from the current point of view there is reason to assume the viral nature of psoriasis. However, for the final confirmation of this theory, it is necessary to isolate and identify the virus.
  • Endocrine and exchange theories had in their time numerous supporters. In patients with psoriasis, various endocrine disorders have often been identified, which has led some researchers to explain the etiology and pathogenesis of this dermatosis from the perspective of endocrine theory. There were violations of the functional state of the gonads, the effects of the menstrual cycle, pregnancy, childbirth, the lactation period on the course of the disease, and also found marked changes in the pituitary-adrenal system in patients.
  • Neurogenic theory – the onset of the disease after a nervous shock. About 31% of patients associate the exacerbation of psoriasis with stress. Thus, in this category of patients, a significant decrease in the ability to resist stress and cope with their consequences was noted, and the existing asthenic, astheno-depressive, vegetative-vascular-dystonic and vegetative-vascular-visceral disorders with neurotic reactions in such patients contribute to the formation or aggravate the existing vicious circle.

Smoking also adversely affects the course of psoriasis. Associations of the disease with smoking in women have been established, as well as an increased risk of exacerbation of psoriasis in smoking men who have fallen into extreme situations. Alcohol causes an immune imbalance and induces changes in the capillaries of the skin, but the intimate mechanisms of the effect of ethanol on the epidermis in psoriasis are not fully understood. Cases of the occurrence or exacerbation of psoriasis after taking certain medications are described: terbi-nafina, captopril, anabolic steroid hormones, α- and β-interferons. More often than others, antibiotics (26%) caused exacerbation of psoriasis: tetracycline, penicillin, bicillin, chloramphenicol; nonsteroidal anti-inflammatory drugs (15%): butadione, ibuprofen, indomethacin, etc .; B vitamins (15%): thiamine bromide (B1), pyridoxine hydrochloride (B6), cyanocobalamin (B12); delagil, various cytostatics, vaccines, serums, β-blockers (13%). Psoriasis is often exacerbated or manifests (manifested) after taking β-blockers. In HIV-infected patients, a more severe course of psoriasis, characterized by frequent exacerbations, was observed. At the same time, the mechanisms of the provoking action of HIV infection in patients with psoriasis are not fully disclosed.

In psoriasis, under the influence of a hypothetical factor, a deep imbalance is formed in all parts of the cellular and humoral immunity. Changes in the immune system can lead to the involvement of a number of endogenous, in particular leukocyte antigens, in the formation of immune complexes in patients with psoriasis. In turn, immune complexes can directly damage tissues and, moreover, stimulate many humoral and cellular systems of the body, which is accompanied by excessive production of biologically active substances that are also involved in the defeat of the epidermis, thus closing the formed vicious circle in the chain of autoimmune reactions.

In addition to immunological, non-immune mechanisms may also be involved in the pathogenesis (developmental mechanism) of psoriasis. However, none of these theories makes it possible to explain all cases of psoriasis. According to modern concepts, the main role in the development of psoriasis is played by hereditary factors. The so-called latent (hidden) psoriasis is inherited. By this definition is meant a genetically determined predisposition, which is manifested in disorders of cellular metabolism, in particular, in changes in the exchange of nucleic acids in the epidermis. Modification of metabolic processes (metabolism) is observed in both affected and clinically and histologically healthy skin, not only in patients with psoriasis, but also in healthy family members. The result of the interaction of hereditary and provoking factors is the acceleration of reproduction and the lack of maturation of cells in the epidermis (pathological acceleration), as well as circulatory disturbance occurring in the papillary dermis.

Symptoms of Psoriasis

The primary elements on the skin are flat inflammatory papules. It is sharply limited, reddish-pink towering seals. Their surface is covered with dry, loosely located, easily falling silvery-white scales. The peculiar morphological structure of psoriatic papules determines the triad of symptoms pathognomonic for psoriasis, which is determined by scraping the surface of the papule with a nail or a scalpel.

Initially, due to crushing of flakes, a pattern is observed that resembles that when scraping a frozen drop of stearin, a sign of a stearic stain. Then, due to the fact that between the prickly and horny layers there is no granular layer connecting them, the compact layers of the horny plates are separated in the form of a film, exposing the wet surface of the spinous layer (a sign of a psoriatic film). Further slight scraping leads to damage to the capillaries in the elongated papillae, with the release of droplets of blood (a symptom of blood dew, a symptom of point bleeding).

The lesion begins with a rash of miliary papules, which, gradually increasing along the periphery, turn into lenticular and nummular, merge with each other and form a different-sized plaque. In the development of the psoriatic process on the skin, three stages can be identified.

The first stage is progressive, which is caused by the appearance of new papules on the skin and an increase in the size of existing elements with the formation of an erythematous border around the lesions, which is called a peripheral growth zone. The marginal zone of the plaque is free from peeling. It, being the final stage of the inflammatory process, as if not keeping pace with the growth of psoriatic elements.

In the acute phase of psoriasis, the formation of psoriatic papules can occur on the spot, even minor trauma to the skin (Kebner symptom) – with sunburn, rubbing irritating ointments, injection with an injection needle, scratches, etc. skin, in stressful situations. So psoriatic erythroderma is formed. Over time, the development of new papules and peripheral growth of elements is completed, the peeling can increase up to the defeat of the entire surface of the skin or mucous membrane, and psoriasis flows in the stationary period.

In this stage, the emergence of new elements ceases, but the size of existing papules and plaques remain unchanged. Education papules can end at any stage. Therefore, in the stationary period, both nummular and lenticular and even miliary papules can be seen simultaneously. Often there is a common rash, papules can be lenticular in size, and this is where the development of the process stops. This course of psoriasis is usually determined by local infection in the tonsils (tonsillogenic psoriasis). In the stationary period, after cessation of papule growth, a gentle folding of the stratum corneum 2–7 mm wide is often formed around it. After resorption of psoriatic lesions, temporary hypopigmentation (leucoderma or a lighter skin area) appears, less often – hyperpigmentation (darker skin area).

The third stage is regressive (reverse), one of the main signs of which is the gradual disappearance of lesions with the appearance of a pseudosclerotic whitish rim (Voronov’s rim) around the lesions. Only a small number of patients have a slight itch. Subjective feelings are mild or may be absent altogether. The resolution of psoriatic elements is carried out in their central part.

Semicircular shapes appear, which are characteristic of the progressive period of psoriasis. It is also taken into account that the central resolution of psoriatic plaques may be accompanied by their peripheral growth. In such cases, determine the diagnosis of progressive psoriasis. The different mutual arrangement of psoriatic elements of various sizes, their peripheral growth and resolution in the center lead to the formation of extensive foci of garland-like outlines, which at times resemble a geographical map. Rashes can occur anywhere on the skin, but mostly located on the extensor surfaces of the limbs, especially the knee and elbow joints, in the sacrum, and scalp, especially on the edge of hair growth (“psoriatic crown”). The structure of hair in psoriasis does not change, and the hair does not fall out.

On the extensor surface of the elbow and knee joints, plaques are very often saved for an indefinitely long period of time after the resolution of the rest of the rash (the so-called “duty” plaques). In some patients, there is a lesion of the skin folds (axillary, under the mammary glands, inguinal-femoral), and often it can be isolated. In the latter, due to increased humidity, there is no flaking, and the lesions resemble infectious (for example, streptococcal or candidal) diaper rash. The clinical signs of psoriasis are manifested by severe infiltration, the absence of a horn corolla along the peripheral surface of the plaque and the ability to detect two symptoms of the psoriatic triad – the psoriatic film and blood dew.

One of the features of the rash is symmetry and prevalence (this is typical for the clinic of vulgar psoriasis). Sometimes, as a result of a pronounced, progressive course of the process, in the absence of a resolution, a continuous lesion of the skin of large areas of the body (diffuse psoriasis) and even of the entire skin (universal psoriasis) is formed. In rare cases, the elements of the rash are located on a limited area of ​​the skin (scalp, penis) stripes, asymmetrically, on one half of the body. Psoriasis in children is recognized by the appearance of not nodules, but erythematous foci, most often in the folds of the skin. Sharply outlined pink-red areas tend to peel off. But at times, when the exudation characteristic of children is manifested, maceration and detachment of the horny layer along the periphery can be observed, which may be similar to diaper rash. In children, rash appears in places not typical for psoriasis (face, natural folds, genitals). Often, the first rash forms on the scalp, where, against the background of a slightly infiltrated erythema, clusters of crusty scales form. The most common rashes are located on the red border of the lips, the mucous membrane of the cheeks, tongue. Clinic of lesions of the oral mucosa in psoriasis depends directly on the form of the disease. If a psoriatic plaque forms at the bottom of the oral cavity, then the lesion may be irregular in outline, its surface looks like a sticky film. There is always an inflammatory corolla around such a hearth. In very rare cases, a burning sensation may be associated with psoriatic lesions. Rashes in the mouth are expressed during the exacerbation of the psoriatic process on the skin, however, rashes on the mucous membrane of the mouth disappear and the skin is not always a lump sum. In pustular psoriasis, the mucous membrane is drawn into the process much more often than in normal form. It affects mainly language. In addition to the described classical picture of psoriasis, there are its various variants and quite special forms of the course of the disease in the form of arthritis and erythroderma. Pustular psoriasis is manifested by purulent elements of a superficial nature. There are pustular psoriasis disseminated (type Zumbusha) and palms and soles (type Barber).

Irritated psoriasis. As a result of interaction on the skin of patients with progressive psoriasis, sun rays, irritating ointments, or any other irritants, the plaques become cherry-red in color, become more convex, and a wide hyperthemic belt appears around them, which lubricates the sharpness of the boundaries (after the plaque resolves, it becomes wrinkled ).

Spotted psoriasis. It is manifested by mild infiltration of elements of the rash, which are seen not as papules, but as spots. Formed usually sharp and similar to toksidermiya. The most important differential diagnostic technique is the identification of the psoriatic triad.

Seborrheic psoriasis. Manifested in patients with seborrhea. On the scalp, as well as behind the auricles in the nasolabial folds, on the chest, scapular and subscapular areas of the back, psoriatic scales are saturated with sebum, stick together, stick to the surface of plaques, simulating a picture of seborrheic eczema.

Old psoriasis. This form of the disease can be described by pronounced infiltration of plaques, their bluish color, warty and hyperkeratotic surface. Such foci of psoriasis with great difficulty are treated, and sometimes, extremely rarely, are transformed into a malignant tumor.

Exudative psoriasis. This form of the disease is represented by an excessively pronounced exudative component of the inflammatory response in the progressive period of the disease. Exudate, making its way to the surface of the papule, saturates the accumulation of scales, turning them into formations similar in appearance to the crusts. These secondary elements of the skin rash are called flaky crusts, while having a yellowish color. After their removal, a weeping, slightly bleeding surface is exposed. Drying and layering on each other, scale-crusts can form a dense massive conglomerate, similar to an oyster shell (rupioid psoriasis).

Palmar and plantar psoriasis. It can be detected either by ordinary psoriatic papules and plaques, or by hyperkeratotic, simulating corns and callousness. Sometimes there is a continuous damage to the surface of the skin of the palms or soles in the form of increased keratinization, thickening.

The boundaries of such a lesion are distinct (a characteristic feature of psoriatic plaques). In other rare cases, the palmar and plantar psoriasis may be limited to coarse-shaped peeling.

Psoriasis of the nails. There are three forms of nail damage: atrophic, pinpoint, hypertrophic onycho-dystrophy. A point lesion is described as the formation of pinholes in the nail plates that resemble a working surface of a thimble. Another manifestation of nail psoriasis is extremely similar to onychomycosis: the nail plate from the free edge is modified in color, characterized as dull, easily crumbled. A sign that in these cases can distinguish psoriasis from onychomycosis is an inflammatory rim around the periphery of the affected part of the nail, which is the edge of the papule in the nail bed, translucent through the nail plate. In the atrophic form of onychodystrophy, thinning of the substance of the nail without prior inflammatory changes becomes noticeable. The nail plate gradually becomes significantly thinner, separates from the nail bed, gradually disappears, leaving a small gray residue at the hole. Psoriasis of the mucous membranes is extremely rare. In normal psoriasis, the mucous membrane of the mouth is seized in 2% of patients, most often the rash is located on the tongue, cheeks, lips. Irregular oval shapes appear, bulging above the surrounding mucosa, sharply delimited nodules of a grayish-white color with a pink rim around. At an established stage of its development, the rash can be covered with a whitish, loose patina, which can be easily removed with a spatula. After the removal of such a plaque, a bright red surface is exposed with signs of point or parenchymal hemorrhage.

Psoriatic arthritis. In some patients with psoriasis due to infiltration of periarticular tissues, a lesion of the joints occurs (arthropathic psoriasis). The predominantly interphalangeal joints are affected, but large joints can also be drawn into the pathological process and, very rarely, the sacroiliac joints and the joints of the spine. Initially, patients complain only of pain in the joints (arthralgia), then their swelling is formed, movements are limited, subluxations and dislocations can occur. On radiographs, osteoporosis and narrowing of the joint space are visible.

The process can end with ankylosis and persistent deformities of the joints, which leads to disability. It must be remembered that, unlike other arthritis (inflammation of the joints), psoriatic arthritis is formed in the presence of psoriatic rash, which can often be accompanied by damage to the nails, and also that its onset coincides with the exacerbation of the skin process, which usually acquires nature of exudative psoriasis.

Psoriatic erythroderma. In some patients with psoriasis, most often in the progressive period under the pressure of various irritating factors (autointoxication, vigorous rubbing of the skin with a washcloth, solar irradiation, hot baths, irrational treatment), body temperature can suddenly increase and erythema (red rashes) develop. Initially, they are formed on psoriatic rash-free areas of the skin, then they are combined into continuous erythroderma. Papules and plaques are indistinguishable. The affected skin flakes off strongly with thin lamellar scales; Often hair falls out, nails thicken and easily exfoliate. After a few weeks, erythroderma ends and the usual pattern of psoriasis is restored. In most patients, the disease is characterized by seasonality.

Relapses occur in the autumn-winter (winter form) and spring-summer (summer form) periods. This fact must be known when prescribing a course of treatment, including a sanatorium.

Psoriasis diagnosis

In typical cases, based on the presence of a triad of psoriatic phenomena, on the clinical characteristics of lesions. In the differential diagnostic relation, erythroderma presents great difficulties, especially when it occurs in children. In adults, it is most difficult to diagnose psoriatic lesions of the oral mucosa.

Psoriasis treatment

There are more than 20 different schemes and techniques that have a positive effect in psoriasis, but none of them allowed for a complete cure of dermatosis. The lack of a unified concept of the etiopathogenesis of psoriasis, data on the multifactorial nature of dermatosis cause a variety of drugs and methods for treating the disease in patients. In the recent past, the treatment of patients with this dermatosis was rather symptomatic in nature; at present, it is safe to say about evidence-based pathogenetic therapy for psoriasis. General and external treatment is performed taking into account the stage of the process, seasonality, clinical type of the disease.

In the past, various means were used to treat psoriasis: injections of milk, sulfur, oxygen injections, cystine, D-lactic acid solution, antipsoriatikum preparations, psoriasin preparations, glycerin extracts from psoriatic scales and plaques, specific vaccine, Fowler fluid. In addition, X-ray irradiation of the thyroid and helical glands, indirect radiotherapy were used. However, none of the above methods have found any use for themselves due to lack of effectiveness or high frequency of side effects. The general treatment of patients with advanced psoriasis in the progression stage has long been proposed to be carried out with calcium preparations that provide anti-inflammatory, hyposensitizing and membrane stabilizing effects.

Preparations of sodium, potassium, and magnesium — potassium chloride, sodium thiosulfate, and also potassium asparaginate — have a stimulating effect on the adrenal cortex and normalize tissue metabolism. Sodium thiosulfate also has a pronounced anti-inflammatory, detoxifying and hyposensitizing effect, stimulates the function of the adrenal cortex.

Calcium preparations normalize adenylate cyclase activity, decrease capillary permeability. Of calcium salts, gluco-nat, glycerophosphate, chloride, pantothenate, lactate are used. In the treatment of patients with psoriasis, magnesium sulfate has not lost its relevance, the presence of a sulfur atom in which affects the normalization of the mitotic activity of keratinocytes of the epidermis, the stimulation of the adenylate cyclase system with activation of cAMP. Etiotropic treatment is currently not developed. The focus is on pathogenetic and symptomatic effects. For exudative rashes, common rashes up to erythroderma, acute and severe process with signs of intoxication, accompanied by intense itching, use detoxification means and methods. In a progressive stage, a 25% solution of magnesium sulfate is administered intravenously or intramuscularly (10-12 injections), a 30% solution of sodium thiosulfate intravenously in the amount of 10-15 injections, antihistamines (suprastin, pipolfen, tavegil, etc.) inside or parenteral, intravenous drip hemodez 200-400 ml every other day or 2 times a week.

Hemodez is a drug that contains a 6% aqueous solution of vinylpyrolidone and ions of magnesium, sodium, potassium and chlorine. The drug has dehydrating properties, can bind and excrete toxins with urine, normalize the level of free fatty acids in the blood, positively affect the blood coagulation system and fibrinolysis. Other plasma-substituting solutions can be used (polyglukin, reopolyglukine, etc.), but they are somewhat weaker. Vitamin preparations and their biotransformation products – coenzymes – are widely used in the treatment of psoriasis. The mechanisms of their action are very diverse.

In psoriasis, thiamine (vitamin B1), pyridoxine (vitamin B6), riboflavin (vitamin B2), cyanocobalamin (vitamin B12), folic acid, tocopherol acetate (vitamin E), retinol (vitamin A) have found their use.

The undoubted advantage of using vitamins and coenzymes is the absence of serious side effects and complications, with the exception of individual intolerance. The purpose of therapeutic measures at the beginning of the disease is to stop the progression of the process. It is formed by the general methods of treatment: the appointment of vitamins and calcium preparations. The following treatment regimen proved itself, especially with exudative psoriasis: intravenous administration of 10% solution of calcium chloride or gluconate 10 ml every other day and intramuscular injections of vitamin B12 (400 μg) every other day, ingestion of folic and ascorbic acids. The duration of such treatment is 1-3 months. At present, promising detoxification methods such as hemodialysis, hemosorption, plasmapheresis, hemofiltration, which are especially needed during the progressive process, have been developed and are being introduced. In patients with psoriasis, especially severe forms, there is congestion with pathological immune circulating complexes, depression, blocking of the physiological systems of defense and regulation, functional disorders of the gastrointestinal system. This situation forms the syndrome of endogenous intoxication, as a result of which an excess amount of intermediate and final metabolites accumulate in the body, having a toxic effect on the functional state of the most important organs.

The use of efferent methods has a detoxifying systemic effect, in which, as a result of the removal of xenobiotics and various toxic effects, non-drug stimulation of the systems of natural immunity, physiological mechanisms of sanogenesis with the normalization of life processes is carried out. Detoxifying hemosorption has been used for many years to treat all forms of psoriasis. Its high efficacy in patients with severe and common forms of the disease has been established. Hemosorption can be used in combination with traditional methods of treatment. Also according to the principle of effective exposure, plasmapheresis is also used, which has a pronounced therapeutic effect. Funds that correct microcirculation disorders, stabilize the microcirculatory vessels, have a beneficial effect on the cyclic nucleotide system, restore cell membranes, and have a hypoglycemic and hypocholesterolemic effect. In psoriasis, andecalin, doxyium, pentoxy-filin (trental), parmidine, complamine, cavinton are used. Heparin in psoriasis is used to prevent the alteration of keratinocyte β-adrenergic receptor immune complexes, inhibit thrombogenesis and stimulate plasmin formation, and restore microcirculatory disorders. Heparin is advisable to use in common forms of psoriasis vulgaris, psoriatic arthritis and erit-rodermia. The beneficial effect on the course of psoriasis in patients is found by Essentiale — a preparation containing “essential” (necessary) phospholipids — diglycerol esters of choline phosphoric acid and unsaturated fatty acids — linoleic (up to 70%), linolenic and others. Zixorin induces the oxidase activity of microsomal liver enzymes, increases the formation of glucuronides, promotes the excretion of endogenous and exogenous metabolites, which generally has a positive effect on the course of the psoriatic process. By biostimulants, traditionally used to treat patients with psoriasis, include pyrogenal and prodigiozan. An important property of Prodigiosan, in addition to the action on T-lymphocytes, macrophages, is the stimulation of the synthesis and emission of corticosteroid hormones, interferons, activation of the pituitary-adrenal system. Levamisole is able to restore the altered functions of T-and B-lymphocytes and phagocytes, to stimulate neutrophil chemotaxis. Due to its thymomimetic effect, the drug can increase the reactivity of immune cells to thymic hormones.

Levamisole does not affect the normal immune response, but restores the latter when it is deficient, and can reduce the CIC content in the blood. There is evidence of the promise of using tactivin as part of immunocorrective therapy for patients with psoriasis. The drug stimulates the quantitative and functional indicators of the T-cell system, normalizes the production of lymphokines, including interferons.

Timalin also performed well in treating patients with psoriasis. The drug regulates the number of T-and B-lymphocytes, has a positive effect on phagocytosis, there are processes of stimulation, regeneration and blood formation. Imunofan has the ability to possess immunoregulatory, hepatoprotective, detoxifying action. Immunoregulatory action of imunofan is manifested by the restoration of impaired cellular and humoral immunity parameters. Proved the effectiveness of imunofana with the most diverse pathology, including psoriasis. In the stationary period of psoriasis, pyrotherapy using intramuscular injections of pyrogenal or prodigiosan is recommended. If treatment with these agents is ineffective, cytostatics from the group of antimetabolites, in particular, methotrexate can be used. The drug is used one tablet 2 times a day in courses for 5-7 days with weekly breaks. Fewer complications occur when taking methotrexate once a week during the day: 2 tablets every 12 hours.

Indications for the use of systemic suppressive drug therapy drugs are psoriatic erythroderma, pustular form of psoriasis and polyarthritis, as well as common vulgar psoriasis resistant to other treatments. The drugs of this group include: neotigazon, aromatic retinoids – etretinat (tigazon), isotretinoin (roaccutane), soriaten. Recently, much attention has also been paid to the use of vitamin D3 and its analogues, takalcitol and calcipotriol, for psoriasis. Interacting with specific receptors in keratinocytes, calcipotriol can cause a dose-dependent inhibition of proliferation of these skin cells, accelerating their morphological differentiation.

Vitamin D3 analogs are widely used in psoriasis; they are well tolerated and are a worthy alternative to topical corticosteroids. Topical cortico-steroids in combination with dithranol, calcipotriol, pimecrolimus and tacrolimus, as well as derivatives of zinc pyrithione (skincap) and tar preparations are currently used as external therapy for psoriasis. External treatment depends on the stage of the disease. In the progressive period, only lubrication of the affected skin is applied with a weak peeling (1-2% salicylic) or corticosteroid ointment. In case of a pronounced inflammatory phenomenon, you can add ointments and creams with glucocorticoid hormones. In the stationary and regressive periods, 3-5% white or 2% yellow mercury, 5-10% ichthyol ointment is used. For the scalp, you can use a 2% mercury-salicylic ointment.

It is advisable external use of DMSO (dimethyl sulfoxide). Applied to the foci of psoriatic elements or to the affected joints in the form of creams or ointments (5-10% or 20%), the drug penetrates deep into the epidermis, dermis, into the synovial membranes of the joints, has an anesthetic, anti-inflammatory and bactericidal effect in the joints, periarticular tissues, as well as directly in the skin. A pronounced effect appears after the use of drugs in the tar in increasing concentrations (5-10-20%). First use tar paste, then ointment. To enhance the effect of the latter, they gradually change the method of their application: lubrication, application under the dressing, then under the compression dressing, rubbing. The tar bath is an excellent effect – a general warm bath for 30-60 minutes, which is taken 10-15 minutes after rubbing pure tar into the affected skin. In case of surface infiltration of psoriatic elements, they are lubricated with heparin ointment with the addition of 50-70% dimexid solution, furoccin, a mixture of tar, ether and alcohol, taken in equal proportions, with a 5% potassium permanganate solution, and Castellani liquid. In the case of psoriatic erythroderma, it is necessary to use glucocorticosteroids. Psoriatic arthritis requires combined treatment with corticosteroids, methotrexate, anabolic drugs and indomethacin (brufen); In addition, they use mud therapy, paraffin baths, massage, therapeutic exercises, and ultrasound. It should be noted that the treatment of patients with psoriasis for any concomitant disease with streptomycin or penicillins often leads to exacerbation of the course of psoriasis, and especially psoriatic arthritis.

It is necessary to limit carbohydrates in food, to use unloading diets, including fasting, general heat (36-37 ° C) baths every other day, appropriate psychotropic drugs, removal (according to indications) of the tonsils. Physiotherapy treatments for psoriasis are currently complemented by PUVA therapy or photochemotherapy. This treatment has a cytostatic effect: irradiation of the skin with long-wave ultraviolet rays (UVA) of high energy, carried out after ingestion of photosensitizing drugs – puvalene, psoralen, etc. -4 times a week (20-40 procedures). Side effects and complications of PUVA therapy are a tendency to the appearance of tumor and precancerous conditions, radiation damage to the eyes, the formation of photodermatosis, cataracts, toxic hepatitis, dry skin, papillomatosis, dizziness, dyspeptic disorders, itching.

For patients with the winter form of psoriasis, a combination of this treatment with general ultraviolet irradiation is useful, starting with sub-erythemal doses. On torpid current plaques it is necessary to apply erythemic doses of ultraviolet rays. You need to know that ultraviolet radiation can not be combined with the reception of methotrexate. From other physiotherapeutic methods of treating psoriasis, phonophoresis of ointment with hydrocortisone, laser therapy in combination with a permanent magnetic field (magnetic laser therapy) are used. Also use induction therapy, laser puncture, acupuncture, hyperthermia in a heat chamber (42-45 ° C). Applications of ozokerite, paraffin can be used both for the treatment and for the prevention of relapses. For the prevention of recurrence of psoriasis, ultraviolet irradiation of the entire skin is recommended during remissions.

The problem of treating patients with psoriasis remains highly relevant in modern conditions, despite the large arsenal of proposed drugs and developed therapies. A significant part of the proposed therapeutic agents is not sufficiently effective, since it does not take into account the nature and severity of immunological and metabolic shifts in the body of patients, and also has a diverse range of side effects.

It is necessary to further develop pathogenetically substantiated areas of therapy that effectively correct immunological and metabolic disorders in the body in case of psoriasis, reduce endotoxicosis and shorten the duration of treatment for patients. During the stabilization process, sanatorium-resort treatment is recommended. Also, patients with psoriasis in the inpatient and regressive periods recommended spa treatment: heliotherapy, sea bathing, sulfur baths, massage, exercise therapy. With summer form of psoriasis, heliotherapy is absolutely contraindicated. In all periods of psoriasis, it is necessary to observe a rational sanitary and hygienic regimen, diet therapy.

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