Psoriasis is an autoimmune disease with an unfavorable combination of genesis factors with recurring evolution, a variety of phenotypes, clinical varieties and the possible detection of various chronic diseases.According to literature, the prevalence of world psoriasis is 4 to 7%.
According to K. Reich, the mild forms of the disease affecting less than 3 to 5% of the body area and do not give significant changes in the patient's immune state, only require local treatment.The psoriasis of the moderate and severe course is a systemic and inflammatory process, leading to the development of concomitant pathologies or to their worsening, and they themselves have a huge impact on the patient's health and quality of life.
The problem of treatment of psoriasis does not lose its relevance and, despite the emergence of new modern treatment methods, remains a difficult task requiring 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 the personified therapy, the prevalence and severity of psoriasis, the stage of the process, its clinical form, as well as the attitude towards the patient's disease himself is taken into account.Thus, 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 serious psycho -emotional emotional experiences.According to the study by G. Krueger et al.(2001), 40% of patients with psoriasis were disappointed with the ineffectiveness of the resulting treatment and 32% considered insufficient treatment.
Psoriasis system therapy
Systemic glucocorticoids in the form of a tablet are extremely rare in relation to many side effects.However, like the "ambulance" of the drug to stabilize the psoriatic process with a progressive stage, erythroderma is advisable to use systemic glucocorticoids extended for intramuscular administration in the form of short courses.A similar approach to therapy avoids unwanted 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 dihydrofolateredustase, which transforms acidic dihydrofolic into tetrahydrofolic and is a donor of simple carbon groups in the synthesis of purine nucleotides and thymidylate necessary for the synthesis of DNA.In this regard, the simultaneous goal of folic acid helps to avoid metabolic anemia.
Cyclosporin, a-cyclical polypeptide, isolated from the Tolypocladium inflatum gams fungus, has an immunosuppressive effect by removing the activity of T cells and reducing their antigenic sensitivity due to the immune system.The drug has high effectiveness in the treatment of a psoriasis which flows slowly, psoriatic erythroderma.
Since 1997, the second generation aromatic retinoids have been used to treat the refractory forms of psoriasis, the basis of the chemical formula is steree.The medication inhibits the proliferation of epidermis cells, normalizes the process of keratinization, has an immunomoduced effect.The effectiveness of the product depends on the dose: higher doses lead to a faster resolution of psoriatic eruptions.
Relatively recently, a new group of drugs has appeared - biological drugs, which include recombinant protein substances, synthesized by biotechnological by living cells of animals, plants and microorganisms.The indications for the prescription of organic drugs are serious forms of psoriasis resistant to other system drugs.
The treatment of moderate and severe forms of psoriasis (more than 10% of the body surface) is carried out taking into account the conditions under which the patient has several chronic diseases such as metabolic syndrome, cardiovascular diseases, diabetes mellitus disorders, non -alcoholic fatty liver and lipid metabolic disorders.According to statistical studies, these psoriasis conditions are observed more often 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 under which the patient has several chronic diseases detected individually in each patient.Indeed, certain pharmacological drugs can negatively affect concomitant cardiovascular and metabolic diseases.The link between psoriasis and cardiac-metabolic disorders has important clinical consequences.First, systemic psoriasis therapy can negatively affect metabolic concomitant diseases, especially in the case of continuous and prolonged treatment.In particular, methotrexate must be prescribed with caution in obesity, diabetes mellitus, not alcoholic liver disease due to an increase in the risk of liver fibrosis.Cyclosporin, or can cause appearance or worsen the course of high blood pressure, improve insulin resistance and affect the metabolism of fatty acids, has a toxic effect.
Acitrotine also promotes hypertriglyceridemia and / or hypercholesterolemia.Thus, when driving patients with psoriasis, it is necessary to take into account all the data.
A special place in the treatment of psoriasis receives phototherapy.The positive effect of ultraviolet radiation on the skin is associated with selective inhibition of the T cell of immunity.Depending on the literature, the following areas of the action of phototherapy are distinguished: anti-inflammatory, artificial inhibition of immunity and anti-signing.The effect of ultraviolet rays on immunity is associated with a depth of penetration.UFB rays affect epidermal keratinocytes and changing cells, UFA rays penetrate deeper layers of the skin and have an effect on dermal fibroblasts, dendritic cells and immune system cells.The positive effect of ultraviolet radiation is due to the apoptosis of T cells, a decrease in the number of changing cells, a change in cytokines, growth factors (EGF, VEGF), adhesion and neuropeptides molecules.The purpose of phototherapy is advised for a common skin process.
In the treatment of psoriasis, photochemotherapy (ball therapy) is used - the combined use of ultraviolet long wave (UFA) (UFA) (320–400 Nm) and photosensitizer (8 -Methoxypsoral).PUVA therapy is one of the most effective methods for treating psoriasis, its prescription is recommended for common and common exudative psoriasis, the obstinate course of the disease, severe infiltration.The treatment is carried out according to the irradiation methodology at 3 or 4 racks per week, on average, the course is 20 to 30 procedures.
Currently, selective phototherapy, a combination of wave radiation (280–320 Nm) has lost its position and is prescribed less and less for the treatment of psoriasis.The indication of its objective is psoriasis, characterized by low content in inflamed cells.
UFB therapy with narrow tracks with the peak of emissions with a wavelength of 311 nm in high therapeutic efficiency is comparable to ball therapy, but unlike it does not require the use of a photosensitizer.It is carried out according to the irradiation methodology of 3-5-rack per week with a course of 20 to 30 procedures.
For the treatment of vulgar psoriasis limited to a stationary stage, a very effective therapeutic technique is a demanding laser, which provides high intensity monochromatic light of the wavelength of 308 Nm only to 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, naphthalan, chthyol and salicylic acid.
When choosing topical therapy, an individual approach is important, on which the compliance of the patient with psoriasis will depend.Thus, due to the cosmetic impossibility of treatment, 40% of patients do not respect 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 a decrease in tissue inflammation.The action is associated with the mechanism of the complex of hormones and receptors, which enters the nucleus of the target cell and increases the expression of genes coding for the synthesis of peptides inhibiting the activity of phospholipase.This mechanism leads to a decrease in the formation of mediators of inflammation of phospholipids.Corticosteroid ointments combined and creams with salicylic acid are particularly preferred.Local corticosteroid preparations are not shown for prolonged continuous treatment and suggest combination and rotation patterns, because prolonged use can lead to the development of side effects, such as skin atrophy, hypertrichosis, telangiectasia, steroid acne and oppression of adrenal function.
The synthetic analogues of vitamin D3 have established themselves well as very effective means against psoriasis.The most famous of this group are calcipotriol.The principle of action of the drug is based on the effect of the softening of the keratinized skin with vitamin D3: it inhibits the proliferation of keratinocytes and models of skin differentiation, and also has an immunomodulating effect, in particular by reducing the expression of IL-2 and information.Calcipotriol has a cumulative effect, and therefore the therapeutic effect is observed after 1 to 2 weeks.From the start of treatment.
Unlike topical steroids, long -term use of this group of drugs is possible.To reach the maximum therapeutic effect, the combined goal of calcipotriol and topical steroids is possible.
The action of local calcineurine inhibitors (Takrolimus and Pimecrolimus) is associated with blocking the transduction of the T lymphocytes signal by inhibiting calcineurin.It is especially advisable to prescribe this group of drugs in the event of location of rashes on the face, because they have no side effects such as topical steroids.
The value of the use of attenuating agents, in the treatment of psoriasis, is not in doubt: they soften the skin, reduce the coat and drought, improve its hydration, in particular after an ultraviolet exposure;contribute to a decrease in itching.The largest effect is obtained when applying on wet skin after contact with water (bath, shower).The use of attenuating agents in complex psoriasis therapy reduces the total cost of treatment due to the realization of stabilization of the disease and the start of remission in shorter periods, which contributes to reducing the stay of patients in the hospital.
Thus, the problem of the treatment of psoriasis retains its relevance and remains a complete task, mainly targeting a personified approach to therapy, on which will depend on the compliance of the patient with psoriasis and prospective producer patients, taking into account coordination.