Psoriasis treatment: phototherapy, local and systemic treatment

The treatment of psoriasis is diverse and includes emollients, salicylic acid, tar preparations, anthralin, glucocorticoids, calcipotriol, tazarotene, methotrexate, retinoids, immunosuppressants, immunotherapeutic agents and phototherapy.

Phototherapy

Phototherapy is usually used to treat patients with advanced psoriasis. The mechanism of action is unknown, although UVB rays inhibit DNA synthesis. Phototherapy with psoralen and ultraviolet radiation of spectrum A, the use of methoxypsoralen, photosensitizers is accompanied by long UVA (330-360 nm) waves. Phototherapy has an antiproliferative effect and promotes the normalization of keratinocyte differentiation. The initial dosage with phototherapy is small, but can be increased in the future. Overdosing of medicines or UVA can cause severe burns. Although this form of treatment is easier than using local remedies, long-term remission may develop, but repeated treatment can cause skin cancer. Oral use of retinoids requires less UV light. A narrow spectrum of UVB is an effective treatment and does not require psoralen. Excimer laser therapy is a type of phototherapy using an extremely narrow spectrum of long waves.

Systemic (general) photochemotherapy (PUVA-therapy). In the absence of contraindications to FTX, the sensitivity of the patient's skin to ultraviolet irradiation is necessarily determined. To do this, use biodoza, or MED (minimum erythematous dose), that is, the minimum duration of irradiation, at which there is a clearly defined reddening of the skin. Biodose is expressed in minutes or in the amount of energy per unit area: mJ / cm ² (UV-B), or J / cm ². PUVA-therapy is most effective in the vulgar form of psoriasis. Purification of the skin from psoriatic rashes by 75-90% is noted after 15-20 procedures of PUVA therapy.

Selective phototherapy (SFT). At SFT, medium-wave ultra-violet rays (UV-B) are used at a wavelength of 315-320 nm. Therapy begins with a dose of UV-B rays equal to 0.05-0.1 J / cm ² by the method of 4 6-time exposures per week with a gradual increase in the UV-B dose by 0.1 J / cm ² for each subsequent procedure. The course of treatment usually involves 25-30 procedures.

Aromatic retinoids (AR). Neotigazone is used at the rate of 0.5 mg per 1 kg of the patient's weight. If necessary, the dosage of the drug can be increased to 1 mg per 1 kg of the patient's weight per day. The course of treatment lasts 6-8 weeks. Neotigazone has a good therapeutic effect in the treatment of psoriatic arthritis, psoriasis of the palms and soles, with psoriatic lesions of the nail plates.

Re-PUVA therapy. This method of therapy is based on the combined use of PUVA therapy and AR. At the same time, the dose of UFO and AR decreases significantly (almost half the dose). Re-PUVA therapy has a pronounced therapeutic effect in the treatment of psoriatic erythroderma (after removing acute phenomena), persistent and severe leaking vulgar psoriasis, psoriatic arthritis.

Topical medications for psoriasis

The choice of means for external therapy of psoriasis is extensive and depends on the stage and clinical form of the disease. The use of local drugs reduces inflammation, peeling and infiltration of the skin. Such preparations include ointments and creams containing salicylic acid (2%), sulfur (2-10%), urea (10%), digranol (0.25-3%), and glucocorticoid creams, ointments (diposalik, balsalik , dermoveit, lokazalen, etc.) and lotions (with damage to the scalp), depending on the stage and clinical course of the disease. Local immunomodulators (elidel, protopic) and calcipatriol, application of cytostatics are also effective.

Emollients include creams, ointments, vaseline, paraffin, and vegetable oils. They reduce peeling and are most effective when used 2 times a day or immediately after bathing. The foci can become more red after eliminating the peeling. Emollients are safe and should be used in mild to moderate forms of the disease.

Salicylic acid is a keratolytic that softens the scales, facilitates their removal, and increases the absorption of other drugs, especially helps with the treatment of the scalp, since the peeling of the skin can be quite strong.

Psoriasis subtypes

Subtype	Description	Treatment and prognosis
Teardrop psoriasis	The sharp appearance of numerous plaques on the trunk in children and young people with a diameter of 0.5 to 1.5 cm after streptococcal pharyngitis	Treatment: antibiotics for streptococcal infection Prognosis: good with constant treatment
Psoriatic Erythroderma	Gradual or sudden formation of common erythema with / without plaque formation. Most often occurs due to improper use of local or systemic glucocorticoids or phototherapy	Treatment: potent systemic medicines (eg: methotrexate, cyclosporine) or intensive local therapy. Tar, anthralin and phototherapy can cause an exacerbation. Forecast: good when eliminating causative factors
Common pustular psoriasis	Sudden occurrence of common erythema with pustules	Treatment: use of systemic retinoids Forecast: possible fatal outcome due to cardiac arrest
Pustular psoriasis of the palms and feet	Gradual beginning with the formation of deep pustules on the palms and soles, which can be painful, and lead to disability. Typical rashes may be absent	Treatment: use of systemic retinoids
Psoriasis of large folds	Psoriasis of inguinal, gluteal regions, axillae, podkridinnoy, behind-the-ear areas and the penis with unremoved flesh. Cracks may develop in the center or along the edges of the lesions	Treatment: topical application of glucocorticoids of minimal activity. Tar or antralin can lead to irritation
Psoriasis of the nails	Formation of pits, granularity, spots, discoloration and / or compaction of nail plates with / without detachment (onycholysis). Can resemble a fungal infection. Occurs in 30-50% of patients with other forms of psoriasis	Treatment: well undergoes systemic therapy. Possible injection of glucocorticoids into the lesions Prognosis: usually difficult to treat
Acrodermatitis Gallupo	The defeat of the distal parts of the limbs, sometimes only one finger, followed by the formation of scales	Treatment: use of systemic retinoids, calcipotriol

Ointments, solutions and shampoos containing coal tar have anti-inflammatory effects and reduce hyperproliferation of keratinocytes. Typically, tar used at night and washed off in the morning, it is also possible to use them in combination with topical glucocorticoids or with natural or artificial ultraviolet light in the B-band (280-320 nm) with a gradual increase in exposure (Heckerman's regime).

Antralin - a substance of topical application, has an anti-proliferative and anti-inflammatory effect, the mechanism of which is unknown. The effective dose is 0.1% cream or ointment with an increase in the substance to 1%. Antralin can cause irritation and coloration of the skin, so you should be careful when used in intertriginoznyh areas. Irritation and staining can be avoided by removing anthralin after 20-30 minutes after application. When using liposomal anthralin, there is much less inconvenience.

Glucocorticoids are usually used externally, but can be injected internally. Systemic glucocorticoids can accelerate the development of pustular psoriasis, they should not be used in any form of psoriasis. Glucocorticoids of topical application are used 2 times a day, sometimes with anthralin or coal tar, are applied before bedtime. Glucocorticoids are most effective when applied overnight with the use of occlusive dressings. Creams are used throughout the day without the use of bandages. The choice of glucocorticoids according to the activity class is determined according to the extent of the lesion. As the condition of the foci improves, glucocorticoids should be used less frequently or with lower activity to minimize the formation of striae and telangiectasia. Ideally, after about 3 weeks, replace glucocorticoids with emollients for 1-2 weeks. This will limit the dosage of glucocorticoids and prevent tachyphylaxis. External application of glucocorticoids becomes expensive due to the need for a larger amount of the drug (approximately 1 ounce, or 30 g) when treating the entire body. The use of glucocorticoids for a long period of time on large body surfaces can aggravate the condition. With small, infiltrated, limited or common lesions, the use of strong glucocorticoids with the use of occlusive dressings at night with the replacement in the morning is effective. Relapse after the cessation of topical application of glucocorticoids occurs earlier than when using other means.

Calcipotriol is an analog of vitamin D, which promotes the normalization of proliferation and keratinocyte keratinocytes. Can be used in combination with topical glucocorticoids (for example, calcipotriol can be used on weekdays, and glucocorticoids on weekends).

Tazarotene is a topical retinoid, less effective than glucocorticoids, but is useful as an additional remedy.

Systemic treatment of psoriasis

Oral administration of methotrexate is the most effective treatment for severe forms of psoriasis, especially psoriatic arthritis, or psoriatic erythroderma, or pustular psoriasis, which can not be treated with local drugs or phototherapy with psoralen and ultraviolet radiation from spectrum A.

Methotrexate inhibits the proliferation of epidermal cells. You should constantly monitor the blood formula, kidney function, and liver. Dosage regimen is diverse, therefore only a doctor specializing in this field can prescribe methotrexate. Methotrexate is widely used in the treatment of especially severe cases of refractory psoriasis (arthropathic, pustular, erythroderma) and other lymphoproliferative processes. Usually it is prescribed daily in 2 divided doses of 2.5 mg or 5 mg once a day intramuscularly for 5 days followed by a 3-day break. In another scheme, methotrexate is taken in doses up to 25 mg orally or 25-30 mg intramuscularly, or intravenously once a week. To achieve a clinical remission of psoriasis, usually 4 or 5 such cycles are performed. Clinical experience shows that methotrexate (EBEWE), along with a high therapeutic effect, has less side effect. To avoid side effects, it is advisable to combine it with calcium folinate.

The use of systemic retinoids (acitretin, isotretinoin) can be effective in the persistent course of vulgar psoriasis, pustular psoriasis (in the treatment of which it is preferable to use isotretinoin) and palmar-plantar psoriasis. Because of the teratogenic effect and prolonged presence of acitretin in the body, it can not be taken by pregnant women, and pregnancy should be avoided for at least 2 years after discontinuation of treatment. Restrictions for pregnancy also exist when using isotretinoin, but it does not stay in the body for more than 1 month. Long-term treatment can cause a widespread idiopathic skeletal hyperostosis.

Ciclosporin is an immunosuppressant that can be used to treat severe forms of psoriasis. The course of treatment is carried out for several months (sometimes up to 1 year), alternating with other types of therapy. The impact on the kidneys and prolonged exposure to the immune system interferes with long-term use. Ciclosporin A (sandimmun-neoral)> is administered orally at a dose of 3-4 mg / kg / day. Cyclosporine is indicated for patients with severe forms of psoriasis, when conventional therapy is ineffective or there are contraindications to other methods of treatment.

Other immunosuppressants, such as uric acid, 6-thioguanine and mycophenolate mofetil, are not entirely safe and are used only in persistent psoriasis.

Immunotherapeutic drugs include inhibitors of tumor necrosis factor (TNF) -alpha (etanercept and infliximab), alefacept and ehlalizumab. TNF-alpha inhibitors lead to the resolution of psoriasis, but their safety is still being studied. Alefacept is a recombinant human protein mixture that consists of CD2 bound to the leukocyte functionally bound antigen (LFA) of type 3 and the Fc fragment of human IgG _. Alephacett inhibits the number of memory T cells without compromising the number of T cells themselves and effectively prevents the formation of plaques. Ephalizumab is a monoclonal antibody that competitively binds CD 11a, subgroups of LFA-1, thus blocking T cell activity.

Glucocorticoids are prescribed for pustular, arthropathic psoriasis and psoriatic erythroderma, when other methods of systemic therapy are contraindicated to the patient, were less effective or the effect was absent. It is advisable to use triamcinalone or dexamethasone, rather than prednisolone. The dose of the hormone is determined individually depending on the severity and clinical course of psoriasis. Usually, small (25-30 mg / day) or medium (40-50 mg / day) doses are prescribed.

In recent years, fundamentally new groups of medicines have been developed and introduced into clinical practice, called "biological" agents, which selectively affect certain links in the pathogenesis of the disease and, to a minimal degree, the normal function of the immune system. Preparations of infliximab and etanercept block the tumor necrosis factor alpha (TNF-a), reduce its activity, and as a result, the inflammatory process in the outbreak decreases. These drugs are approved in the therapy of psoriasis and psoriatic arthritis. Other "biological" agents - zalizumab and alefacept - are antagonists of T cells and accordingly block these cells. They are indicated for the treatment of psoriasis alone.

The choice of therapy for psoriasis

The choice of a specific drug and combinations requires close cooperation with the patient, bearing in mind the possibility of adverse reactions. There is no separate ideal combination, but simple methods of treatment should be followed. It is preferable to use monotherapy, but combination therapy is also the norm. Rotational therapy consists of replacing one type of treatment with another after 1-2 years to reduce the adverse effects of chronic use and control the resistance of the disease. Consecutive treatment consists of the initial use of powerful agents (eg, cyclosporine) to quickly achieve the result, followed by the use of safer means.

For the treatment of mild psoriasis, emollients, keratolytics, tar, local glucocorticoids, calcipotriol and / or anthralin alone or in combination can be used. Perhaps the use of sunlight, but this can cause an exacerbation of the disease.

When treating the medium-heavy form of psoriasis with the formation of plaques, phototherapy or oral medications should be used. Immunosuppressants are used for rapid, short-term control of the disease and for severe forms of the disease. Immunotherapy is used for moderate and severe forms of the disease, with no response to other methods of treatment.

Plaques on the skin of the scalp are difficult to treat, resistant to systemic therapy, since hair interferes with the application of medicines and protects the skin from UV rays. A solution of 10% salicylic acid in the mineral oil can be rubbed into the scalp before going to sleep manually or with a toothbrush, then put on the shower cap to increase penetration and avoid contamination and wash off in the morning. More cosmetically acceptable solutions of glucocorticoids can be applied throughout the day. Treatment of psoriasis should continue until the effect is achieved. With stable preservation of plaques, it is possible to use intraluminal chewing of triamcinolone acetonide in physiological saline 2.5 or 5 mg / ml, depending on the size and severity of the lesion. Injections can lead to local atrophy, which is usually reversible.