Treatment of psoriasis. Modern medications - Causes, symptoms and treatment. MF.

Treatment of psoriasis should be aimed at eliminating inflammation, suppressing the proliferation of epithelial cells, normalizing their differentiation.

To date, many different medications and treatments for psoriasis have been developed. Given the limited volume of the article, it lists the most effective of them.

When prescribing treatment for patients with psoriasis, it is necessary to take into account the prevalence of skin lesions, the stage of the disease, age, sex, the presence of concomitant diseases and contraindications to one or another method of treatment or drug.

Treatment of psoriasis should be comprehensive and combine the use of both drugs for local( external) and systemic therapy.

External means of treatment of psoriasis

Application of local preparations in the form of lotions, creams and ointments reduces inflammation on the skin, its peeling and infiltration. Such medicines include ointments and creams containing salicylic acid( 2%), sulfur( 2-10%), urea( 10%), dithranol( 0.25-3%), and glucocorticoid creams, ointments and lotions( solutions).Lotions are usually used to treat lesions of the scalp, ointments and creams - any other part of the body.

In case of exacerbation of the disease, salicylic ointment or anti-inflammatory hormonal ointment is usually prescribed. Begin with the easiest - hydrocortisone, prednisolone. With repeated exacerbations, severe inflammation, it is necessary to use stronger drugs - fluorinated drugs( Tselestoderm, synalar, vipsogal, belosalik and others).So, for example, with the use of the "Belosalik" ointment containing b-metazone dipropionate and salicylic acid, in 60-70% of patients there is a complete regression of the rashes within 14 days. When lotion is prescribed for 21-28 days, a pronounced clinical effect is observed in more than 80% of patients.

In recent years non-halogenated glucocorticoid ointments ( advantan, elokom) have been used. Unlike their predecessors, they do not contain fluorine and chlorine-containing components, which significantly reduces the risk of local and systemic adverse reactions. Such ointments and creams can be used in the elderly and even early childhood.

The external preparations containing dithranol ( psorax, cignoline, zignoderm) have an expressed antipsoriatic effect. Dithranol has an antiproliferative and anti-inflammatory property. The drug is prescribed in increasing concentrations by different methods: short-term( application to the rash for 20-30 minutes) or prolonged( application once a day).The duration of common forms of the disease is from 2 to 8 weeks. A significant improvement and clinical recovery as a result of dithranol treatment was noted in 70% of cases. Side effects of the drug - the possibility of developing local edema, itching, erythema.

Recently, a remedy has appeared, the action of which is based on a direct effect on the pathogenetic links of psoriasis - ointment psorutkutan .Its chemical structure is based on calcipotriol, the synthetic analogue of the most active metabolite of vitamin D3.Interacting with the receptors of keratinocytes, it suppresses their excessive division, normalizes the processes of morphological differentiation, has anti-inflammatory and immunocorrecting properties. Such properties of psorcutane determine good results of treatment of psoriasis. To date, has already accumulated a fairly extensive clinical experience in the use of psorokutana. According to the Center for Combating Psoriasis, which treats more than 200 patients with psorrutane, the effect is usually observed already on the 7th-10th day after the start of therapy: the ecdysis disappears, the papules become pale, flattened and flattened. By the end of the 8th week there is a complete disappearance of the rash or a significant improvement in the skin condition in the vast majority of patients. What is important, psorcutane does not cause, in contrast to glucocorticoids, skin atrophy and gives a lasting effect after application. The remission of the disease is sometimes more than a year.

It is good to combine treatment with psorquatane with ultraviolet irradiation( PUVA or SFT).The expressed clinical effect in the form of regression of rashes with monotherapy with psorquatane is 43%, in combination with selective phototherapy - 86% and PUVA - 91%.

With prolonged course of the disease, with frequent and persistent exacerbations of psoriasis, it makes sense to periodically change the ointments or alternate them, as the skin gets used to medicines and the long-acting ointment has less effect.

Systemic therapy of psoriasis

Aromatic retinoids , used for about 20 years in the dermatological practice of treating a number of skin diseases, have taken a leading place in the treatment of psoriasis patients. The mechanism of action of aromatic retinoids in psoriasis is inhibition of proliferation( proliferation) of epithelial cells, normalization of the processes of keratinization and stabilization of cell membrane structures, including liposomes.

Developments in recent years have led to the introduction of a new aromatic synthetic analogue of retinoic acid - acetitrite.

Unlike its predecessor, etretinate, it has a number of significant advantages: it is not cumulated in the body and its half-life is 50 hours( vs. 100 days).This allows to avoid or quickly eliminate a number of side effects that arise when treating with aromatic retinoids. Acetritin is the active substance of the drug, which is called neotigazone.

Neotigazone is used in a dosage of 20-25 mg per day. If necessary, the dosage of the drug can be increased to 50-75 mg per day. The course of treatment lasts 6-8 weeks.

Treatment with neotigazone has a pronounced therapeutic effect in the treatment of psoriasis of the scalp, psoriatic arthritis and psoriatic lesions of the nail plates.
Many years of experience in the use of aromatic retinoids in the Center for Combating Psoriasis in more than 3,000 patients have shown that combined use of retinoids with ultraviolet irradiation( PUVA or SFT) and local antipsoriatic drugs affecting proliferative processes in the skin is most effective.

For comparison, the following figures can be cited. Monotherapy with aromatic retinoids leads to clinical cure in 12% of patients, to a significant improvement in 41% and improvement in 47% of patients. Combination therapy in 84% of cases gives a clinical cure, in 12% - a significant improvement and in 4% - an improvement. In those cases where there are contraindications for the use of ultraviolet irradiation, a pronounced clinical effect( 67%) gives a combination of retinoids with psorquutane.

Cyclosporin A is a cyclic polypeptide with an immunosuppressive effect. The effect of cyclosporine is due to the suppression of secretion of interleukins and other lymphokines by activated T lymphocytes, which leads to a decrease in T-lymphocyte activity both in the dermal layer and in the epidermis of psoriasis patients and indirectly affects vascular status, epidermal hyperproliferation, and inflammatory cell activity. Along with this, cyclosporine inhibits the growth of keratinocytes. This effect may be due to the suppression of the growth factor of keratinocytes from mononuclear leukocytes in combination with direct action on the growth of keratinocytes. Cyclosporine is indicated for patients with severe forms of psoriasis, when conventional therapy is ineffective or there are contraindications to other methods of treatment.

The drug is prescribed at the rate of 1.25 - 2.5 mg per 1 kg of body weight per day. If necessary, the dose can be increased to 5 mg per 1 kg of body weight per day. The duration of treatment is 4-8 weeks.

Methotrexate. Is an antagonist of folic acid, cytostatics. In connection with the antifolia effect, the drug suppresses the synthesis of DNA and the multiplication of cells and, to a lesser extent, the synthesis of RNA and protein. The cells with active proliferation, in particular skin epithelial cells, are most sensitive to the preparation. Assign methotrexate in especially severe cases of refractory psoriasis( arthropathic, pustular psoriasis, erythroderma).

Methotrexate treatment methods are different. Taking into account the data on the pharmacokinetics of the drug, cell proliferation in psoriasis, it is most advisable to administer it in three oral doses of 2.5-5 mg with a 12-hour interval every week or once in doses of 7.5-25 mg orally or 7.5-30mg intramuscularly or intravenously once a week. It is recommended to start treatment with a small dose( 5-10 mg once a week), gradually increasing it to an effective therapeutic dose with good tolerability and normal laboratory tests. The course lasts about 4 weeks.

Non-steroidal anti-inflammatory drugs. For arthropathic psoriasis, as well as for the purpose of reducing inflammation in exudative psoriasis and erythroderma, non-steroidal anti-inflammatory drugs are prescribed: indomethacin, diclofenac( 0.025-0.05 g 3 times a day), naproxen( 0.25-0.75 g 2times a day).Daily doses and duration of treatment depend on the severity of inflammatory changes, the intensity of pain in the joints, the tolerability of drugs.
The duration of treatment is usually 4-6 weeks.

Photochemotherapy( PUVA). Combined application of long-wave ultraviolet rays( UV-A) with a wavelength of 360-365 nm and a photosensitizer( 8-methoxypsoralen).In photochemotherapy, the main significance is given to the interaction of the photosensitizer activated with long-wavelength ultraviolet rays with DNA, with the formation of mono- or bifunctional bonds, leading to inhibition of cell proliferation by suppressing the synthesis of nucleic acids and protein. The effect of photochemotherapy can also be associated with immunomodulating effect with normalization of the cellular immunity, direct exposure to immunocompetent cells in the skin, influence on biosynthesis and metabolism of prostaglandins. Photochemotherapy is carried out with an initial dose of UV-A equal to 0.25-0.5 J / cm2 by the method of 4-time irradiation per week with a gradual increase in the dose of UV-A by 0.25-0.5 J / cm2.The course of treatment usually consists of 20-30 procedures.

Selective phototherapy( SFT). With selective phototherapy, medium-wave ultraviolet rays( UV-B) at a wavelength of 315-320 nm are used. Treatment begins with a dose of UV-B rays equal to 0.05-0.1 J / cm2 according to the 4-6 method of one-time irradiation per week with a gradual increase in the UV-B dose by 0.1 J / cm2 for each subsequent procedure. The course of treatment usually involves 25-30 procedures.

Climatotherapy. The climatotherapy( sanatorium treatment) on the Black Sea coast or the Dead Sea in Israel gives good results. The Dead Sea therapeutic factors include UV radiation, air temperature, humidity, atmospheric pressure and salt composition in the Dead Sea water. The Dead Sea is located 395 meters below the level of the World Ocean, and these additional layers of the atmosphere, as well as evaporation from the water surface, filter and detain the harmful rays of the sun, create an ideal ratio of long-wave( UFA 315-390 nm) and medium-wave( UVB 300-315 nm)UV rays. The average relative air humidity is low, and the air temperature is high, the number of sunny days per year reaches 330.

In the Dead Sea region, the highest( 800 mm Hg) barometric pressure is observed on the Earth. The oxygen content in the air is 6-8% of molecules per m higher than at the level of the Mediterranean Sea. The Dead Sea water contains a large amount of minerals and salts. The concentration of salts is approximately 300 g of salt per liter of water, whereas in the Mediterranean Sea it is approximately 35 g of salt per liter of water.

Treatment on the coast of the Dead Sea includes sunbathing, starting from 5 to 15 minutes 2 times a day with a constant increase in solar exposure by 10 minutes to a maximum of 6-8 hours daily, in combination with sea baths lasting from 10 to 60 minutes 2 - 3times a day. Depending on the condition of the skin, correction of the time spent in the sun and sea water is performed.

As an external therapy, natural oils( avocados, olive), indifferent creams and moisturizers, shampoos containing Dead Sea minerals, and tar are used. Sometimes, in the first days of treatment, ointments containing sulfur, salicylic acid and tar are used.

The recommended length of stay at the Dead Sea is 28 days.

As the observations showed, at the completion of the course of treatment, complete cleansing of the skin was noted in 68% of patients, a significant improvement in 22%, improvement in 10% of patients. None of the patients experienced any impairment.

Aerogeliotalassotherapy on the Black Sea coast showed the following results: after a 21-30 day course, remission of the disease was noted in 23.3% of patients, in 40.2% - a significant improvement and in 36.3% - improvement.

The above results and comparative data indicate the high efficiency of climatotherapy in the Dead Sea.

Summing up, we can say that the treatment of psoriasis must necessarily be comprehensive and take into account the stage of the disease and the peculiarities of its course. In any case, a full-time doctor's consultation is needed to prescribe medications and to identify contraindications to this or that method of treatment.