Psoriasis is a common chronic recurrent inflammatory skin disease clinically characterized by characteristic scaly erythema. The incidence of the disease is high, and according to statistics, there are about 5_6 million people suffering from the disease in China. The cause of the disease is unknown, and there is no special treatment drug and method so far, it is easy to relapse after healing, and is chronic, sometimes often accompanying the patient’s life. In addition, patients or doctors’ failure to treat, mis-treatment, indiscriminate treatment, often also bring serious side effects caused by drugs, causing great physical and mental pain to patients.
Psoriasis is clinically divided into four types: common type, joint type, erythrodermic type and pustular type, among which common type psoriasis is the most common and is the focus and difficulty of clinical research.
The treatment of common psoriasis with TCM has better efficacy and relatively less side effects. It is the historical responsibility of every dermatologist to excavate, organize, inherit and explore the treatment of psoriasis with TCM, and finally achieve innovation and improvement. The following is a brief introduction to some of our understanding and treatment experience of common psoriasis.
I. Clinical manifestations
The main manifestation of common psoriasis is symmetrical erythema on the extremities, covered with multiple layers of easily scraped silvery white scales, scraped scales with film phenomenon and punctate bleeding.
Psoriasis vulgaris can be divided into three stages: progressive, quiescent and regressive.
It can be divided into various subtypes according to the rash pattern and onset part.
If the lesions are scattered all over the body in the form of droplets, it is called “droplet psoriasis”; if the lesions expand into round flat patches shaped like coins, it is called “coin-shaped psoriasis”; if the lesions are in the form of irregular maps, it is called “map-shaped psoriasis”; thick accumulation of scales like oyster shells is called “oyster shell psoriasis”; the rash can also be ring-shaped or band-shaped, called “ring-shaped psoriasis” and “band-shaped psoriasis” respectively.
Psoriasis vulgaris often starts on the scalp or calves, and sometimes the scalp damage coexists with the rash of the whole body, and its occurrence on the scalp alone is called “scalp psoriasis”, which is difficult to distinguish from seborrheic dermatitis or asbestosis; those occurring in the folds are called “reverse psoriasis “If it occurs in the mucous membrane, it is called “mucous membrane psoriasis”; if it occurs in the nail and palmoplantar, it is called “nail psoriasis” and “palmoplantar psoriasis” respectively.
If the disease is heavy in winter and light in summer, it is called “winter-type psoriasis”, and if it is heavy in summer and light in winter, it is called “summer-type psoriasis”.
Histopathology
The epidermis is hyperkeratotic and underkeratotic, Munro microabscesses can be seen in the stratum corneum or under the stratum corneum, the stratum granulosum is thinning or disappearing, the stratum spinosum is hypertrophic, the epidermis protrudes regularly and the superficial dermis is infiltrated by inflammatory cells.
Exploration of etiology and pathogenesis
Clinically, the skin lesions of psoriasis are mostly manifested as skin erythema, desquamation, itching and dry skin, and the tongue and pulse are not much abnormal. According to the theory of traditional Chinese medicine, “heat wins redness”, “wind wins itch”, “dryness wins dryness”, and “prolonged illness will lead to stasis”. In addition, there are not many abnormalities in the pulse and tongue signs. Therefore, we believe that the location of common psoriasis should be on the surface, and the nature of the disease should be wind, heat, dryness and stasis. In the initial stage, wind-heat and dryness attack the table, or wind-heat is knotted in the throat and wind-heat attacks the top; further development of the disease, dryness and heat will be so strong that heat enters the blood; in the later stage, evil heat stays for a long time, and yin and blood are more depleted, which is mostly manifested as dryness and heat; if heat is tormented and heat knots blood stasis, the plaque will be stubborn and hard to disappear. Heat, dryness and stasis are always present in the disease.
IV. Treatment
(A) Chinese medicine treatment
1. Internal treatment
(1) Lung (Wei) Yin deficiency and dryness-heat evidence
Evidence: skin droplet erythema or red papules, itchy skin, often accompanied by sore throat; or scaly scalp erythema, itchy scalp, red tongue, thin yellow coating, floating pulse.
Treatment: Nourishing Yin and moistening lung, draining wind and clearing heat
Formula: Yin nourishing and clearing the lung with silver dandruff (empirical formula)
Drugs: Radix Rehmanniae, Mai Dong, Radix et Rhizoma Ginseng, Rhizoma Polygonati, Radix Polygonati, Radix et Rhizoma Gastrodiae, etc.
(2) Incendiary evidence of dryness and heat (blood-heat evidence)
Main symptoms: Rash with continuous appearance, rapid development, bright red color, red skin over most of the body, increased scaling, intense itching; accompanied by dry mouth and tongue, sore throat, irritability, dry stools, yellow and red urine; red tongue, thin yellow fur, smooth or numbered pulse.
Treatment: Cool the blood and clear heat to remove spots.
Formulas: Cool the Blood and clear the surface (Experienced formula)
Drug: Buffy’s horn, Danpi, Xuan Shen, Huang Lian, Sheng Di, Mai Dong, Red Peony, Jin Yin Hua, etc.
(3) Liver and kidney yin deficiency evidence
Main manifestations: Prolonged illness with soreness and weakness of the waist and knees, dizziness, deafness, dry mouth, constipation, red urine, red tongue, little coating, thin pulse.
Treatment: Nourishing Yin, clearing heat and quenching wind
Recipe: Nourishing water and clearing liver drink
Drugs: raw gardenia, Radix Angelicae Sinensis, Radix et Rhizoma Dioscorea, Cornu Cervi Pantotrichum, Dampi, Poria, Zedoary, Huai Shan, etc.
(4) Qi and blood stagnation evidence
Main symptoms: repeatedly unhealed skin lesions, rash in the form of patches, thick scales, dark red color, purple and dark tongue with petechiae, petechiae, astringent or slow pulse.
Treatment: Promote blood circulation, resolve blood stasis, detoxify and promote circulation.
Recipe: Revitalize the ligament and effect the elixir
Drugs: Salvia, angelica, frankincense, myrrh, peach kernel, safflower, etc.
(5) Dampness and heat accumulation evidence
Main symptoms: Skin lesions mostly occur in the axillae, groin and other folds, erythema vesiculosum, sticky scabs, intense itching; or palmoplantar erythema, pustules, peeling skin; or with joint pain, swelling, heavy lower limbs; red tongue, yellow greasy coating, slippery pulse.
Treatment: Clearing away damp-heat, detoxifying and clearing the channels.
Formulation: Clearing heat and removing dampness soup (experienced formula)
Drug: Fu Ling, Atractylodes, Atractylodes, Bitter Ginseng, Salvia, Qiang Wu, Dou Shu, etc.
2.External treatment
(1) Chinese herbal medicinal bath: Pai Huang lotion (empirical formula) medicinal bath: the formula consists of 17 herbs such as Phellodendron spp. leaf, Radix et Rhizoma, Xuan Shen, Scutellaria baicalensis, etc. to clear heat and detoxify, nourish yin and moisten dryness, dispel wind and relieve itching, which is adapted to psoriasis of common type and erythrodermic type.
(2) Chinese medicine vapor therapy: Chinese medicine vapor therapy is a treatment for skin diseases through the action of drug vapor when the patient lies in the Chinese medicine vapor therapy cabin. For common psoriasis, Dermatitis 2 (experienced formula) and Dermatitis 1 (experienced formula) can be used for herbal steam therapy.
(II) Western medicine treatment
1.Internal treatment
(1) Retinoic acid drugs: It can improve the hyperkeratosis of psoriasis and maintain the normal turnover of epithelial cells. Such as isotretinoin and avea, etc. have better therapeutic effect on psoriasis, especially plaque type psoriasis. Its main side effects are dryness and chapping of the lips and mouth, dryness of the mucous membrane of the nose, cheeks and eyes, headache, dizziness and nausea, etc. It has been reported that it can increase blood lipids and liver enzymes, early closure of epiphysis and has teratogenic effects in serious cases. Children and women of childbearing age should not be used as much as possible.
(2) Antibiotics: It is effective for the punctate psoriasis induced by streptococcal infection, and penicillin, erythromycin or cephalosporin antibiotics can be used.
(3) Leigengtang preparations: such as Leigengtang polysaccharide tablets taken internally have better efficacy on common psoriasis, its adverse reactions are mainly gastrointestinal reactions and menstrual disorders, a few patients have elevated transaminases and decreased white blood cells, so liver function and blood picture should be checked regularly.
(4) Licorice extract: Licorice extract is extracted from Chinese herbal medicine licorice. It was originally used for the treatment of hepatitis, and in recent years it has been found to have therapeutic effect on common psoriasis with heavy inflammation. There are mainly two kinds, one is Glycyrrhizin, a kind of intravenous drip drug, each time with 150-250mg of Glycyrrhizin, added into 5% glucose solution 250ml intravenous drip, once a day, 10 days as a course of treatment, can be used for 2 courses; one is Glycyrrhizin tablets, each time 150mg, taken orally, 3 times a day.
(5) Glucocorticosteroids: not used as regular treatment for common psoriasis, but only for external use to prevent the condition from rebounding or transforming common psoriasis into erythrodermic type or pustular psoriasis.
(6) Diyin Tablet: a compound preparation containing a variety of active peptides, amino acids and a variety of biological elements. It enhances human immunity, improves microcirculation, regulates the growth and differentiation of epidermal cells, and maintains the balance of protein metabolic process and various biological elements in the body. It is suitable for all types of psoriasis. Side effects are dry and flaky skin, peeling skin and elevated blood lipids.
(7) Immunotherapy
Cyclosporine has a cellular immunosuppressive effect and may also have some direct anti-epidermal proliferative effect. It is suitable for all types of psoriasis, especially for erythrodermic type, pustular type and severe joint type. Side effects are gastrointestinal reactions, increased blood pressure, liver and kidney damage, decreased white blood cells, and urinary tract irritation. The efficacy is good, but the price is high and difficult to popularize.
Mycophenolate mofetil is a new type of immunosuppressive agent. Mycophenolate mofetil selectively inhibits the proliferation of lymphocytes. In addition, it inhibits the formation of new blood vessels, antibody production, and the expression of glycoprotein molecules (e.g., adhesion factors) on the surface of lymphocytes. Side effects include nausea, dyspepsia, infection, leukopenia, and increased transaminases. The dose is 0.75-1.5 g/d, divided into 2-3 oral doses, and the course of treatment is more than 3 months.
Macrolide immunosuppressants such as tacrolimus and meclizine are new drugs newly developed for the treatment of psoriasis. They can inhibit the release of cytokines and suppress the activation and proliferation of T cells. Adapted to plaque type psoriasis.
Antimetabolites: such as methotrexate, etc. The side effects are large, such as bone marrow inhibition and liver toxicity, which are not applied in general.
(8) Biological agents: there are three main categories of biological agents used for psoriasis: recombinant human cytokines and growth factors, monoclonal antibodies, and fusion proteins.
Alfacet: a drug that reduces pathogenic T cells, is a human-derived lymphocyte function-associated antigen-3 (LFA-3) IgG-1 fusion protein that blocks the binding of LFA-3 on antigen-presenting cells to CD2 on T cells.
Ontac: Made by fusing the IL-2 receptor binding region with an enzymatically active diphtheria toxin transmembrane fragment. The affinity for IL-2R of activated T cells is 1000 times higher than that of resting T cells, so it can selectively kill activated T cells.
Infliximab (Remicade): a tumor necrosis factor alpha (TNF-α) monoclonal antibody that kills TNF-α-containing cells on the membrane surface by cytotoxic action and also induces apoptosis of activated T cells. In unstable erythrodermic or pustular psoriasis, it can rapidly control the disease and has no nephrotoxicity or hepatotoxicity compared with methotrexate, with the disadvantage that it must be injected slowly. It has been reported that the drug can cause relapse of tuberculosis, so it should be used with caution in people with a history of tuberculosis, and it has also been reported that rapid hypersensitivity reactions can occur with the application of the drug.
……
The efficacy of biological agents on psoriasis varies, and their clinical application is limited by factors such as more expensive drugs, still unable to solve the problem of relapse, and some biological agents have obvious side effects.
2, external treatment (1) keratin exfoliators and lubricants: such as salicylic acid ointment, urea cream, etc.
(2) Corticosteroids: have anti-inflammatory, reduce the mitotic and total mitotic rate of basal cells at the lesions and antipruritic effects. Hormone topical application has side effects such as skin atrophy, acne, capillary dilation and pigmentation changes, so it is only suitable for small skin lesions and not for large areas and long-term application.
(3) Retinoids: Regulate the mitosis of epidermal cells and the renewal of epidermal cells, so that the proliferation and differentiation of diseased skin can be normalized. Compared with internal retinoic acid, there are no systemic adverse reactions such as teratogenic and lipid-raising. For example, tazarotene is more effective in hypertrophic infiltrative psoriatic lesions, and it is more effective when combined with hormones and can reduce the side effects of hormones.
(4) Vitamin D3 derivatives: such as calcipotriol (Hercules) and tazarotene (Mengfu). It can regulate the differentiation and proliferation of keratinocytes. Used for resting skin lesions, the efficacy is better than hormone, and the combination with hormone can reduce the adverse effects. It has temporary local irritation and cannot be used on the face and thin skin areas.
(5) Capsaicin: It is a natural plant alkali, which can inhibit the inflammatory process involved in substance P. The main adverse effect of topical application is skin irritation.
(6) Tacrolimus: In addition to systemic application, it can also be used topically, avoiding some adverse reactions brought about by systemic application.
(7) Anthralin preparations: control the overproliferation of cells in the lesion area by inhibiting the division of DNA. It is suitable for the quiescent and regressive stages of psoriasis. Not for use on the face and genitalia. It can cause inflammation of the surrounding skin and coloration of the skin, hair and clothing.
Coal tar preparation: such as Zeta lotion, but the smell is unpleasant and difficult for patients to accept.
3.Physical therapy
(1) Ultraviolet ray therapy: It is suitable for patients with winter-type psoriasis vulgaris.
PUVA therapy: It is a traditional photochemotherapy and has a definite efficacy on common psoriasis. Through our 62 cases of clinical observation, the clinical cure rate is 78% and the effective rate is 89%. However, the main disadvantage is that it requires oral administration of photosensitizing drugs such as 8-methoxypsoralen, and it takes a long time to wait for the treatment after taking the drug, and it is inconvenient to use the sunscreen after taking the drug and on the day after the treatment. Its side effects include cataract and the possibility of causing skin cancer, so it limits its clinical application.
NB-UVB: In recent years, narrow-wave ultraviolet ray (NB-UVB) with a wavelength of 311nm has been developed for the treatment of psoriasis, and its efficacy is comparable to that of PUVA therapy, and no oral photosensitizer is needed. The treatment method is 2-3 times a week, the dose adjustment method is fixed each time to increase 0.1J/cm2, or increase the last dose of 15%-20%. Often irradiation about 8-15 times both visible lesion reduction, continue treatment until the lesions fade after maintaining irradiation for a period of time.
(2) Excimer laser: It is a new method of treating psoriasis in recent years. By directly irradiating the psoriasis lesions with extremely intense light, the laser can clear the lesions more quickly while avoiding the risk of damaging normal skin with UV light therapy.
Clinical studies have demonstrated improvement in plaque psoriasis lesions using excimer lasers capable of emitting 308 nm UVB with multiple minimal erythema exposures. In recent years, it has also been found that xenon chloride UVB laser capable of emitting 308nm UVB has better efficacy on plaque psoriasis than 311nm NB-UVB, which is more likely to cause T lymphocyte apoptosis.
4, psychotherapy: because psoriasis is a psychogenic skin disease, so on the basis of drug treatment to strengthen the psychological guidance of patients can often receive twice the effect with half the effort. Patients should be relieved of various misunderstandings and concerns about psoriasis and enhance their confidence in fighting with the disease.
(3) Combined treatment of Chinese and Western medicine
Under the guidance of the principle of diagnosis and treatment, the clinical efficacy is better with the main treatment of traditional Chinese medicine, combined with phototherapy, or with the external application of western medicine. According to the condition, Chinese medicine can be used internally and externally, combined with corticosteroid ointment or retinoid or calcipotriol, Meng’er skin topical; or Chinese medicine can be used internally and externally, combined with narrow-wave UVB or PUVA treatment, etc.
(D) medicine and food should be prohibited
Certain drugs can induce or aggravate psoriasis, the more certain ones are: β-blockers such as insulin, insulin, anti-inflammatory pain, tetracycline, chloroquine and other drugs. Patients with psoriasis, or those with a family history of psoriasis, are advised not to apply these drugs easily.
Some western drugs have serious side effects such as liver and kidney damage or bone marrow suppression, so they should be used with clinical caution, and when they must be used, they should strictly grasp the indications and regularly check liver and kidney functions and blood picture.
On the diet is best to caution patients to try not to eat beef and mutton, do not drink alcohol. Some scholars have suggested that eating beef and mutton can make the body leukotriene increase, aggravating the itchy skin disease.
As for the question of whether seafood and chili peppers can be eaten, there are two views. The traditional view is that these two foods will trigger or aggravate the disease and cannot be eaten, while the new view is that sea fish contains fish oil which is beneficial to psoriasis and advocates eating more sea fish. Chili peppers contain capsaicin which is effective for topical psoriasis and can be eaten by psoriasis patients. However, it is observed that clinically some psoriasis patients do get worse after eating seafood (including sea fish) or eating chili peppers. It is possible that what we usually eat is not only fish oil or capsaicin, but also other substances that may be detrimental to psoriasis, which is worth studying. If a certain food has no effect on the disease, it can be eaten boldly, and if not, it cannot be eaten.
V. Prognosis and regression
Most of the common psoriasis can be clinically cured after proper treatment, and even no recurrence for many years. Some patients first have common type skin lesions and then appear joint type performance. Patients with psoriasis vulgaris may be transformed into erythrodermic type or pustular type with improper treatment.