I. Incidence rate
Compared with the prevalence rate of 1% to 2% in Europe and America, the prevalence rate of psoriasis in China is relatively low, which is 0.123% (1982). Because of the large population base in China, the absolute number of psoriasis patients is large and is increasing year by year.
Second, the classification of severity
Before formulating a reasonable treatment plan for psoriasis patients, clinicians need to assess the severity of psoriasis.
A simple method of defining the severity of psoriasis is called the tenth rule.
This means that a body surface area affected (BSA) >10% (the area of 10 palms) or a psoriasis area and severity index (PASI) >10 or a dermatologic quality of life index (DLQI) >10 is considered severe psoriasis. BSA <3% is considered mild, and 3% to 10% is considered moderate. Many factors such as the extent of skin lesions, location and the impact on quality of life should also be considered.
III. Treatment principles
The purpose of psoriasis treatment is to control the disease, slow down the process of development to the whole body, reduce symptoms such as erythema, scaling and local patch thickening, stabilize the disease, avoid recurrence, try to avoid side effects and improve the quality of life of patients. Communication with patients and assessment of their conditions during treatment is an important part of treatment.
When the effect of single therapy is not obvious in patients with moderate or severe psoriasis, combined, rotating or sequential therapy should be given. The following treatment principles should be followed.
①Regular: emphasize the use of currently accepted therapeutic drugs and methods in the dermatological science community.
②Safety: All treatment methods should be used to ensure the safety of the patient as the first priority, and serious adverse reactions should not occur in the pursuit of recent efficacy. Patients should not be made to apply methods that are harmful to their health for a long time without medical guidance.
③Individualization: When choosing a treatment plan, the patient’s condition, needs, tolerance, affordability, previous treatment history and adverse reactions to drugs should be taken into consideration comprehensively and reasonably to choose and formulate a treatment plan.
Treatment options for various types of psoriasis.
①Mild psoriasis: external drug treatment is the main treatment, phototherapy can be considered, and internal drug treatment if necessary, but possible adverse drug reactions must be considered.
②Moderate to severe psoriasis: ultraviolet light, photochemotherapy, methotrexate, cyclosporine, retinoids, biological agents, combination therapy.
③Pustular psoriasis: retinoids, methotrexate, cyclosporine, phototherapy/photochemotherapy, biologics, supportive therapy, combination therapy.
④Erythrodermic psoriasis: retinoids, cyclosporine, methotrexate, biologics, supportive therapy, combination therapy.
⑤ Arthritic psoriasis: non-steroidal anti-inflammatory drugs, methotrexate, leflunomide, cyclosporine, azathioprine, lujiazosulfapyridine, biological agents, supportive therapy, combined therapy.
IV. Topical drug treatment of psoriasis
It is appropriate to use mild protective agents and emollients in the acute stage of psoriasis; drugs with stronger effects are available in the stable and receding stages, but they should start from low concentrations. Generally, 2 times a day.
①Emollient: petroleum jelly, glycerin, mineral oil, urea, etc.
②Keratin promoter: 2%-5% coal tar or bran distillate, 5%-10% black bean distillate, 3% salicylic acid, 3%-5% sulfur, 0.1%-0.5% dithranol, 0.001% carbostriol ointment, 5% fish lithin.
③Keratolytic agents: 5%-10% salicylic acid, 10% razosin, 10% sulfur, 20% urea, 5%-l0% lactic acid, 0.1% vincristine, 10%-30% ichthyolipid
④Glucocorticoids: low potency: 0.5%-2.5% hydrocortisone acetate, 0.25%-l% methylprednisolone; medium potency: 0.1% hydrocortisone butyrate, 0.1% dexamethasone, 0.1% tretinoin, 0.03% flumethasone pivalate, 0.1% mometasone furoate; strong potency: 0.5% botrytisine, 0.1% betamethasone valerate, 0.1% harcionide; extra strong potency: 0.05% clobetasone propionate 0.05% clobetasol propionate, 0.05% halometasone, 0.05% diflubenzone.
⑤ Retinoic acid: 0.025%-0.1% all-trans retinoic acid, 0.05% isotretinoin, 0.1% adapalene gel, 0.01%, 0.05% and 0.1% tazarotene, etc.
(6) Vitamin D3 derivatives: carboxytriol, tacalcitol, osteoporotic triol.
(7) Dithranol: 0.1%-0.5% dithranol ointments, creams, pastes and compound preparations.
(8) Tar: 5% coal tar, l%-5% coal tar, 5%-10% black bean distillate, 5% bran distillate.
⑨ cytotoxic drugs: 0.05% aqueous solution of nitrogen mustard hydrochloride or ethanol solution.
⑩Other: 0.01%-0.025% chorine ointment, 10%-15% camptothecin, etc. Tazarotene, medium- and strong-acting glucocorticoids, and carboplatinol can be used as the first-line drugs for local treatment.
V. Physical therapy
1.Long wave ultraviolet (UVA): wavelength of 320-400 nm, the application of UVA irradiation treatment alone will produce mild to moderate improvement, not recommended for simultaneous other forms of phototherapy, UVA treatment is most commonly used as a component of PUVA therapy.
2. Photochemotherapy (PUVA): Photochemotherapy is a combination of oral or topical psoralen (8-MOP, 5-MOP) and UVA, and a few can also apply UVB (290-320 rim). It is mainly used for the treatment of moderate and severe psoriasis. It includes generalized psoriasis vulgaris, limited plaque psoriasis (topical psoralen + UVA) erythrodermic psoriasis and pustular psoriasis. Oral psoralen can cause gastrointestinal symptoms, such as nausea; high UVA exposure can cause skin erythema, burning, blistering, etc. Long-term application of PUVA can lead to skin aging, pigmentation and skin cancer; there is an increased risk of cataract.
3. Broad-spectrum UVB: Medium-wave UVB with a wavelength of 290 to 320 nm. It is often used for the treatment of moderate and severe psoriasis, or local stubborn plaques. However, it can cause erythema, sunburn and hyperpigmentation. Long-term exposure has the potential to cause cancer. Broad-spectrum UVB can be used in combination with internal and/or external drugs to increase the efficacy.
4. Narrow-spectrum UVB: Medium-wave UVB with a wavelength of 311 rim (308, 310, 311, 312 am). It has good efficacy in the treatment of psoriasis, and has small side effects such as erythema, pigmentation, DNA damage and carcinogenesis. Narrow-spectrum UVB treatment is superior to broad-spectrum UVB and safer than PUVA treatment. The effectiveness of narrow-spectrum UVB is the same as the early stage of PUVA, but the remission period is not durable. Narrow-spectrum UVB can be used alone or in combination with some topical preparations and internal drugs. It is one of the more widely used phototherapy for all types of common psoriasis. Patients with erythrodermic and pustular psoriasis should be used with caution.
Sixth, internal drug treatment
1, anti-infective drugs: bacterial, viral or fungal infection is an important cause of psoriasis, and infection can be controlled by applying drugs. The purpose of treating psoriasis can be achieved. It is mainly applied to the punctate psoriasis, common psoriasis and some erythrodermic and pustular psoriasis with upper respiratory tract infection, and the corresponding antibiotics or antibacterial drugs effective against Streptococcus haemolyticus can be used, such as penicillin, erythromycin, cephalosporin, etc.
2.Methotrexate: It is an effective drug for psoriasis treatment. Methotrexate is applied according to the severity of the disease, tolerance, urgency of treatment and the patient’s compliance with medical advice. It is mainly used for erythrodermic psoriasis, arthritic psoriasis, acute generalized pustular psoriasis, psoriasis with severe functional effects, such as palmar and plantar, and extensive plaque psoriasis.
3.Vitaminic acid: Avia is effective in the treatment of plaque, pustular, palmoplantar, droplet, and erythrodermic psoriasis. 57% decrease in psoriasis rash and severity was observed at 12 weeks. Significant improvement was observed in 70% of severe patients after 1 year of treatment. It is safe for long-term use. There is no time limit, so continued treatment is effective. Although symptoms of bone changes are rare, long-term use should be limited in some patients who develop calcification of ligaments and tendons. Preferred treatment: generalized pustular psoriasis, erythrodermic psoriasis; in combination with other treatments: palmoplantar pustulosis, generalized plaque psoriasis; alone therapy or adjuvant therapy: arthritic psoriasis.
4.Cyclosporine: it has definite efficacy on psoriasis. It is relatively safe to follow strictly the dermatological application dose <5 mg・(kg・d)-1". Nephrotoxicity is its main adverse effect. Therefore it should be carefully monitored and a nephrologist should be consulted if necessary. Severe psoriasis may recur 2 months after cessation of cyclosporine treatment. It is effective for all types of psoriasis, but should be used in patients with severe and failed psoriasis treated with various therapies.
5. Glucocorticoids: Application of glucocorticoids may lead to erythrodermic or generalized pustular psoriasis. Therefore, they should only be applied when deemed absolutely necessary by the dermatologist. Indications: Erythrodermic psoriasis that is difficult to control; generalized pustular psoriasis in which other drugs are ineffective or contraindicated; acute polyarticular psoriasis that can cause severe joint damage.
6.Other drugs that may be applied: salazosulfapyridine, tacrine, aminophenazone, methylsulfonamides, levamisole, transfer factor, colchicine, vitamins.
7.Biological agents (etanercept): etanercept is a human-derived TNF-α receptor antibody fusion protein, commonly known as recombinant human type II TNF-α receptor antibody fusion protein for injection. It was approved by the FDA in 1998 for the treatment of rheumatoid arthritis, in 2002 for the treatment of psoriatic arthritis, and in 2004 for the treatment of common psoriasis. Etanercept is the only biological agent approved by the FDA for the treatment of psoriasis in China, and there are other agents currently in clinical trials. The drug must be selected for treatment of moderate or severe psoriasis with a PASI score ≥ 10 and significantly affects the patient’s quality of life (DLQI > 10); the condition persists for 6 months. Treatment is ineffective and requires systemic therapy. In addition to this, at least one of the following must be met: (i) the condition is at a high-risk level and it is difficult to use standard therapy due to drug-related toxicity; (ii) standard systemic therapy is not tolerated; (iii) the efficacy of standard therapy is poor; (iv) repeated hospitalizations are necessary to control the condition; (v) the use of systemic therapy drugs is hindered by the presence of comorbidities; (vi) the presence of severe erythrodermic and pustular psoriasis; (vii) the presence of arthritic psoriasis.
Traditional Chinese medicine
Using the method of evidence-based medicine, the clinical manifestations of psoriasis are combined with the dialectical diagnosis of TCM to summarize the main TCM syndromes, treatment principles and herbal medicines.
(1) Blood-heat and wind-rich type (ordinary progressive stage): the treatment is to clear heat and cool the blood to remove wind, and the formula is based on cooling the blood and removing wind.
(2) Blood stasis in the skin type (unusual stationary phase): the treatment is to invigorate the Blood and remove stasis.
(③) Blood deficiency and wind dryness type (unusual waning phase): the treatment is to nourish Blood and remove wind.
(4) Damp-heat type (limited or palmoplantar pustular): the treatment is to clear heat and relieve dampness, and the formula is based on Cao Xie Di Dampness Tang with addition and reduction.
(⑤) Fire-poison incandescent type (generalized pustularity): the treatment is to remove the fire and detoxify the toxin, and the formula is based on Huang Lian Detoxification Tang with Wu Wei Disinfection Drink.
(6) Wind-dampness blocking the ligaments (arthropathic): the treatment is to remove wind and dampness, invigorate the blood and open the ligaments, using Douwuxiaosheng Tang and Santo Plus and Minus.
(7) Erythrodermic psoriasis (heat and toxicity injuring Yin): The treatment is to clear heat and detoxify toxins, nourish Yin and cool Blood. Lei Gong Vine, Kun
The treatment is to clear heat, nourish yin and cool the blood. Compound Qing Dai capsule (pill), Yu Jin Yin Qi tablets, Yin Qi Ling and Yin Qi Punch are mainly used for clearing heat and detoxifying toxins, and are suitable for the treatment of common psoriasis and other types of adjuvant therapy. Danshen and viper antithrombin injection are mainly herbal medicines for activating blood circulation and removing blood stasis; Qingkai Ling, licorice sweetener and Chuansuuning injection are mainly herbal medicines for clearing heat and detoxifying toxins, and Huangqi injection is mainly used for regulating immunity.
VIII. Psychotherapy
Psychotherapy is to use the principles and methods of medical psychology to change the patient’s feeling, awareness, emotion, character, attitude and behavior through the words, expressions, posture, attitude and behavior of medical personnel or through the corresponding instruments and environment, so as to enhance the patient’s confidence and eliminate tension, and to promote the patient’s compensation and recovery of regulatory functions, thus achieving the purpose of treating the disease. Psychological treatment can be done by individual therapy, group therapy, family therapy and social therapy. Biofeedback therapy and abdominal breathing training can also be used to enhance the patient’s intrinsic immune regulation function.
Prevention
Prevention of psoriasis currently refers to avoiding the aggravation and recurrence of the patient’s disease, i.e. prolonging the remission period. It is especially important for psoriasis patients to maintain good living habits and not to be addicted to smoking and alcohol. In addition, colds and inflammation of the throat can cause recurrence or aggravation of the disease. Proper physical exercise, improving physical fitness and maintaining mental and physical health are the keys to preventing psoriasis. As for the patient’s diet taboos need to vary from person to person, the patient can decide the trade-off depending on his or her skin reaction. Mental and psychological factors play an important part in the development of psoriasis, so relaxation is also important in prevention.