Compared with the prevalence rate of 1% to 2% in Europe and America, the prevalence rate of psoriasis in China is relatively low, 0.123% (1982). Because of the large population base in China, the absolute number of psoriasis patients is high and is increasing year by year.
Classification of severity
Before a reasonable treatment plan can be developed for a patient with psoriasis, the clinician needs to assess the severity of psoriasis. A simple way to define the severity of psoriasis is called the ten-point rule: i.e., psoriasis is considered severe if the body surface area involved (BSA) >10% (area of 10 palms) or the Psoriasis Area and Severity Index (PASI) >lO or the Dermatologic Disease Quality of Life Index (DLQI) >10. BSA <3
Principles of treatment
The aim 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 patient’s quality of life. 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: NSAIDs, methotrexate, leflunomide, cyclosporine, azathioprine, salazosulfapyridine, biologics, supportive therapy, combination therapy.
Topical treatment of psoriasis
Mild protective agents and emollients are appropriate in the acute phase of psoriasis; drugs with stronger effects can be used in the stable and receding phases, but should be started at low concentrations. Generally, they should be used once a day.
①Emollient: petroleum jelly, glycerin, mineral oil, urea, etc.
② keratin promoter: 2% to 5% coal tar or bran distillate, 5% to 10% black bean distillate, 3% salicylic acid, 3% to 5% sulfur, 0.1% to 0.5% anthracenol, 0.001% carbostriol ointment, 5% fish lithin.
③Keratolytic agent: 5%-10% salicylic acid, 10% rezosin, 10% sulfur, 20% urea, 5%-lo% Vulinic acid, o.1% vincristine, 10%-30% ichthyolipid.
Glucocorticoids: 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% difluazone.
⑤ Vitamin A acid class: 0.025% a 0.1% all-trans vitamin A 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% to 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% a 0.025% chorine ointment, 10% a 15% camptothecin, etc. Tazarotene, medium- and strong-acting glucocorticoids, and carboplatinol can be used as the first-line drugs for local treatment.
Physical therapy
1, long-wave ultraviolet (UVA): wavelength of 320-400nm, 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 a MOP) and UVA, a few can also apply UVB (290-320rim) method. It is mainly used for the treatment of moderate and severe psoriasis. It includes generalized common psoriasis, limited plaque psoriasis (topical psoralen + UVA can be used) 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 cause skin aging, pigmentation and skin cancer; there is an increased risk of cataract.
3.Widespectrum UVB: Medium-wave UVB with wavelength of 290-320nm. It is commonly used in the treatment of moderate and severe psoriasis, or local stubborn plaques. However, it can cause erythema, sunburn and hyperpigmentation. Long-term exposure has the possibility of causing 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 wavelength 311rim (308, 310, 311, 312am). It has good efficacy in the treatment of psoriasis, and little 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. It should be used with caution in patients with erythrodermic and pustular psoriasis.
Internal drug treatment
1, anti-infective drugs: bacterial, viral or fungal infection is an important cause of psoriasis, and infection can be controlled through the application of drugs. The purpose of treating psoriasis can be achieved. It is mainly applied to drippy 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 strictly follow the dermatological application dose <5mg?kg--?d". Nephrotoxicity is its main adverse effect. Therefore it should be carefully monitored and a nephrologist should be consulted if necessary. Severe psoriasis may recur up to 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, tacrolimus, aminophene, methomycin, levamisole, transfer factor, colchicine, vitamins.
7, biological agents (etanercept): etanercept is a human source TNF a only receptor antibody fusion protein, the generic name of injectable recombinant human type II TNF-ot receptor antibody fusion protein. 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 psoriasis vulgaris. 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 systemic therapy is required. In addition to this at least one of the following must be met.
(i) The condition is at a high risk level, making it difficult to use standard therapy due to drug-related toxicity.
(ii) Inability to tolerate standard systemic therapy.
(iii) Poor efficacy to standard therapy.
④ repeated hospitalizations are necessary to control the condition.
⑤ having comorbidities that prevent the use of systemic therapy drugs.
(vi) having severe erythrodermic and pustular psoriasis
⑦ Suffering from arthritic psoriasis.
TCM adopts the method of evidence-based medicine and combines the clinical manifestations of psoriasis with the dialectical identification of the disease in TCM to summarize the main TCM syndromes, treatment principles and TCM.
(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 (confined or palmoplantar pustular): the treatment is to clear heat and relieve dampness, using Cao Xie Xue Damp Tang plus or minus.
(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 poisoning and Yin injury type): the treatment is to clear heat and detoxify the toxins, nourish Yin and cool Blood. Lei Gong Tang and Kunming Shan Hai Tang have reliable efficacy on common, palmoplantar pustular and arthritic psoriasis. Compound Qing Dai capsule (pill), Yu Jin Yin Qi tablets, Yin Qi Ling and Yin Qi Punch are mainly used to clear heat and detoxify 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.
Psychotherapy.
Psychotherapy is to use the principles and methods of medical psychology, through the words, expressions, postures, attitudes and behaviors of medical personnel, or through the corresponding instruments and environment to change the patient’s feelings, awareness, emotions, personality, attitudes and behaviors, so as to enhance the patient’s confidence, eliminate tension, and achieve the purpose of promoting the recovery of the patient’s compensatory and regulatory functions, thus achieving the treatment of disease. Psychological treatment can be done by individual therapy, group therapy, family therapy and social therapy, or biofeedback therapy and abdominal breathing training can be used to enhance the patient’s intrinsic immune regulation function.
Prevention.
Prevention of psoriasis currently refers to avoiding exacerbation and relapse 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 alcohol and tobacco. 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.