Psoriasis is an immune-related chronic recurrent inflammatory skin disease. The aim of treatment is to control the disease, slow down its progression to the whole body, reduce self-conscious symptoms and skin damage, avoid recurrence as much as possible and improve the patient’s quality of life. Communication with patients and assessment of their condition are important parts of treatment.
When the effect of single therapy is not obvious in patients with moderate or severe psoriasis, combined, replacement or sequential therapy should be given. The following treatment principles are proposed.
①Regular: emphasize the use of currently accepted therapeutic drugs and methods in dermatological science;
②Safety: all treatment methods should ensure the safety of patients as the first priority, and the occurrence of serious adverse reactions should not be neglected in the pursuit of recent curative effects;
③Individualization: When choosing treatment plans, we should consider the condition, needs, tolerance, affordability, past treatment history and adverse reactions of drugs of patients with psoriasis comprehensively and reasonably formulate treatment plans.
I. Topical drug treatment
For limited psoriasis with lesions < 3% of the body surface area, topical medication can be used alone; for severe cases with a large area of involvement, in addition to topical medication, physiotherapy and systemic treatment can also be combined. Combination and sequential therapy with glucocorticoids, vitamin D3 derivatives, and tazarotene are often the first line of clinical treatment.
Replacement therapy means that one topical drug is used for a period of time and replaced with another drug before its adverse effects appear; for example, super-potent glucocorticosteroids are used first and then replaced with a lower grade glucocorticosteroid after the inflammation improves, which can avoid rapid tolerance. Precautions: mild and non-irritating topical drugs should be used in the acute stage, and stronger-acting drugs can be applied in the stable and receding stages, and starting from low concentrations; at the same time, the application of emollients should be strengthened, which can reduce local irritation symptoms and drug dosage.
Second, physical therapy
Narrow-spectrum UVB, with a wavelength of 311 nm, has become the main physical therapy for psoriasis. The effectiveness of narrow-spectrum UVB is the same as the early stage of photochemotherapy (PUVA), but the remission period is shorter. Narrow-spectrum UVB can be used alone or in combination with other topical agents or internal medications. PUVA is mainly used for the treatment of moderate to severe psoriasis, including generalized plaque, erythrodermic and pustular psoriasis. Note: Long-term application of PUVA can cause skin aging, pigmentation and skin cancer; there is an increased risk of cataract.
Systemic treatment
First-line drugs include methotrexate (MTX), cyclosporine, and vitamin A acid; second-line drugs include azathioprine, hydroxyurea, leflunomide, mescaline, glucocorticoids, and antibiotics.
1. MTX: mainly used for erythrodermic, arthritic, acute generalized pustular psoriasis and palmar and plantar, widespread plaque psoriasis that severely affects function. It can be given orally, intramuscularly or intravenously as a single dose or in 3 doses per week. Clinically effective in 4-12 weeks, with a 75% reduction in PASI scores in 60% of patients after 16 weeks. The initial dose is 5-10 mg/week; the average dose is 10-15 mg/week; as the lesions improve, the dose is gradually reduced by 2.5 mg every 4 weeks; the initial dose for the elderly is 2.5-5 mg/week (no more than 30 mg); the dose must be determined on an individual basis; hematological monitoring must be performed, and MTX must be applied once a week, followed by folic acid 5 mg 24 h later and once a day thereafter to reduce adverse effects without affecting the efficacy.
2. Cyclosporine: It has definite efficacy in psoriasis. It is mainly used for patients who are not well treated with other traditional treatments. It is usually applied for a short period of 2-4 months, and the course of treatment can be repeated at certain intervals for a maximum of 1-2 years. It is relatively safe if dermatological doses (<5 mg kg-1 d-1) are strictly adhered to. Nephrotoxicity is its main adverse effect and should be carefully monitored. Patients with severe psoriasis may relapse about 2 months after cessation of cyclosporine treatment.
3.Vitamin A acid: Avi A is effective in treating plaque, pustular, palmoplantar, drip, and erythrodermic psoriasis. 57% reduction in psoriasis rash and severity was observed at 12 weeks. In severe cases, 70% of patients showed significant improvement after 1 year of treatment. It is safe and effective for long-term use. Ave A is preferred for the treatment of generalized pustular psoriasis and erythrodermic psoriasis, alone or in combination with other treatments for palmoplantar pustulosis and generalized plaque psoriasis.
IV. Biological agents
According to different mechanisms of action, they can be divided into two categories: antagonizing key cytokines and targeting T cells or antigen-presenting cells. At present, biologic agents that have been used in the clinical treatment of psoriasis or are undergoing clinical trials in China mainly include tumor necrosis factor α antagonists (Etanercept, Infliximab, Adalimumab) and interleukin 12/23 antagonists (Ustekinumab). Each of these biologics has shown good efficacy and safety in the clinical treatment of psoriasis abroad. It is worth noting that the clinical application of biological agents for psoriasis is still short, and their long-term efficacy and safety need further observation.
V. Traditional Chinese medicine
1. Compound Chinese medicine: compound Qing Dai capsule (pill), Yu Jin Yin Qi tablets, Yin Qi Ling, Yin Qi punch, Ke Yin Wan, Yin granules, Yin tablets, etc. The main effect is to clear heat and detoxify, cool blood and dispel wind. It is used for heat toxicity, blood-heat and wind-rush type of common progressive psoriasis. The main efficacy of tablets, capsules and oral liquid, such as Blood stasis, Blood circulation, moistening and relieving itching, is to invigorate blood stasis, nourish blood and dispel wind, which is applicable to ordinary stationary psoriasis of blood stasis and wind dryness.
2. Single-formula and single-formula Chinese patent medicines: mainly Lei Gong Tang, Kunming Shan Hai Tang, Bai Shao Total Glycoside Capsule, Glycyrrhiza Sweetener, Glycyrrhizic Acid and Psoralen. During the use, blood and urine routine and liver and kidney function need to be strictly monitored.
VI. Psychotherapy
Through the medical personnel’s words, expressions, posture, attitude and behavior, or through the corresponding instruments and environment to change the patient’s feelings, awareness, emotions, personality, attitude and behavior, so that patients can enhance confidence and eliminate tension, so as to achieve the purpose of treating the disease. Psychological treatment can be done by individual therapy, group therapy, family therapy and social therapy, and biofeedback therapy and abdominal breathing training can also be used.
VII. Treatment of different types of psoriasis
1. Plaque psoriasis: topical glucocorticoids are the most widely used, and super-potent glucocorticoids have the best efficacy. Vitamin D3 derivatives are slower than glucocorticosteroids in clinical effect, but have relatively few adverse effects. Sequential therapy, in which glucocorticosteroids and vitamin D3 derivatives are used separately or in combination, can be used to improve efficacy. Vitamin A acid analogues can be used alone to treat mild plaque psoriasis.
Patients with moderate to severe plaque psoriasis need to be treated with systemic therapy, phototherapy, and a combination of other topical medications. MTX is currently the most cost-effective drug for plaque psoriasis, but long-term use can lead to liver fibrosis and acute bone marrow suppression. Cyclosporine for plaque psoriasis is characterized by a rapid onset of action and is generally used for short-term induction therapy.
2. Dropsy psoriasis.
Actively treat upper respiratory tract infections, reduce psychological stress, and avoid trauma (allogeneic reactions). Weak or medium-acting glucocorticoids can be used alone or in combination with vitamin D3 derivatives, emollients, and UVB. Tacalcitol is less irritating and can be used to treat acute drip psoriasis. Phototherapy should be used with caution in the acute inflammatory phase. Those caused by upper respiratory tract streptococcal infection can be given antibiotic treatment appropriately, commonly used penicillin, cephalosporin antibiotics, erythromycin, azithromycin, etc. Chinese medicines that clear heat and cool the blood, such as silver dandruff granules and compound Qing Dai Wan, etc., are also available. Some severe acute drip psoriasis or patients for whom the above treatments are ineffective can consider short-term application of immunosuppressants such as MTX, cyclosporine and morte-macrolide.
3. Pustular psoriasis.
(1) Limited pustular psoriasis: topical drug therapy is preferred for both palmoplantar pustulosis and continuous acrodermatitis, and the first-line drugs include potent glucocorticoids, vitamin D3 derivatives and vitamin A acid drugs. They should be used alone, in combination or in a sequential fashion. Intractable or frequently recurring cases are treated with NB-UVB or 308 nm excimer light. In severe or recalcitrant cases, systemic medication is often required, with Ave A being the first choice;
②Pustular psoriasis: most of them need systemic treatment. Ave A, MTX and cyclosporine are the first-line drugs, which can be selected according to the patient’s condition and individual situation. Foreign literature reports that biological agents are effective for various kinds of pustular psoriasis.
4. Erythrodermic psoriasis: Clean and disinfect rooms and clothing. Use low-irritant or non-irritant protective agents, such as petroleum jelly topical application; 1:8000 potassium permanganate solution or starch soaking bath. Cyclosporine and infliximab have a rapid onset of action in the treatment of erythrodermic psoriasis, while Avelox A and MTX have a slower onset of action and are currently the first-line agents used in the treatment of the disease. Sometimes they can be used in combination. The systematic application of glucocorticosteroids is generally not advocated, but can be used with caution if the patient’s toxic symptoms are severe and life-threatening.
5.Psoriatic psoriasis (PsA): The treatment drugs include NSAIDs, anti-rheumatic drugs to improve the condition, glucocorticoids and biological agents.
①Non-steroidal anti-inflammatory drugs are suitable for patients with mild active arthritis, but they are not effective for skin lesions and joint destruction;
②Anti-rheumatic drugs have a slow onset of action and do not have obvious pain relief and anti-inflammatory effects, but can control the deterioration of the disease and delay the destruction of joint tissue, and are mostly used in moderate to severe cases;
(iii) Biological agents have good clinical efficacy and can stop the development of PsA imaging;
④Legomitra has both anti-inflammatory and immunosuppressive effects, and is effective in relieving joint swelling and pain;
⑤ Total peony glucoside has been used for many years to treat rheumatoid arthritis and can reduce arthritic symptoms.
6.Treatment of reverse psoriasis: this type is mainly treated with local medication, and phototherapy can be applied when necessary, and systemic treatment is generally not used. Weak and medium-acting glucocorticoids can be used for the treatment of reverse psoriasis for a short period of time. It should be administered twice a day and should not be used continuously for more than 2 weeks; strong or super-strong glucocorticoids tend to lead to skin atrophy in the above-mentioned areas and are not advocated to be applied.
Calcium-regulated neurophosphatase inhibitors exert immunosuppressive effects by blocking the synthesis of various cytokines. Tacrolimus ointment at 0.1% or 0.03% and pimecrolimus cream at 1% are commonly used. Tacrolimus ointment is less irritating and well tolerated by patients, and can be used for the treatment of reverse psoriasis lesions.
VIII. Treatment of psoriasis in special areas
1. Scalp psoriasis: for mild scalp psoriasis, patients are advised to avoid scratching and use medium-acting glucocorticoids or vitamin D3 derivatives or both locally; for patients with thick scalp scales, salicylic acid preparations, tar lotion or vegetable oil or mineral oil can be used to seal the package overnight to remove scales, and then short-term intermittent use of glucocorticoid preparations or glucocorticoids and vitamin D3 derivatives can be used. compound preparations.
2. Nail psoriasis: super-potent glucocorticoids or vitamin D3 derivatives are commonly used as local encapsulation therapy. For nail matrix psoriasis (such as nail dimples and nail longitudinal ridge), the nail damage may be cured by only treating the lesions in the nail folds externally; for nail bed lesions (such as nail stripping), the nail plate should be cut off or sealed with highly concentrated urea ointment for about 1 week (protect the skin around the nail with adhesive tape before applying the drug), so that the nail plate softens and falls off, and then topical glucocorticoids or vitamin D3 derivatives are applied externally.
Tazarotene is more effective for nail stripping and nail pits. For patients with nail pits and nail stripping, topical application of 1% methicillin solution on the terminal fingers followed by UVA irradiation, 2-3 times a week, has certain efficacy.
3, vulvar psoriasis: weak, medium-acting or soft hormones should be used. Calcium-regulated phosphatase inhibitors are effective for psoriasis of mucous membrane. Mucosal sites are generally intolerant of vitamin D3 derivatives. Avoid irritating agents such as dithranol or vitamin A acids.
IX. Treatment of psoriasis in special groups
1. Children with psoriasis: Emollients are routinely applied to children with mild disease, and topical treatment with weak glucocorticoids can reduce erythema and desquamation, especially for children with mainly pruritic symptoms. Coal tar is commonly used as an effective drug for the treatment of psoriasis in children, and carbotriol is well evaluated for use in children. Narrow-spectrum UVB therapy for psoriasis in children is effective and less likely to cause cancer, but it should be noted that PUVA therapy is not suitable for pediatric patients. The most commonly used systemic therapies include retinoids, MTX and cyclosporine, which are generally used only in children with pustular, erythrodermic, arthritic or other treatments that are ineffective and must be monitored over time.
2. Psoriasis in pregnant women: try to make the disease stable or in remission before pregnancy to facilitate smooth passage through pregnancy. Emollients, topical glucocorticoids, and dithranol are considered safe for pregnant women. uvb is a safe second-line treatment after cyclosporine. the effectiveness of uvb has not been evaluated separately in pregnant women, but randomized controlled trials of patients with psoriasis have shown it to be effective in 65% of the population. There are data suggesting that etanercept and infliximab have no effect on the fetus and are recommended with caution.
3. Lactating psoriasis: First-line treatment for lactating women is limited to emollients and appropriate topical glucocorticoids as well as dithranol. Topical treatment should be used after breastfeeding. Retinoids, MTX, cyclosporine, biologic therapy, and PUVA are all relatively contraindicated in lactating women. The safest second-line treatment is UVB, and if further treatment is needed, the duration of breastfeeding should be shortened.
4. Aged psoriasis: treatment is more difficult, and data on effective treatment are lacking. The main treatment is topical treatment with carbotriol lentamethasone, UVB, betamethasone, etanercept and MTX. When other treatments are ineffective, cyclosporine needs to be used with caution.