Psoriasis is an immune-related chronic recurrent inflammatory skin disease. The aim of treatment is to control the disease, slow down the progression to the whole body, reduce the 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: ① regular: emphasize the use of currently accepted therapeutic drugs and methods in the dermatological science community; ② safety: all kinds of 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 efficacy; ③ individualization: when choosing a treatment plan, the condition, needs, tolerance, affordability, previous treatment history and adverse reactions of drugs of patients with psoriasis should be comprehensively considered. (3) Individualization: when choosing the treatment plan, we should comprehensively consider psoriasis patients’ condition, needs, tolerance, financial ability, previous treatment history and adverse reactions of drugs, etc., and formulate the treatment plan in a comprehensive and reasonable manner.
I. Topical drug treatment
For limited psoriasis with lesions < 3% of the body surface area, topical medication can be used alone; for severe cases and large areas of involvement, in addition to topical medication, physiotherapy and systemic treatment can be combined. Combination and sequential therapy with glucocorticoids, vitamin D3 derivatives, and tazarotene are often the first line of clinical treatment. Replacement therapy means using one topical drug for a period of time and switching to another drug before it has adverse effects; for example, super-potent glucocorticosteroids are used first, and then lower-grade glucocorticosteroids are used after the inflammation improves to 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; meanwhile, the application of emollients should be strengthened, which can reduce local irritation symptoms and drug dosage.
Second, physical therapy
Narrow-spectrum UVB, whose main wavelength is 311 nm, has become the main physical therapy for the treatment of 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 preparations or internal medications. PUVA is mainly used for the treatment of moderate to severe psoriasis, including generalized plaque, erythrodermic and pustular psoriasis, with an efficiency of about 80% when irradiated 3 ~ 4 times a week. 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 retinoids; 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, extensive plaque psoriasis that severely affects function. It can be given orally, intramuscularly or intravenously as a single dose or in 3 doses per week. It is clinically effective in 4 to 12 weeks, with a 75% reduction in PASI scores in 60% of patients after 16 weeks. Starting dose 5-10 mg/week; mean dose 10-15 mg/week; tapered to 2.5 mg every 4 weeks as lesions improve; initial dose 2.5-5 mg/week (no more than 30 mg) in elderly; dose must be determined on an individual basis; hematologic monitoring must be performed and MTX applied once a week, followed by folic acid 5 mg 24 h later and once daily thereafter, without compromising efficacy. reduce adverse effects.
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 2~4 months for a short period of time, and the course of treatment can be repeated at certain intervals for a maximum of 1~2 years. It is relatively safe if the dermatological dose (< 5 mg?kg-1?d-1) is strictly followed. Nephrotoxicity is its main adverse effect and therefore should be carefully monitored. Patients with severe psoriasis may relapse about 2 months after cessation of cyclosporine treatment.
3. Retinoic acid: Avelox is effective in the treatment of plaque, pustular, palmoplantar, drip, and erythrodermic psoriasis. 57% decrease in psoriasis rash and severity was observed at 12 weeks. Of the severe patients, 70% showed significant improvement after 1 year of treatment. It is safe and effective for long-term use. Avia 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, the biological agents that have been used in the clinical treatment of psoriasis or are under clinical trials in China mainly include tumor necrosis factor α antagonists (Etanercept, Infliximab, Adalimumab) and interleukin 12/23 antagonists (Ustekinumab). Each of these biologic agents has shown good efficacy and safety in the clinical treatment of psoriasis abroad. It is worth noting that the clinical application of biologic 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 pill, Yin elimination granules, Yin elimination 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-rich 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 the super-potent glucocorticoids have the best efficacy. Vitamin D3 derivatives have a slower clinical onset than glucocorticoids, but have relatively few adverse effects. Sequential therapy, in which glucocorticoids are used in combination with vitamin D3 derivatives separately or in combination, can be used to improve efficacy. Retinoids 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 in combination with 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. Droplet psoriasis: actively treat upper respiratory tract infections, reduce psychological stress and avoid trauma (allogeneic reaction). 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, are also available. Some patients with severe acute drip psoriasis or those for whom the above treatments are ineffective can consider short-term application of immunosuppressive drugs such as MTX, cyclosporine and morte-macrolide.
3.Pustular psoriasis: ①Limited pustular psoriasis: whether it is palmoplantar pustulosis or continuous acrodermatitis, topical drug therapy is preferred, and the first-line drugs include potent glucocorticoids, vitamin D3 derivatives and vitamin A acid drugs. They should be applied alone, in combination or in sequence. Intractable or frequently recurring cases can be treated with NB-UVB or 308 nm excimer light. Severe or recalcitrant cases often require systemic medication, with Avia preferred. If the effect is unsatisfactory or not tolerated, MTX, tretinoin, cyclosporine and morte mescaline can be chosen; ②Pustular psoriasis: most of them require systemic treatment. Avia, 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 for external application; 1:8,000 potassium permanganate solution or starch bath. Cyclosporine and infliximab have a rapid onset of action in the treatment of erythrodermic psoriasis, while Avelox and MTX have a slower onset of action and are currently used as first-line agents 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 cautiously if the patient’s toxic symptoms are heavy and life-threatening.
5.Psoriatic psoriasis (PsA): Treatment drugs include NSAIDs, anti-rheumatic drugs to improve the condition, glucocorticoids and biological agents. ①NSAIDs 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 although they do not have obvious pain relief and anti-inflammatory effects, they can control the deterioration of the disease and delay the destruction of joint tissues, and are mostly used for moderate to severe cases; ③biological agents have good clinical efficacy and can stop the development of PsA imaging; ④Raglan has anti-inflammatory and pain relief and immunosuppressive dual effect 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 if 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 daily and should not be used continuously for more than 2 weeks; strong or super-strong glucocorticoids are likely to lead to skin atrophy in the above-mentioned areas and their application is not advocated. 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 instructed to avoid scratching and use medium-acting glucocorticoids or vitamin D3 derivatives locally, or use them together; 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 the scales, and then glucocorticoid preparations can be used intermittently for a short period of time, or glucocorticoids and vitamin D3 derivatives can be used in combination. D3 derivatives.
2. Nail psoriasis: super-potent glucocorticoids or vitamin D3 derivatives are commonly used as local encapsulation therapy. For nail matrix psoriasis (such as nail pit 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 is first 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 dents. For patients with nail dents and nail stripping, first apply 1% methoxsalen solution topically to the terminal finger, and then irradiate UVA, 2 to 3 times a week, which has certain efficacy.
3.Psoriasis of vulva: weak, medium-acting or soft hormones should be used. Calcium-regulated phosphatase inhibitors are effective for psoriasis of mucous membrane. Mucosal sites generally cannot tolerate vitamin D3 derivatives. Avoid irritating agents such as dithranol or retinoids.
IX. Treatment of psoriasis in special populations
1. Children with psoriasis: routine application of emollients and topical treatment with weak glucocorticoids in children with mild disease can reduce erythema and desquamation, especially for children with predominantly 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 therapy drugs include retinoids, MTX and cyclosporine, which are generally used only for children with pustular, erythrodermic, arthritic or other treatments that are ineffective and must be monitored for a long time.
2, pregnant women with psoriasis: try to smooth or remit the disease 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 to be used with caution.
3. Psoriasis during lactation: 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. Elderly psoriasis: treatment is more difficult, and data on effective treatment are lacking. Treatment is mainly topical with carbotriol/betamethasone, UVB, betamethasone, etanercept and MTX. When other treatments are ineffective, cyclosporine needs to be used with caution.