Are there procedures and standards for the treatment of psoriasis? International standard and regimen for the treatment of psoriasis with medications. No conflict of interest

Psoriasis is a disease that is not viral or fungal in nature, so it is not transmitted through the air, household objects, or through personal contact with a patient. The prerequisites for the occurrence of the disease are hereditary, psychological, and physiological factors.

Therapy for this dermatological disease involves the use of complex methods and approaches. There is a special treatment regimen for psoriasis, the use of which helps to effectively eliminate obvious and hidden symptoms of the disease. It is based on the following principles:

• Initially, the external manifestations of lichen planus are suppressed. For this, a number of local preparations are used in the form of sprays, ointments, balms, creams, lotions. With their help, the main symptoms of the disease are eliminated - itching and inflammation. The products also help improve the condition of the skin and make it elastic. Along with topical medications, a number of procedures are prescribed - physiotherapy, ultrasound, herbal medicine, electrosleep, PUVA method, light therapy, laser therapy, cryotherapy.
• Use of hormonal drugs. They are used only in extreme cases, they can quickly eliminate the symptoms of psoriasis, but have a significant disadvantage - a negative effect on other human organs.
• Biologics (monoclonal antibodies, GIPs) help the body's immune system cope with the manifestations of the disease.
• An important role is played by the prescription of vitamin complexes with the obligatory inclusion of vitamin D.

In addition to generally accepted therapy, there are other standards for the treatment of psoriasis: the Hungarian scheme, the Duma technique, the nsp program, the protocol for the treatment of psoriasis.

Hungarian psoriasis treatment regimen

There are several effective regimens that are widely used by doctors to maximize the period of remission of psoriasis. The Hungarian scheme is one of these. It was introduced into widespread medical practice in 2005.

This method of therapy is based on the idea of ​​protecting the human body from endotoxins. According to the hypothesis, they penetrate the intestinal wall, influencing the pathogenesis of the disease. This effect is achieved through the use of bile acid. It is used in the form of capsules or powder. This treatment helps to protect the body from the appearance of cytotoxins that provoke the development of skin diseases.

The Hungarian treatment regimen for psoriasis involves several stages:

1. Focusing. This period, which is 24 days, is needed to carry out a number of diagnostic measures with a detailed study of the patient’s tests. The purpose of this stage is to detect infections, fungi, and pathogenic microorganisms in the body.
2. Drug therapy. It lasts up to 2 months. During this time, the patient should take 1 capsule of dehydrocholic acid with meals in the morning and evening. If a person does not have breakfast in the morning, then it is allowed to take the drug at lunch.
3. Additional activities. With an advanced stage, the doctor may prescribe several injections (gluconate or calcium chloride).
4. A strict diet with the use of vitamins D, B12.

The Hungarian method was created and researched by Hungarian dermatologists, which is why it received the same name.

How is the Duma technique used for psoriasis?

This method of treating a disease involves consuming food, medications, various herbs and vitamins at a certain time, according to a schedule.

The Duma technique for psoriasis should provide the patient with the desired result only if all its principles are observed. This is the main difficulty of this type of therapy. The daily regimen begins at 8 am with the use of a herbal decoction (St. John's wort, chamomile and phytohepatol No. 3), and ends at 22:45 with a soothing herbal tea. The day is strictly divided into morning, lunch, evening and night.

In the morning there is a mandatory shower using tar soap. During breakfast, you should take milk thistle oil, Essentiale (2 capsules), vitamins A and E, and a zinc-based product. After 40 min. after breakfast you should take one of the probiotics (Bifikol, Kipacid, Linex, Probifor). The morning ends with a light fruit lunch.

The medications should be repeated for lunch and dinner. At night, take a herbal bath made from a decoction of chamomile and calendula. At approximately 10 pm, it is necessary to lubricate the skin affected by the disease with salicylic ointment.

What is the NSP psoriasis treatment program?

NSP is a manufacturer of drugs for psoriasis. Accordingly, from their products, the company’s specialists created their own method for getting rid of the skin disease, which was called the NSP Psoriasis Treatment Program.

Patients use Chlorophylli Liquid. Take it up to 2 times a day for one and a half to two months. The main property of the drug is to strengthen cell membranes and prevent the formation of pathological processes in the body's gene pool. Next, the drug Burdock is introduced into the regimen, which is taken 2 times a day, 2 capsules for 1 month.

After 3 weeks, patients are given Calcium Magnesium Chelate, Eight, Omega-3 if necessary. A course of therapy with these drugs allows one to achieve excellent results in the patient’s condition.

Dead Sea psoriasis treatment protocol

Some doctors recommend using the influence of the Dead Sea as one of the effective methods of treating psoriasis. There is a certain procedure that regulates the therapy of this dermatological disease - this is the protocol for the treatment of psoriasis. It should be prescribed individually to each patient by an experienced dermatologist.

It should be noted that therapy at the Dead Sea is not suitable for all patients, and for some it is simply contraindicated.

For limited rashes, external therapy is recommended.

Topical glucocorticosteroids are recommended:
Hydrocortisone** 1% ointment for external use is applied to skin lesions 2 times a day for 3–4 weeks.

Or.
Apply Alclomethasone cream 0.05%, ointment 0.05% to skin lesions 2-3 times a day for 3-4 weeks.
(Strength of recommendation level B (level of evidence –2++).
Or.
Triamcinolone ointment 0.1%, 0.025% for external use is applied to the affected areas of the skin 2 times a day for 3–4 weeks.
(Strength of recommendation level B (level of evidence –2++).
Or.
Apply mometasone** cream 0.1%, ointment 0.1%, lotion in a thin layer to the affected areas of the skin once a day for 3–4 weeks.
(Strength of recommendation level B (level of evidence –2++).
Or.
Methylprednisolone cream 0.1%, ointment 0.1%, emulsion 0.1% for external use, apply a thin layer to the affected areas of the skin once a day for 3–4 weeks.
(Strength of recommendation level B (level of evidence 2++).
Or.
Apply hydrocortisone butyrate cream 0.1%, ointment 0.1% to the affected areas of the skin 1-3 times a day for 3-4 weeks.
(Strength of recommendation level B (level of evidence –2++).
Or.
Betamethasone** cream 0.05%, 0.1%, 1%, ointment 0.05%, 0.1%, spray 0.05% applied to the affected areas of the skin 2 times a day for 3–4 weeks.
(Strength of recommendation level B (level of evidence –2++).
Or.
Fluocinolone ointment for external use 0.025%, cream for external use 0.025% is applied to the affected areas of the skin 2-4 times a day for 3-4 weeks.
(Strength of recommendation level B (level of evidence –2++).
Or.
Fluticasone ointment 0.005% for external use, cream 0.05% for external use is applied to the affected areas of the skin 2 times a day for 3–4 weeks.
(Strength of recommendation level B (level of evidence –2++).
Or.
Apply Clobetasol ointment, cream for external use 0.05% to the affected areas of the skin in a very thin layer once a day for 3-4 weeks.
(Level of strength of recommendation: C (level of evidence -2++).
Comments. Depending on the nature and localization of psoriatic rashes, topical glucocorticosteroid drugs are used in the form of various dosage forms - ointments, creams, sprays or lotions. If the severity of symptoms decreases, you can reduce the frequency of their use or prescribe treatment with other means of external therapy. In childhood, treatment should begin with topical glucocorticosteroid drugs of weak or moderate activity. For children of the first years of life, it is not recommended to use topical glucocorticosteroid drugs on the skin of the face, neck and natural folds, or to prescribe fluoride-containing drugs.
For severe peeling in areas of skin lesions, external products containing salicylic acid are recommended:
Salicylic acid** 2–5% ointment for skin lesions with severe peeling.
Strength of recommendation: D (level of evidence: 4).
Or.
Topical glucocorticosteroid drugs in combination with salicylic acid:
Betamethasone + salicylic acid ointment, cream, lotion for external use, apply to affected areas of the skin 2 times a day.

Or.
Mometasone 0.1% + salicylic acid 5% ointment is applied in a thin layer to the affected areas of the skin 2 times a day.
(Strength of recommendation: C (level of evidence: 2++).
Comments. In the progressive stage of psoriasis, it is recommended to use external agents containing salicylic acid in a low concentration of 2%. In the stationary and regressing stages, it is possible to prescribe products with a higher concentration of salicylic acid - 3% and 5%.
Preparations for external therapy containing analogues of vitamin D3 are recommended.
Apply calcipotriol cream, ointment 2 times a day to the affected areas of the skin for 6–8 weeks.

Comments. For long-term treatment, the daily dose should not exceed 15 g, and the weekly dose should not exceed 100 g of cream or ointment. It is not recommended to apply the drug to large areas of skin, the area of ​​which exceeds 30% of the body surface. Repeated courses of treatment are possible for subsequent exacerbations. The use of vitamin D analogues can serve as a method of choice for the treatment of psoriasis vulgaris, but they should not be prescribed before UV irradiation.
Or.
Betamethasone + calcipotriol ointment 1 time per day for adults for a period of no more than 4 weeks.
Level of strength of recommendation A (level of certainty of evidence – 1+).
Or.
Betamethasone + calcipotriol gel 1 time per day for adults for 8 weeks.

Comments. The area of ​​application of the combined drug betamethasone + calcipotriol should not exceed 30% of the body surface. The maximum daily dose is no more than 15 g, the maximum weekly dose is 100 g. The drug should remain on the skin overnight or during the day to achieve an optimal therapeutic effect. It is possible to re-use the drug under medical supervision. The use of a combination drug of calcipotriol and the corticosteroid betamethasone dipropionate can accelerate the achievement of clinical effect. Simultaneous external use of salicylic acid preparations leads to inactivation of vitamin D3 analogues.
Recommended preparations containing activated zinc pyrithione:
Pyrithione zinc aerosol is sprayed from a distance of 15 cm onto the affected areas of the skin 2-3 times a day. To achieve a lasting effect, it is recommended to continue use of the drug for 1 week after the disappearance of clinical symptoms.
Or.
Pyrithione zinc cream is applied in a thin layer to the affected areas of the skin 2 times a day for 1–1.5 months.

In the stationary stage, patients with dense infiltrated plaques are recommended:
5-10% ointment containing ichthyol; Apply to affected areas 1-2 times a day.
Strength of recommendation: D (level of evidence: 4).
Or.
Apply Naftalan oil 5-10% ointment to the affected areas 1-2 times a day.
Strength of recommendation: D (level of evidence: 4).
Or.
Apply birch tar ointment 5-10% to the affected areas 1-2 times a day.
Strength of recommendation: D (level of evidence: 4).
Recommended for psoriasis of the scalp:
Apply Clobetasol 0.05% shampoo daily to dry scalp (exposure 15 minutes), then rinse.
Strength of recommendation: D (level of evidence: 4).
Comments. Long-term proactive therapy with this shampoo for up to six months twice a week prevents the development of another exacerbation of dermatosis on the scalp.
Or.
Betamethasone dipropionate 0.05% + salicylic acid 2% lotion, spray applied to affected areas.
Strength of recommendation: C (level of evidence: 2+).
Or.
Betamethasone + calcipotriol gel 1 time per day for adults for 4 weeks.
Strength of recommendation: B (level of evidence: 1++).
Or.
Apply pyrithione zinc shampoo to damp hair, followed by a scalp massage, then rinse your hair, reapply and leave the shampoo on your head for 5 minutes, then rinse your hair thoroughly with plenty of water. Apply 2-3 times a week; course of treatment – ​​5 weeks.
Strength of recommendation: D (level of evidence: 4).
Comments. During the period of remission, shampoo can be used 1-2 times a week as a means of preventing relapses.
It is recommended for resistance to external therapy, widespread rashes (with moderate or severe psoriasis), systemic therapy (drugs of the antimetabolite group, systemic retinoids or immunosuppressants) or phototherapy:
Methotrexate** orally, intramuscularly or subcutaneously 10-15-20 mg, if necessary - up to 25-30 mg, 1 time per week.
Strength of recommendation level A (level of evidence – 1++).
Comments. Methotrexate is effective for psoriasis vulgaris, psoriatic erythroderma, pustular and arthropathic psoriasis. Before prescribing methotrexate and during treatment with methotrexate, the patient's condition is monitored. In order to timely identify side effects, it is necessary to monitor the condition of peripheral blood, for which a general blood test is performed once a week to determine the number of leukocytes and platelets. It is necessary to monitor the activity of liver transaminases, kidney function, and, if necessary, conduct an X-ray examination of the chest organs. Methotrexate therapy is stopped if the leukocyte count in the blood is less than 1.5x109/l, the neutrophil count is less than 0.2x109/l, and the platelet count is less than 75x109/l. An increase in creatinine levels by 50% or more of the initial level requires repeated measurement of creatinine levels. An increase in bilirubin levels requires intensive detoxification therapy. If diarrhea and ulcerative stomatitis develop, methotrexate therapy should be interrupted. If signs of pulmonary toxicity (especially dry cough without sputum) appear, methotrexate treatment should be discontinued. Signs of bone marrow suppression, unusual bleeding or hemorrhage, black tarry stools, blood in the urine or stool, or pinpoint red spots on the skin require immediate consultation with a doctor. Men and women of childbearing age should use reliable contraception during treatment with methotrexate and for at least 3 months afterward to avoid conception. Patients receiving methotrexate should avoid immunization (unless approved by a physician) for at least 3 months. Up to 1 year after taking the drug.
To reduce the likelihood of adverse events, treatment with methotrexate should be accompanied by oral folic acid 5 mg once a week 1–3 days after taking methotrexate.
After achieving a therapeutic effect, maintenance therapy is possible at the minimum effective dose (no more than 22.5 mg per week).
Or.
Acitretin at an initial dose of 0.3–0.5 mg per kg of body weight per day; the drug is taken 1–2 times a day; duration of use is 6–8 weeks, the optimal dose of the drug is selected taking into account the achieved result.

Comments. The drug is taken with food or with milk. Before prescribing acitretin and during therapy with acitretin, it is necessary to monitor the condition of patients. Liver function should be monitored before starting treatment with acitretin, every 1–2 weeks for the first month after starting treatment, and then every 3 months. If test results indicate pathology, monitoring should be carried out weekly. If liver function does not normalize or worsens, the drug should be discontinued. In this case, it is recommended to continue monitoring liver function for at least 3 months.
Fasting serum cholesterol and triglyceride levels should be monitored.
In patients with diabetes mellitus, acitretin may worsen glucose tolerance, so in the early stages of treatment, blood glucose concentrations should be checked more often than usual.
Due to the potential for impaired night vision, careful monitoring for visual impairment is necessary.
Due to the high teratogenicity of acitretin, a negative pregnancy test result should be obtained 2 weeks before starting treatment. During treatment, it is recommended to conduct additional pregnancy tests at least once a month. It is absolutely essential that every woman of childbearing potential use effective contraception without interruption for 4 weeks before starting treatment, during treatment, and for two years after completing treatment with acitretin. Acitretin should not be prescribed to nursing mothers. For children, acitretin is prescribed only if all other treatment methods are ineffective.
Or.
Cyclosporine** at an initial dose of 2.5–3 mg per kg of body weight per day in 2 divided doses (morning and evening). If no improvement is observed after 4 weeks of treatment, the dose can be increased to 5 mg per kg of body weight per day in the absence of clinically significant deviations in laboratory parameters.

Comments. Before prescribing cyclosporine and during treatment with cyclosporine, the patient's condition should be monitored. Regular monitoring of plasma creatinine concentration is necessary - an increase may indicate a nephrotoxic effect and require a dose reduction: by 25% if the creatinine level increases by more than 30% from the original, and by 50% if its level doubles. If dose reduction within 4 weeks does not lead to a decrease in creatinine levels, cyclosporine is discontinued. It is recommended to monitor blood pressure, blood levels of potassium, uric acid, bilirubin, transaminases, and lipid profile. When a satisfactory clinical result is achieved, cyclosporine is discontinued, and in the event of a subsequent exacerbation, it is prescribed at the previous effective dose. The drug should be discontinued gradually, reducing its dose by 1 mg/kg per week for 4 weeks or by 0.5–1 mg/kg every 2 weeks. The drug should be discontinued if a satisfactory response is not achieved after 6 weeks of treatment at a dose of 5 mg/kg per day. When treated with cyclosporine, the risk of developing lymphoproliferative diseases and other malignancies, especially of the skin, increases. The use of live attenuated vaccines during treatment with cyclosoprine is not recommended. Patients using cyclosporine should not receive concomitant PUVA therapy or midwave UV therapy.
Or.
Tofacitinib 10 mg twice daily orally, with or without food.
Strength of recommendation level B (level of evidence 2++).
Comments. During therapy, dose adjustment or discontinuation of therapy may be required if dose-dependent laboratory abnormalities develop, including lymphopenia, neutropenia and anemia. The drug is contraindicated during pregnancy, during breastfeeding, children under 18 years of age, with severe liver dysfunction, creatinine clearance less than 40 ml/min, severe infections, if infected with hepatitis B and C viruses. Before starting treatment with tofacitinib and during treatment, it is necessary monitor the content of hemoglobin, lymphocytes and neutrophils in the blood. Tofacitinib therapy is not initiated or discontinued in patients with a hemoglobin level less than 9 g/dL (or a decrease of more than 2 g/dL) or an absolute neutrophil count of less than 1000 cells/mm3 or a lymphocyte count of less than 500 cells/mm3 confirmed by re-evaluation . If the absolute neutrophil count persistently decreases to 500–1000 cells/mm3, the dose of tofacitinib should be reduced or discontinued until the absolute neutrophil count reaches more than 1000 cells/mm3.
Or.
Apremilast 30 mg 2 times a day, morning and evening, at intervals of approximately 12 hours, orally, regardless of meal time. An initial titration of the dose is required; after the initial titration, repeat titration is not required.
Strength of recommendation level B (level of evidence –2++).
Comments. Apremilast is effective in the treatment of moderate and severe psoriasis, including psoriasis of the nails, scalp, palmoplantar psoriasis, as well as various manifestations of arthropathic psoriasis - enthesitis, dactylitis, spondylitis. The administration of apremilast does not require continuous laboratory monitoring or screening. Taking apremilast is contraindicated during pregnancy. Before starting treatment, pregnancy must be excluded. Women of childbearing potential should use an effective method of contraception during therapy. Should not be used during breastfeeding. The drug is contraindicated in children under 18 years of age.
Or.
Phototherapy.
Strength of recommendation level B (level of evidence –2++).
Comments. Before prescribing phototherapy, patients' individual sensitivity to ultraviolet radiation is determined using a Gorbachev-Denfald biodosimeter on areas of untanned skin (on the forearm, lower abdomen, back or buttock), phototesting is carried out to determine the minimum erythemal dose (MED) during UVB therapy, with PUVA -therapy - minimum phototoxic dose (MPD). The results of phototesting for UVB therapy are assessed after 24 hours, for PUVA therapy - after 48 or 72 hours. The initial dose of radiation is prescribed based on the patient’s individual sensitivity to phototherapy or depending on skin type (according to T. B. Fitzpatrick’s classification) and the degree of tanning.
With all phototherapy methods, the main adverse reactions are erythema and itching. Less common are blistering, hyperpigmentation, or dry skin. Long-term multi-course phototherapy dose-dependently causes the development of symptoms of chronic photodamage to the skin. Lentigo, diffuse hyperpigmentation, and actinic elastosis most often develop. Less common are reticular seborrheic keratosis, telangiectasia, and mottled skin pigmentation. Since psoralens can penetrate into the bloodstream into the lens of the eye and bind to lens proteins under the influence of UVA, there is a potential risk of developing cataracts during PUVA therapy. With long-term multi-course PUVA therapy, the risk of developing squamous cell skin cancer increases. Factors that increase the risk of carcinogenic effects of PUVA therapy include a total number of sessions of more than 200; cumulative UVA dose more than 1100 J/cm2; irradiation of the genital organs in men; a large number of sessions in a short period; Skin types I and II; previous tumor processes of the skin; therapy with ionizing and x-ray radiation; treatment with arsenic preparations; other carcinogenic factors (smoking, insolation, treatment with cyclosporine, methotrexate, etc.);
To reduce itching and dry skin, patients must use emollients or moisturizers during the course of treatment. In cases of persistent itching, antihistamines and sedatives are prescribed. When hyperpigmentation of the skin occurs, zinc paste or photoprotective cream is applied to the pigmented areas to protect the skin from further irradiation. When conducting phototherapy, the following precautions must be observed: during the entire course of treatment, patients should avoid exposure to the sun and protect the skin of exposed areas of the body from sunlight with clothing or photoprotective cream; during a phototherapy session (with PUVA therapy - throughout the day), it is necessary to protect your eyes with photoprotective glasses with side protection, the use of which will help avoid the development of keratitis, conjunctivitis and cataracts; during procedures, lips, ears, nipples, as well as areas exposed to chronic sun exposure (face, neck, back of the hands) should be protected with clothing or photoprotective agents, if there are no rashes on them; the use of other photosensitizing drugs and cosmetics should be excluded: tetracycline, griseofulvin, sulfonamides, thiazide diuretics, nalidixic acid, phenothiazines, coumarin anticoagulants, sulfonylurea derivatives, methylene blue, toluidine blue, coal tar, aromatic oils, etc.;
Patients with psoriasis receiving multi-course phototherapy (UVB, UVB-311, PUVA therapy, PUVA baths, excimer light) must record the total number of procedures and the cumulative radiation dose received during their lifetime, indicating the date of the course of treatment, the method of phototherapy, number of procedures and total radiation dose. For patients with moderate forms of psoriasis who have previously received courses of PUVA therapy, rotation to a safer method of narrow-band medium-wave phototherapy is recommended.
Methods of medium-wave phototherapy (UVB/UVB-311) and PUVA therapy methods are recommended for the treatment of patients with psoriasis with widespread rashes (moderate and severe severity):
Selective phototherapy (broadband ultraviolet therapy): the initial radiation dose is 50–70% of the MED. When dosing irradiation depending on the skin type and degree of tanning of the patient, irradiation begins with a dose of 0.01–0.03 J/cm2. The procedures are carried out 3–5 times a week. In the absence of erythema, the single dose is increased every 2–3rd procedure by 5–30%, or by 0.01–0.03 J/cm2. 15–35 procedures are prescribed per course.
Strength of recommendation: C (level of evidence: 2+).
Or.
Narrowband mid-wave ultraviolet therapy: the initial radiation dose is 50–70% of the MED. When dosing irradiation depending on the skin type and degree of tanning of the patient, irradiation begins with a dose of 0.1–0.3 J/cm2. Procedures are carried out 3–4 times a week. In the absence of erythema, the single dose is increased each procedure or every other procedure by 5–30%, or by 0.05–0.2 J/cm2; if mild erythema appears, the dose is left constant. 15–35 procedures are prescribed per course.
Strength of recommendation level B (level of evidence –2++).
Comments. Narrowband medium wavelength 311 nm (UVB-311) is a more effective method of UVB therapy compared to selective phototherapy. Narrowband midwave therapy at 311 nm (UVB-311) is preferred for minor infiltration into skin lesions.
Or.
Excimer UV light therapy. When the rash is localized on the face, neck, torso, upper and lower extremities (except for the elbow and knee joints) and there is slight infiltration of the lesions, treatment begins with a radiation dose equal to 1 MED, with severe infiltration of the lesions - with a dose equal to 2 MED. When rashes are localized on the skin of the elbow and knee joints and there is slight infiltration of psoriatic plaques, the initial radiation dose is 2 MED, in the presence of dense infiltrated plaques - 3 MED. The single radiation dose is increased every procedure or every 2nd procedure by 1 MED, or 25% of the previous dose. Treatment is carried out with a regimen of 2–3 times a week. 15–35 procedures are prescribed per course.
Strength of recommendation level B (level of evidence –2++).
Comments. Treatment with excimer UV light is indicated mainly for limited forms of psoriasis with an affected area of ​​no more than 10% of the body surface.
Or.
PUVA therapy with oral photosensitizers. Oral photosensitizing drugs are taken in a dose of 0.6–0.8 mg per 1 kg of body weight at a time, 1.5–2 hours before irradiation with long-wave UV light. The initial UVA dose is 50–70% of the MFD. When dosing radiation depending on the skin type and degree of tanning of the patient, the initial dose is 0.25–1.0 J/cm2. Procedures are carried out 2–4 times a week. In the absence of erythema, the single dose of radiation is increased every 2nd procedure by a maximum of 30%, or by 0.25–1.0 J/cm2. When mild erythema appears, the radiation dose is left constant. The maximum values ​​of a single UVA dose are 15–18 J/cm2. 15–35 procedures are prescribed per course.
Strength of recommendation: A (level of evidence –1++).
Comments. PUVA therapy is preferable for severe infiltration in skin lesions. Before prescribing treatment, to identify contraindications, a clinical examination of the patient and a set of laboratory tests are recommended, including a general blood test, a general urinalysis, a biochemical blood test (including determination of liver and kidney function indicators), consultation with a therapist, ophthalmologist, endocrinologist, and gynecologist. According to indications, examination by other specialists is recommended. For widespread rashes, the entire skin is irradiated (general phototherapy); for limited rashes, the affected area of ​​the body is irradiated (local phototherapy). In a number of patients, lesions on the scalp and extremities regress more slowly than on other parts of the body. In such cases, general skin irradiation is combined with subsequent local irradiation of the head and/or extremities.
To reduce dyspeptic symptoms observed with oral administration of photosensitizers, they should be taken with meals, washed down with milk, or the dose should be divided into 2 consecutive doses with an interval of 30 minutes. In some cases, it is recommended to reduce the dose of the drug taken.
Or.
PUVA therapy with external application of photosensitizers. Photosensitizing drugs for external use are applied to the lesions 15–60 minutes before irradiation. The initial UVA dose is 20–30% of the MFD. When dosing radiation depending on the skin type and degree of tanning of the patient, the initial dose is 0.2–0.5 J/cm2. Procedures are carried out 2–4 times a week. In the absence of erythema, the single dose of radiation is increased every 2–3rd procedure by a maximum of 30%, or by 0.1–0.5 J/cm2. When mild erythema appears, the dose is left constant. The maximum values ​​of a single UVA dose are 5–8 J/cm2. 20–50 procedures are prescribed per course.
Strength of recommendation level B (level of evidence –2++).
Or.
PUVA baths with an aqueous solution of ammi major furocoumarin fruit. The initial UVA radiation dose is 20–30% of the MFD, or 0.3–0.6 J/cm2. For both general and local PUVA baths, irradiation is carried out 2–4 times a week. In the absence of erythema, the single dose is increased every 2nd procedure by a maximum of 30%, or by 0.2–0.5 J/cm2. In patients with skin types I–II, dosing is carried out in the dose range of 0.5–1.0–1.5–2.0–2.5–3.0 J/cm2. In patients with skin types III–VI, irradiation is carried out in the dose range of 0.6–1.2–1.8–2.4–3.0–3.6 J/cm2. When mild erythema appears, the dose is left constant. The maximum single dose of radiation for patients with skin types I–II is 4.0 J/cm2, for patients with skin types III–VI – 8.0 J/cm2. 15–35 procedures are prescribed per course.
Level of strength of recommendations (level of evidence: 2++).

Recommended
Expert advice
RSE at the RVC "Republican Center"
healthcare development"
Ministry of Health
and social development
Republic of Kazakhstan
from November 30, 2015
Protocol No. 18

Psoriasis- a chronic systemic disease with a genetic predisposition, provoked by a number of endo and exogenous factors, characterized by hyperproliferation and impaired differentiation of epidermal cells.

Protocol name: Psoriasis.

ICD X code(s):
L40 Psoriasis:
L40.0 Psoriasis vulgaris;
L40.1 Generalized pustular psoriasis;
L40.2 Persistent acrodermatitis (allopo);
L40.3 Palmar and plantar pustulosis;
L40.4 Guttate psoriasis;
L40.5 Arthropathic psoriasis;
L40.8 Other psoriasis;
L40.9 Psoriasis, unspecified

Date of development of the protocol: year 2013.
Protocol revision date: 2015

Abbreviations used in the protocol:
ALT - alanine aminotransferase
AST - aspartate aminotransferase
BR-Reiter's disease
DBST-diffuse connective tissue diseases
Mg - milligram
Ml - milliliter
INN - international nonproprietary name
CBC - complete blood count
OAM - general urine analysis
PUVA - therapy - a combination of long-wave ultraviolet (320-400 nm) irradiation and oral administration of photosensitizers

ESR - erythrocyte sedimentation rate
SFT - selective phototherapy
UFT - narrowband phototherapy

Protocol user: Dermatovenereologist at the skin and veins dispensary.

Clinical classification:

Psoriasis is divided into the following main forms:
vulgar (ordinary);
· exudative;
· psoriatic erythroderma;
· arthropathic;
· psoriasis of the palms and soles;
· pustular psoriasis.

There are 3 stages of the disease:
progressive;
· stationary;
· regressing.

Depending on prevalence:
· limited;
· widespread;
· generalized.

Depending on the season of the year, types:
· winter (exacerbation in the cold season);
· summer (exacerbation in the summer);
· uncertain (exacerbation of the disease is not associated with seasonality).

Diagnostic criteria:

Complaints and anamnesis
Complaints: skin rashes, itching of varying intensity, peeling, pain, swelling in the joints, limitation of movement.
History of the disease: onset of the first clinical manifestations, time of year, duration of the disease, frequency of exacerbations, seasonality of the disease, genetic predisposition, effectiveness of previous therapy, concomitant diseases.

Physical examination
Pathognomonic symptoms:
· psoriatic triad during scraping (“stearic spot”, “terminal film”, “blood dew”);
· Koebner's symptom (isomorphic reaction);
· presence of a growth zone;
· dimensions of elements;
· characteristics of the location of scales;
· psoriatic lesions of the nail plates;
· joint condition.

List of diagnostic measures

Basic diagnostic measures (mandatory, 100% probability):
general blood test in the dynamics of treatment
· general urine analysis in the dynamics of treatment

Additional diagnostic measures (probability less than 100%):
Determination of glucose
Determination of total protein
· Cholesterol determination
Determination of bilirubin
· Definition of ALaT
· Definition of ASaT
Determination of creatinine
Determination of urea
· Level I and II immunogram
Histological examination of skin biopsy (in unclear cases)
· Consultation with a therapist
· Consultation with a physiotherapist

Examinations that need to be carried out before planned hospitalization (minimum list):
· general blood analysis;
· general urine analysis;
· biochemical blood tests: AST, ALT, glucose, total. bilirubin.;
microreaction of precipitation;
· examination of stool for helminths and protozoa (children under 14 years of age).

Instrumental studies: not specific

Indications for consultation with specialists(in the presence of concomitant pathology):
· therapist;
· neurologist;
· rheumatologist.

Laboratory research
Leukocytosis, increased ESR
Histological examination of a skin biopsy: pronounced acanthosis, parakeratosis, hyperkeratosis, spongiosis and accumulation of leukocytes in the form of piles of 4-6 or more elements of “Munro microabcesses” (without vesiculation). In the dermis: cellular exudate; exocytosis of polynuclear leukocytes.

Differential diagnosis:

Seborrheic dermatitis	Lichen planus	Parapsoriasis	Pink lichen of Zhiber	Papular (psoriasiform) syphilide
Erythematous lesions in seborrheic areas of the skin, with greasy dirty yellowish scales on the surface.	The mucous and flexor surfaces of the extremities are affected. Papules are polygonal in shape, bluish-red in color, with a central umbilical depression, and a waxy sheen. Wickham grid when wetting the surfaces of plaques with oil.	The papules are lenticular, round, pink-red in color, flat with pronounced polygonal fields of skin pattern. The scales are round, large, and removed like a “wafer.”	On the skin of the neck and body there are pinkish spots with peripheral growth, the larger ones resemble “medallions”. The largest "maternal plaque".	On the lateral surfaces of the body there are pink miliary papules with slight peeling. Positive complex of serological reactions.

Treatment goals:

· stop the severity of the process;
· reduce or stabilize the pathological process (absence of fresh rashes) on the skin;
· remove subjective sensations;
· maintain ability to work;
· improve the quality of life of patients.

Treatment tactics.

Non-drug treatment:
Mode 2.
Table No. 15 (limit: intake of spicy foods, spices, alcoholic beverages, animal fats).

Drug treatment.

Treatment should be comprehensive, taking into account the basic aspects of pathogenesis (elimination of inflammation, suppression of keratinocyte proliferation, normalization of their differentiation), clinical picture, severity, complications.
Other drugs from these groups and new generation drugs can be used.

Main therapeutic approaches:
1. Local therapy: used for all forms of psoriasis. Monotherapy is possible.
2. Phototherapy: used for all forms of psoriasis.
3. Systemic therapy: used exclusively for moderate and severe forms of psoriasis.

Note: The following grades of recommendation and levels of evidence are used in this protocol
A - convincing evidence of the benefits of the recommendation (80-100%);
B - satisfactory evidence of the benefits of the recommendations (60-80%);
C - weak evidence of the benefits of recommendations (about 50%);
D - satisfactory evidence of the benefits of recommendations (20-30%);
E - convincing evidence of the uselessness of recommendations (< 10%).

List of essential medicines (mandatory, 100% probability) - drugs of choice.

Pharmacological group	INN of the drug	Release form	Dosage	Frequency of application	Note
Immunosuppressive drugs (Cytostatics), including anticytokine drugs	Methotrexate	ampoules, syringe Pills	10, 15, 25, 30 mg 2.5 mg	Once a week for 3-5 weeks Doses and prescription regimen are selected individually.	Methotrexate was approved for the treatment of psoriasis without any of the double-blind, placebo-controlled studies that are currently required. Clinical guidelines were developed by a group of dermatologists in 1972, defining the main criteria for prescribing methotrexate for psoriasis.
	Cyclosporine (level of evidence B-C)	Concentrate for the preparation of solution for infusion, capsules	(1 ml ampoules containing 50 mg); capsules containing 25, 50 or 100 mg of cyclosporine.		Cyclosporine concentrate for intravenous administration is diluted with isotonic sodium chloride solution or 5% glucose solution in a ratio of 1:20-1:100 immediately before use. The diluted solution can be stored for no more than 48 hours. Cyclosporine is administered intravenously slowly (drip) in an isotonic sodium chloride solution or 5% glucose solution. The initial dose is usually 3-5 mg/kg per day when administered into a vein, and 10-15 mg/kg per day when administered orally. Next, doses are selected based on the concentration of cyclosporine in the blood. Determination of concentration must be done daily. The radioimmunological method using special kits is used for the study. The use of cyclosporine should only be performed by physicians who have sufficient experience in the treatment of immunosuppressants.
	Infliximab (level of evidence - B)	powder d/p solution	100 mg	5 mg/kg according to the schedule
	Ustekinumab (level of evidence - A-B)	Bottle, syringe	45 mg/0.5 ml and 90 mg/1.0 ml	45 - 90 mg according to the schedule	It is used for moderate to severe forms of psoriasis, with the area and severity of skin lesions exceeding 10-15%. Selective inhibitor of pro-inflammatory cytokines (IL-12, IL - 23)
	Еtanercept* (level of evidence - B)	Solution for subcutaneous administration	25 mg - 0.5 ml, 50 mg - 1.0 ml.	Etanercept is prescribed at 25 mg twice a week, or 50 mg twice a week for 12 weeks, then 25 mg twice a week for 24 weeks.	It is used mainly for arthropathic psoriasis. Selective tumor factor inhibitor - alpha
External therapy
Vitamin D-3 derivatives	Calcipotriol (level of evidence - A-B)	ointment, cream, solution	0.05 mg/g; 0.005%	1-2 times a day	The use of calcipotriol more often than TGCS leads to skin irritation. Combination with TGCS may reduce the incidence of this effect. Dose-dependent side effects include hypercalcemia and hypercalciuria.
Glucocorticosteroid ointments (level of evidence B - C) Very strong (IV)	Clobetasol propionate	ointment, cream	0,05%	Continuous therapy: 2 times a day, for 2 weeks, then switch to a weaker TGCS Intermittent therapy: 3 times a day on days 1, 4, 7 and 13, then switch to a weaker TGCS	Intermittent therapy allows you to reduce the steroid load and minimize the risk of adverse events. The effectiveness of treatment will increase with complex therapy with corneoprotectors
Strong (III)	Betamethasone	ointment, cream	0,1%	1-2 times a day	Local use of THCS can cause stretch marks and skin atrophy, and these side effects are more pronounced with the use of highly active drugs and occlusive dressings.
	Methylprednisolone aceponate	ointment, cream, emulsion	0,05%	1-2 times a day
	Mometasone furoate	cream, ointment	0,1%	1-2 times a day
	Fluocinolone acetonide	Ointment, gel	0,025%	1-2 times a day
Moderately strong (II)	Triamcinolone	ointment	0,1%	1-2 times a day
Weak (I)	Dexamethasone	ointment	0,025%	1-2 times a day
	Hydrocortisone	cream, ointment	1,0%-0,1%	1-2 times a day
Calcineurin inhibitors	Tacrolimus (level of evidence: C)	ointment	100 g of ointment contains 0.03 g or 0.1 g of tacrolimus	1-2 times a day	There are several RCTs confirming the effectiveness of psoriasis therapy
Zinc preparations	Pyrithione zinc activated (level of evidence - C)	cream	0,2%	1-2 times a day	There are several comparative, randomized, multicenter, double-blind (with an additional open-label) placebo-controlled studies of the effectiveness of topical application of activated zinc pyrithione in mild to moderate papulous plaque psoriasis.

List of additional medicines (probability less than 100%)

Pharmacological group	INN of the drug	Release form	Dosage	Frequency of application	Note
Antihistamines*	Cetirizine	pills	10 mg	Once a day No. 10-14	To provide pronounced antiallergic, antipruritic, anti-inflammatory and antiexudative effects.
	Chloropyramine	pills	25 mg	Once a day No. 10-14
	Diphenhydramine	ampoule	1%	1-2 times a day No. 10-14
	Loratadine	pills	10mg	Once a day No. 10-14
	Clemastine	pills	10 mg	1-2 times a day No. 10-14
Sedatives*	Valerian extract	pills	2 mg	3 times a day10 days	If the pathological process on the skin is accompanied by an anxious state of mind and body associated with anxiety, tension and nervousness
	Guaifenesin. Dry extract (obtained from rhizomes with roots of valerian officinalis, lemon balm herb, St. John's wort herb, leaves and flowers of hawthorn or prickly hawthorn, passionflower herb (passionflower), common hop fruits, black elderberry flowers)	bottle	100 ml	5 ml 2 times a day
	Peony evasive rhizomes and roots	bottle	20-40 drops	2 times a day for a course of therapy
Sorbents*	Activated carbon	tablet	0.25 gr.	Once a day for 7-10 days
Desensitizing drugs*	Sodium thiosulfate	ampoules	30% - 10.0 ml	Once a day for 10 days
	Calcium gluconate	ampoules	10% - 10.0 ml	Once a day for 10 days
	Magnesium sulfate solution	ampoules	25% - 10.0 ml	Once a day for 10 days
Drugs that correct microcirculation disorders*	Dextran	bottles	400,0	Once a day No. 5
Vitamins*	Retinol	capsules	300-600 thousand IU (adults) 5-10 thousand IU per 1 kg (children)	1-2 months daily	Compound:
	Alpha tocopheryl acetate, retinol palmitate	capsules	100-400 IU	1-2 times a day 1.5 months
	Thiamine	ampoules	5%-1.0 ml	Once a day for 10-15 days
	Pyridoxine	ampoules	5%-1.0 ml	Once a day for 10-15 days
	Tocopherol	capsules	100mg, 200mg, 400mg	3 times a day 10-15 days
	Cyanocobolamine	ampoules	200µg/ml, 500µg/ml	1 time per day every other day No. 10
	Folic acid	pills	1mg, 5mg	3 times a day 10-15 days
	Ascorbic acid	ampoules	5%-2.0 ml	2 times a day for 10 days
Glucocorticosteroids*	Betamethasone	Suspension for injection	1.0 ml	Once every 7-10 days
	Hydrocortisone	Suspension for injection	2,5%	dose and frequency are determined individually	according to indications, depending on severity
	Dexamethasone	pills ampoules	0.5 mg; 1.5 mg 0.4% - 1.0 ml	dose and frequency are determined individually	according to indications, depending on severity
	Prednisolone	pills ampoules	5 mg 30 mg/ml	dose and frequency are determined individually	according to indications, depending on severity
	Methylprednisolone	Pills, Lyophilisate for the preparation of solution for injection	4 mg; 16 mg 250, 500, 1000 mg	dose and frequency are determined individually	according to indications, depending on severity
Drugs that improve peripheral circulation*	Pentoxifylline	ampoules	2% - 5.0 ml	Once a day for 7-10 days
Means that help restore intestinal microbiological balance*	1. Germless aqueous substrate of metabolic products of Escherichia coli DSM 4087 24.9481 g 2. germ-free aqueous substrate of metabolic products Streptococcus faecalis DSM 4086 12.4741 g 3. germless aqueous substrate of metabolic products Lactobacillus acidophilus DSM 4149 12.4741 g 4. germless aqueous substrate of metabolic products of Lactobacillus helveticus DSM 4183 49.8960 g.	bottle	100.0 ml	20-40 drops 3 times a day for 10-15 days
	Lebenin powder	capsules		3 times a day 21 days
	Lyophilized bacteria	bottle capsules	3 and 5 doses	3 times a day for the entire course of treatment
Hepatoprotectors*	Fumigata extract, milk thistle	capsules	250 mg		According to indications, mainly if there is concomitant liver pathology.
	Ursodeoxycholic acid	capsules	250 mg	1 capsule 3 times a day for the entire course of treatment
Immunomodulators*	Levamisole	pills	50 - 150mg	Once a day in courses of 3 days with a 4-day break	Mainly in case of identified disorders of the immune status. In order to normalize immunity.
	Liquid extract (1:1) from the grass of tussock pike and ground reed grass)	dropper container	25ml, 30 ml, 50 ml.	according to the scheme: 1 week - 10 drops x 3 times a day Week 2 - 8 drops x 3 times a day Week 3 - 5 drops x 3 times a day Week 4 - 10 drops x 3 times a day
	Sodium oxodihydroacridinyl acetate	pills ampoules	125 mg 1.0/250 mg	2 tablets 5 times a day No. 5 1 ampoule 4 times a day No. 5
Biogenic stimulants*	Phibs	ampoules	1.0 ml	s/c once a day for a course of 10 injections
External therapy*	CycloPyroxolAmin	shampoo	1,5%	Rub onto damp scalp until foam forms. Leave the foam for 3-5 minutes, rinse. Repeat the procedure 2nd time	During the period of relapse every other day. In stationary and regression stage 1 time per week
	Ketoconazole	shampoo	2%	1-2 times a day	Mainly in stationary and regression stages
Corneoprotectors	Preparations of PalmitoylEthanolAmine based on Derma-Membrane-Structure (DMS)	Cream, Lotion	17% 31%	Adjuvant therapy during remission: apply to the skin of the entire body 10 minutes before TGCS applications, daily, 2 times a day. Prevention of exacerbations in the stationary and regression stages: daily, 2 times a day for the whole body.	To restore the integrity of the stratum corneum, it has a local antipruritic, anti-inflammatory and antioxidant effect. Reduces skin sensitivity, reduces the frequency of TGCS use, and helps prolong remission.

Note: * - medicines for which the evidence base today is not sufficiently convincing.

Other types of treatment.

Physiotherapy:
· phototherapy (level of evidence from A to D. There are many therapeutic combinations where the effectiveness of phototherapy methods in complex treatment has been proven at a high level): PUVA therapy, PUVA - baths, SFT + UFT.
· phonophoresis, laser magnetic therapy, balneotherapy, heliotherapy.

Surgical intervention - no reason

Indicators of treatment effectiveness and safety of diagnostic and treatment methods:
· significant improvement - regression of 75% of rashes or more;
· improvement - regression from 50% to 75% of rashes.

Indications for hospitalization indicating the type of hospitalization:
· progression of a disease resistant to therapy (planned).
· acute joint damage, erythroderma (planned).
· severity and severity of the course (planned).
· torpid course of the disease (planned).

Preventive actions:
Diet low in carbohydrates and fats, enriched with fish and vegetables
· elimination of risk factors
· treatment of concomitant pathologies
· courses of vitamin therapy, herbal medicine, adaptogens, lipotropic agents
hydrotherapy
· Spa treatment.
· corneoprotectors (to restore the integrity of the stratum corneum, help prolong remission).
· emollients (mainly during the inter-relapse period - to restore the hydrolipid layer)

Further management:
Dispensary registration at the place of residence with a dermatologist, preventive anti-relapse treatment, sanatorium-resort treatment.
Patients are subject to referral to VTEK to determine disability (in severe clinical forms - employment with restriction of work in warm rooms).

1. Minutes of meetings of the Expert Council of the RCHR of the Ministry of Health of the Republic of Kazakhstan, 2015< >List of used literature: 1. “Skin and venereal diseases.” Guide for doctors. Edited by YK Skripkin. Moscow. - 1999 2. “Treatment of skin and venereal diseases.” Guide for doctors. THEM. Romanenko, V.V. Kaluga, SL Afonin. Moscow. - 2006. 3. “Differential diagnosis of skin diseases.” Edited by A.A. Studnitsina. Moscow 1983 4. Rational pharmacotherapy of skin diseases and sexually transmitted infections. Guide for practicing physicians. // Edited by A.A. Kubanova, V.I. Kisina. Moscow, 2005 5. “European Guide to the Treatment of Dermatological Diseases” Ed. HELL. Katsambasa, T.M. Lottie. // Moscow Medpress inform 2008.-727 p. 6. “Therapeutic reference book on dermatology and allergology.” P. Altmaier Ed. house GEOTAR-Med Moscow.-2003.-1246 p. 7. A 52-week trial comparing briakinumab with methotrexate in patients with psoriasis. Reich K, Langley RG, Papp KA, Ortonne JP, Unnebrink K, Kaul M, Valdes JM. // Source Dermatologikum Hamburg, Hamburg, Germany. [email protected]. http://www.ncbi.nlm.nih.gov/pubmed/22029980. 8. Weekly vs. daily administration of oral methotrexate (MTX) for generalized plaque psoriasis: a randomized controlled clinical trial. Radmanesh M, Rafiei B, Moosavi ZB, Sina N. // Source Department of Dermatology, Jondishapour University of Medical Sciences, Ahvaz, Iran. [email protected]. http://www.ncbi.nlm.nih.gov/pubmed/21950300 9. Weber J, Keam SJ. Ustekinumab // BioDrugs. 2009;23(1):53-61. doi: 10.2165/00063030-200923010-00006. 10. Farhi D. Ustekinumab for the treatment of psoriasis: review of three multicenter clinical trials // Drugs Today (Barc). 2010.-Apr; 46(4):259-64. 11. Krulig E, Gordon KB. Ustekinumab: an evidence-based review of its effectiveness in the treatment of psoriasis // Core Evid. 2010 Jul 27; 5:-22. 12. Kubanova A.A. Activated zinc pyrithione (Skin-cap) in the treatment of mild and moderate papulous plaque psoriasis. Results of the randomized, placebo-controlled trial ANTHRACITE. Vestn. dermatol. Venerol., 2008;1:59 - 65. 13. Safety and efficacy of a fixed-dose cyclosporinmicroemulsion (100 mg) for the treatment of psoriasis. Shintani Y, Kaneko N, Furuhashi T, Saito C, Morita A. // Source Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan. [email protected]. http://www.ncbi.nlm.nih.gov/pubmed/21545506. 14. Psoriasis in the elderly: from the Medical Board of the National Psoriasis Foundation. Grozdev IS, Van Voorhees AS, Gottlieb AB, Hsu S, Lebwohl MG, Bebo BF Jr, Korman NJ; National Psoriasis Foundation.// Source. Department of Dermatology and Murdough Family Center for Psoriasis, University Hospitals Case Medical Center, Cleveland, OH 44106, USA. J Am Acad Dermatol. 2011 Sep;65(3):537-45. Epub 2011 Apr 15. http://www.ncbi.nlm.nih.gov/pubmed/21496950 15. The risk of infection and malignancy with tumor necrosis factor antagonists in adults with psoriatic disease: a systematic review and meta-analysis of randomized controlled trials. Dommasch ED, Abuabara K, Shin DB, Nguyen J, Troxel AB, Gelfand JM. // Source Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. http://www.ncbi.nlm.nih.gov/pubmed/21315483 16. Infliximab monotherapy in Japanese patients with moderate-to-severe plaque psoriasis and psoriatic arthritis. A randomized, double-blind, placebo-controlled multicenter trial. Torii H, Nakagawa H; Japanese Infliximab Study investigators. http://www.ncbi.nlm.nih.gov/pubmed/20547039. 17. Efficacy of systemic treatments for moderate to severe plaque psoriasis: systematic review and meta-analysis. Bansback N, Sizto S, Sun H, Feldman S, Willian MK, Anis A. // Source Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada. http://www.ncbi.nlm.nih.gov/pubmed/19657180. 18. Long-term efficacy and safety of adalimumab in patients with moderate to severe psoriasis treated continuously over 3 years: results from an open-label extension study for patients from REVEAL. Gordon K, Papp K, Poulin Y, Gu Y, Rozzo S, Sasso EH. http://www.ncbi.nlm.nih.gov/pubmed/21752491 19. Efficacy and safety of adalimumab in patients with psoriasis previously treated with anti-tumour necrosis factor agents: subanalysis of BELIEVE Ortonne JP, Chimenti S, Reich K, Gniadecki R, Sprøgel P, Unnebrink K, Kupper H, Goldblum O, Thaçi D. // Source. Department of Dermatology, University of Nice, Nice, France. [email protected]. http://www.ncbi.nlm.nih.gov/pubmed/21214631 20. Integrated safety analysis: short- and long-term safety profiles of etanercept in patients with psoriasis. Pariser DM, Leonardi CL, Gordon K, Gottlieb AB, Tyring S, Papp KA, Li J, Baumgartner SW. // Source. Eastern Virginia Medical School and Virginia Clinical Research Inc, Norfolk, Virginia, USA. [email protected]. http://www.ncbi.nlm.nih.gov/pubmed/22015149. 21. Development, evaluation and clinical studies of Acitretin loaded nanostructured lipid carriers for topical treatment of psoriasis. Agrawal Y, Petkar KC, Sawant KK. // Source. Center for PG Studies and Research, TIFAC CORE in NDDS, Department of Pharmacy, The M.S. University of Baroda, Vadodara 390002, Gujarat, India. http://www.ncbi.nlm.nih.gov/pubmed/20858539. 22. Quality of life in patients with scalp psoriasis treated with calcipotriol/betamethasone dipropionate scalp formulation: a randomized controlled trial. Ortonne JP, Ganslandt C, Tan J, Nordin P, Kragballe K, Segaert S. // Source. Service de Dermatologie, Hôpital L'Archet2, Nice, France. [email protected]. http://www.ncbi.nlm.nih.gov/pubmed/19453810 23. A calcipotriene/betamethasone dipropionate two-compound scalp formulation in the treatment of scalp psoriasis in Hispanic/Latino and Black/African American patients: results of the randomized , 8-week, double-blind phase of a clinical trial. Tyring S, Mendoza N, Appell M, Bibby A, Foster R, Hamilton T, Lee M. // Source. Center for Clinical Studies, Department of Dermatology, University of Texas Health Science Center, Houston, TX, USA. http://www.ncbi.nlm.nih.gov/pubmed/20964660. 24. Psoriasis in the elderly: from the Medical Board of the National Psoriasis Foundation. Grozdev IS, Van Voorhees AS, Gottlieb AB, Hsu S, Lebwohl MG, Bebo BF Jr, Korman NJ; National Psoriasis Foundation. Source. // Department of Dermatology and Murdough Family Center for Psoriasis, University Hospitals Case Medical Center, Cleveland, OH 44106, USA. http://www.ncbi.nlm.nih.gov/pubmed/21496950. 25. Topical treatments for chronic plaque psoriasis. Mason AR, Mason J, Cork M, Dooley G, Edwards G. // Source. Center for Health Economics, University of York, Alcuin A Block, Heslington, York, UK, YO10 5DD. [email protected]. http://www.ncbi.nlm.nih.gov/pubmed/19370616. 26. European S3-Guidelines on the systemic treatment of psoriasis vulgaris. D Pathirana, AD Ormerod, P Saiag, C Smith, PI Spuls, A Nast, J Barker, JD Bos, G-R Burmester, S Chimenti, L Dubertret, B Eberlein, R Erdmann, J Ferguson, G Girolomoni, P Gisondi, A Giunta , C Griffiths, H Honigsmann, M Hussain, R Jobling, S-L Karvonen, L Kemeny, I Kopp, C Leonardi, M Maccarone, A Menter, U Mrowietz, L Naldi, T Nijsten, J-P Ortonne, H-D Orzechowski, T Rantanen, K Reich, N Reytan, H Richards, HB Thio, P van de Kerkhof, B Rzany. October 2009, volume 23, supplement 2. EAVD. 27. Evaluation of methylprednisolone aceponate, tacrolimus and combination thereof in the psoriasis plaque test using sum score, 20-MHz-ultrasonography and optical coherence tomography. Buder K, Knuschke P, Wozel G. // Source. Department of Dermatology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany. http://www.ncbi.nlm.nih.gov/pubmed/21084037. 28. Efficacy and safety of the Betamethasone valerate 0.1% plaster in mild-to-moderate chronic plaque psoriasis: a randomized, parallel-group, active-controlled, phase III study. Naldi L, Yawalkar N, Kaszuba A, Ortonne JP, Morelli P, Rovati S, Mautone G. // Source. ClinicaDermatologica, OspedaliRiuniti, Centro Studi GISED, Bergamo, Italy. http://www.ncbi.nlm.nih.gov/pubmed/21284407. 29. Evaluation of methylprednisolone aceponate, tacrolimus and combination thereof in the psoriasis plaque test using sum score, 20-MHz-ultrasonography and optical coherence tomography. Buder K, Knuschke P, Wozel G. // Source. Department of Dermatology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany. http://www.ncbi.nlm.nih.gov/pubmed/21084037. 30. Bioavailability, antipsoriatic efficacy and tolerability of a new light cream with mometasonefuroate 0.1%. Korting HC, Schöllmann C, Willers C, Wigger-Alberti W. // Source Department of Dermatology and Allergology, Ludwig Maximilian University, Munich, Germany. [email protected]. http://www.ncbi.nlm.nih.gov/pubmed/22353786. 31. Mometasonefuroate 0.1% and salicylic acid 5% vs. mometasonefuroate 0.1% as sequential local therapy in psoriasis vulgaris. Tiplica GS, Salavastru CM. // Source. Colentina Clinical Hospital, Bucharest, Romania. [email protected]. http://www.ncbi.nlm.nih.gov/pubmed/19470062. 32. Kligman A.M., Review Article Corneobiology and Corneotherapy - a final chapter. // International Journal of Cosmetic Science, 2011, - 33, - 197 33 Zhai H, Maibach H.I. Barrier creams - skin protectants: can you protect skin? // Journal of Cosmetic Dermatology 2002, 1, (1), - 20-23. 34. V.V. Mordovtseva “Corneotherapy for psoriasis” // Journal Corneoprotectors in Dermatology, 2012, pp. 25 - 28 (56).

List of developers:
Baev A.I. - Ph.D. senior researcher at the Research Institute of Dermatovenerology of the Ministry of Health of the Republic of Kazakhstan

Reviewers:
1. G.R. Batpenova - Doctor of Medical Sciences, chief freelance dermatovenerologist of the Ministry of Health of the Republic of Kazakhstan, head of the department of dermatovenereology of JSC "MUA"
2. Zh.A. Orazimbetova - Doctor of Medical Sciences, Head. course at the Kazakh-Russian Medical University
3. S.M. Nurusheva - Doctor of Medical Sciences, Head. Department of Kazakh National Medical University named after. S.D. Asfendiyarova

Indication of the conditions for reviewing the protocol: Protocols are updated as proposals are received from users of the protocol and new medicines are registered in the Republic of Kazakhstan.

Clinical protocols for diagnosis and treatment are the property of the Ministry of Health of the Republic of Kazakhstan

It is a difficult skin disease to treat and has a chronic course. In the mild stage, outpatient treatment can be carried out in a hospital. In case of a complicated medical history, if more than 30% of the skin is affected, treatment is carried out at the Central Clinical Hospital (CDH). Successful therapy is carried out only in the Central Clinical Hospital, which has departments based on psoriasis institutes. Psoriasis institutes study in detail the etiology of the development of dermatological problems of patients and provide treatment using a wide range of techniques. When each patient chooses the most appropriate treatment options for himself, remission occurs faster and lasts for a long time. The Moscow Institute specializes in the treatment of psoriasis at different stages and uses various methods for this.

Treatment regimen at the Institute of Psoriasis

The Psoriasis Institute offers treatment for patients with moderate to severe disease in a hospital setting. The history of the disease is carefully studied, and the patient undergoes a medical examination. After drawing up a complete clinical picture, the patient receives high-quality treatment relevant to the given degree of the disease. The therapy protocol is individual for each clinical case; how long the therapy period lasts and how many sessions the patient needs to undergo is determined by the conclusion and recommendation of the treating dermatologist. At the Moscow Institute of Psoriasis, patients undergo medication and physiotherapeutic treatment. Standards of drug therapy:

• sedatives;
• immunostimulants;
• hormonal and non-hormonal drugs;
• local and systemic drugs.

The Institute of Psoriasis and the Ministry of Health of the Russian Federation gives preference to a combined method of treating psoriasis, combining drug therapy with physiotherapy. Physiotherapeutic treatment at the Institute of Psoriasis is carried out using:

• photochemotherapy;
• PUVA baths;
• selective phototherapy.

Recommendations from dermatologists for the treatment of each degree of psoriasis are different; on average, one course of treatment is 20 days, during which it is possible to alleviate the patient’s condition and put him into a state of remission. But the entire clinical picture may change depending on the degree of development of psoriasis and the individual characteristics of the human body, and it is difficult to determine how long therapy will last, even in identical clinical cases.

Drug treatment

Drug therapy for psoriasis is determined by the standard of the Ministry of Health of the Russian Federation, according to the recommendation and conclusion of specialists after examining the person. Treatment of psoriasis in a hospital is carried out using:

• anticoagulants;
• detoxifiers;
• retinoids;
• cytostatics.

These are special medications that help reduce the area of ​​damage, improve regeneration and skin condition, and improve the general condition of the patient.

1. Anticoagulants inhibit the rate of blood clotting, due to which cell growth is inhibited and the progression of rashes stops. There are ointments, creams, and injections based on coagulants.
2. Detoxifiers help bind and remove toxins from the patient’s body, which are formed due to the death of epidermal cells. Treatment with detoxifiers is administered intravenously.
3. Retinoid drugs for psoriasis help cleanse the blood of toxins and regenerate the skin. Retinoids are prescribed to the patient on the recommendation of the attending physician, both during hospital treatment and after discharge.
4. Cytostatics help prevent cell division, this stops rashes and reduces the location of an existing rash on the body.

Fact! With the help of these medications, it is possible to normalize the condition of a patient with psoriasis in order to continue therapy with physiotherapeutic procedures.

UV irradiation in the treatment of psoriasis

Ultraviolet therapy has been successfully used in medical practice at the Central District Hospital and the Institute of Psoriasis for more than 25 years. By exposing the skin to UV radiation of varying power, it is possible to reduce the size of rashes, prevent the progression of psoriasis, improve the condition of the skin, and eliminate itching. In medical practice, UV irradiation is carried out by several types of rays.

1. Alpha ultraviolet rays. This type of UV irradiation is used in combination with special psoralens, which are taken orally by the patient. With the help of psoralens, UV rays are localized at the site of progression of the rash, concentrating the maximum radiation dose in this place.
2. Beta ultraviolet healing. This type of UV treatment for psoriasis is based on studying the skin characteristics of a particular patient and determining the minimum dose of radiation for him. A minimum dose of UV ray is directed to a small surface area of ​​the skin; the dose is subsequently increased several times, expanding the area of ​​the irradiated surface.

Various installations are used to treat psoriasis with ultraviolet rays. A variety of UV installations make it possible to treat psoriasis at a variety of locations and in various positions of the patient, both in a lying and standing position, and to provide both general and local UV effects on the affected areas of the skin. UV cabins, bathrooms, and local installations are used. How long should UV irradiation sessions last, their duration and quantity, is determined by the degree of damage to the epidermis.

Photochemotherapy

The Institute for the Study of Psoriasis in Moscow provides physiotherapeutic treatment of patients using photochemotherapy. This method is used to treat vulgar, exudative, erythrodermic and pustular types of psoriasis. The treatment method consists of long-wave UV exposure to foci of inflammation, taking photosensitizers orally, which increase the effectiveness of exposure to UV radiation on the body. UV rays have a positive effect on the skin with psoriasis, they relieve the inflammatory process, activate the synthesis of melanin in the skin, and have an immunostimulating effect. When the skin is exposed to UV rays, photosensitizers are concentrated in the epidermis. After 3 hours, DNA synthesis of epidermal cells selectively stops, an epidermal chemical reaction occurs, which leads to the death of lymphocytes and keratocytes. The patient begins remission, the epidermis layer is renewed. The photochemotherapy treatment protocol is as follows:

• the photosensitizer Methoxalen or Ammifurin is taken orally;
• UV irradiation of the location of the rash is carried out with a power of 0.25-1 J/cm;
• The UV dose gradually increases by 0.5 J/cm.

Clinical test results after the UV session determine the duration of the patient’s treatment. How many days a patient will need to undergo photochemotherapy depends on the test results, which determine the recommendations of the attending physician. One course of patient treatment consists of 20-25 sessions. In severe forms of psoriasis, the patient needs to undergo 2-4 courses of photochemotherapy.

PUVA baths for psoriasis

The treatment regimen for psoriasis in the hospital using PUVA baths is reminiscent of UV photochemotherapeutic treatment and includes UV exposure to the localized areas of psoriatic rashes after taking a bath with photosensitizing drugs. This method of therapy is less aggressive than taking photosensitizing drugs orally. This is due to the fact that photosensitizing drugs, when taken orally, cause such adverse reactions in patients as nausea, renal failure, and gastrointestinal disorders. PUVA bath provides only local exposure to photosensitizers, which is gentle on the body. The procedure for treating psoriasis with PUVA baths is as follows:

1. The patient takes a bath for 15-25 minutes with photosensitizers, which are solutions of Ammifurin or Mitoxalen. An alcoholic 3% solution of Ammifurin is diluted with water, 1:3 according to body weight, but not more than 180 mm per bath. Mitoxalen is produced in capsules; for a patient to take one procedure, up to 50 capsules of the drug are used, which are diluted in water, according to the patient’s body weight.
2. Local or general UV irradiation of the patient, with a radiation power of 0.25-1 J/cm.
3. Rest, sleep.

PUVA baths have a relaxing effect on the patient’s body; after such a procedure, the patient is allowed 1.5-2 hours of rest or sleep. The course of treatment consists of 25 sessions, which last several days, sometimes weeks.

Important! The number of procedures required to provide assistance is prescribed by the attending physician, depending on the course of the disease and the characteristics of the body.

PUVA baths are performed both for the treatment of patients and for the prevention of psoriasis in remission.

Selective phototherapy

A medical study of test results and observations of patients from the Institute of Psoriasis shows that selective phototherapy increases the persistence of remission by up to 80%. Selective phototherapy is carried out for patients with 30% of skin lesions, with manifestations of moderate and severe forms of psoriasis, with vulgar and exudative forms of psoriasis. Selective phototherapy involves exposure to combined UV radiation, mid-wave and long-wave ultraviolet rays. The method of selective phototherapy varies in intensity:

1. The first direction is the effect of a minimum dose of UV on the body and its subsequent increase, bringing it to a maximum in a few days. Minimum phototoxic dose of UV. The first session for the patient begins with exposure to a minimum dose of UV, 0.5 J/cm, with an increase in the dose of UV by 0.5 J/cm with each subsequent session in the absence of redness, burns, or allergic reactions on the skin. The treatment protocol determines the duration of the procedure and the number of sessions.
2. The second method involves UV radiation at a certain dose throughout the entire treatment period. A standard phototoxic dose of mid- and long-wave UV radiation is prescribed throughout the entire course of treatment. Treatment with UV radiation of the same power is carried out for several days, repeating 2-3 courses with breaks.

Photosensitizers are not used in selective phototherapy. The Institute focuses on a standard number of sessions of selective phototherapy to provide urgent care to patients at different stages of psoriasis development and to induce a state of long-term remission. These are 20-30 sessions with breaks of several days, if the patient’s condition requires it. For severe dry skin, which is often observed in patients during selective phototherapy, the patient is prescribed nourishing creams and ointments. The institute conducts restorative procedures for patients several days after completing the main rehabilitation course.

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Modern methods of treating psoriasis
Standards of treatment for psoriasis
Psoriasis treatment protocols

Profile: therapeutic, specialty: dermatovenerologist.
Treatment stage: polyclinic (outpatient).
Purpose of the stage: regression of skin rashes (significant reduction in infiltration, peeling).
Duration of treatment: 35 days.

ICD codes:
L40 Psoriasis vulgaris
L40.3 Palmoplantar pustulosis
L40.4 Guttate psoriasis
L40.9 Psoriasis, unspecified.

Definition: Psoriasis is a chronic recurrent genotypic dermatosis of a multifactorial nature, with a predominant localization of epidermal papules, symmetrically located on the extensor surfaces of the extremities, in the scalp, with possible damage to the nail plates and joints.

Classification:
1. Psoriasis vulgaris (vulgar)
2. Exudative psoriasis
3. Seborrheic psoriasis
4. Rupioid psoriasis
5. Eczematoid psoriasis
6. Warty psoriasis
7. Follicular psoriasis
8. Psoriasis of the palms and soles
9. Nail psoriasis
10. Pustular psoriasis
11. Arthropathic psoriasis
12. Psoriatic erythroderma.

According to the course (stages): progressive, stationary, regressive.

Risk factors: Family history, trauma (physical, chemical), endocrine disorders (pregnancy, menopause), psychogenic factors (psycho-emotional stress), metabolic disorders, infection (eg hemolytic streptococcus in the tonsils), use of certain medications (eg beta- adrenergic blockers, antimalarials), alcohol abuse.

Diagnostic criteria:
1. Papules are pinkish-red in color, covered with loose silvery-white scales, with a tendency to grow peripherally and merge into plaques of various sizes and shapes. Plaques can be isolated, small or large, occupying large areas of the skin.
2. Predominant localization - extensor surfaces of the upper and lower extremities (especially elbows and knees), scalp, lumbar region.
3. Psoriatic triad:
- the phenomenon of “stearin stain”: characterized by increased peeling when scraped, which makes the surface of the papules resemble a drop of stearin;
— the phenomenon of “terminal film”: after complete removal of the scales, further scraping peels off a thin, delicate translucent film covering the entire element;
- the phenomenon of “blood dew” (Auspitz phenomenon): with further scraping, after the “terminal film” is rejected, pinpoint (drip) bleeding occurs on the exposed wet surface.
4. “Thimble” symptom - pinpoint depressions on the surface of the nail plates. Loosening of the nails, brittle edges, discoloration, transverse and longitudinal grooves, deformations, thickening, and subungual hyperkeratosis may also be observed.

List of main diagnostic measures:
1. Microreaction
2. General blood test (6 parameters)
3. General urine test
4. Feces on worm eggs
List of additional diagnostic measures:
1. Definition of ALT
2. Determination of ALT
3. Determination of bilirubin
4. Determination of blood sugar
5. Ultrasound of the abdominal organs.

2. Antihistamine therapy (for severe itching): chloropyramine 25 mg, cetiresin 10 mg, ketotifen 1 mg.

3. Topical glucocorticoids: betamethasone 0.1% ointment,
methylprednisolone 0.1% ointment, triamcinolone acetonide 0.1% ointment, hydrocortisone 1% ointment.
Only weak corticosteroids (Class II) should be applied to the face and skin folds.
For the treatment of skin lesions of other localization, only strong and very strong topical glucocorticosteroids (classes III-IV) are considered quite effective.
With progressive psoriasis, local or systemic glucocorticosteroids should not be prescribed, as this can cause worsening of the disease up to the development of erythrodermic or pustular forms, which are difficult to respond to drug therapy.

4. Salicylic acid (ointment). Typically, ointments with a concentration of 0.5 to 5% salicylic acid are used. It has antiseptic, anti-inflammatory, keratoplastic and keratolytic effects and can be used in combination with tar and corticosteroids. Salicylic ointment softens the flaky layers of psoriatic elements, and also enhances the effect of local steroids by enhancing their absorption, therefore it is often used in combination with them.
Salicylic acid itself easily penetrates the skin, it is not used on large surfaces and in concentrations greater than 2%, and in children even 2% ointment is applied only to limited areas of the skin. Intolerance is rare, but salicylic acid may cause increased skin inflammation as a side effect.

5. Naftalan oil. A mixture of hydrocarbons and resins, contains sulfur, phenol, magnesium and many other substances. Naftalan oil preparations have
anti-inflammatory, absorbable, antipruritic, antiseptic, exfoliating and reparative properties.
To treat psoriasis, 5-10% naphthalan ointments and pastes are used. Naphthalan oil is often used in combination with sulfur, ichthyol, boric acid, and zinc paste.

6. 5% sulfur-tar ointment, which has absorbable properties.

7. Zinc pyrithione. Active substance available in the form of aerosols, creams and
shampoos. It has an antiproliferative effect - it suppresses the pathological growth of epidermal cells that are in a state of hyperproliferation. Last property
determines the effectiveness of the drug for psoriasis. The drug relieves inflammation, reduces infiltration and peeling of psoriatic elements.
Treatment is carried out on average for a month. For the treatment of patients with lesions of the scalp, aerosol and shampoo are used (applied 3 times a week), for skin lesions - aerosol and cream (applied 2 times a day). The drug is well tolerated and is approved for use from 3 years of age.

8. Calcipotriol, an analogue of vitamin D3, is registered as a medicinal product in the form of an ointment, cream and solution for rubbing into the scalp. Calcipotriol inhibits the proliferation of keratinocytes, accelerates their morphological differentiation, affects the factors of the skin immune system that regulate cell proliferation, and has anti-inflammatory properties. Not recommended for use on the face and genitals. A maximum of 100 grams can be used weekly. ointment, cream or solution.

11. For severe psoriasis, phototherapy is used as treatment. A significant place in the treatment of psoriasis belongs to long-wave UV rays in combination with photosensitizers (in the stationary stage).

List of essential medications:
1. 30% sodium thiosulfate, amp
2. 10% calcium gluconate, amp
3. 10% calcium chloride, amp
4. Chloropyramine 25 mg, tablet
5. Cetirezin 10 mg, tablet
6. Ketotifen 1 mg, tablet
7. Betamethasone 0.1% ointment
8. Methylprednisolone 0.1% ointment
9. Triamcinolone acetonide 0.1% ointment
10. Hydrocortisone 1% ointment.
11. Salicylic acid 2% ointment
12. Retinol 114 mg, tablets
13. Activated carbon 0.25 g, table.

List of additional medications:
1. 5% sulfur-tar ointment
2. 5-10% naphthalan ointments and pastes
3. Zinc pyrithioneate in the form of aerosols, creams, shampoos
4. Calcipotriol (ointment, cream, solution)
5. Methotrexate, 2.5 mg tablet; fl. 0.005 each; 0.05 and 0.1 g.
6. Prednisolone 5 mg amp, tab.
7. Dexamethasone 4 mg amp.

Criteria for transfer to the next stage:
If treatment is effective: clinical observation once every 3 months.
Criteria for transfer to hospital: slow dynamics and lack of regression of skin rashes, lack of effect of the therapy.

International standard and regimen for the treatment of psoriasis with medications

Appendix G4. Monitoring laboratory parameters during treatment with cyclosporine

In the development of psoriasis, hereditary predisposition, dysfunction of the immune, endocrine, nervous systems, adverse effects of environmental factors, etc. are important.

A number of genes (PSORS) have been described, the presence of which predisposes to the development of the disease. In particular, HLACw6 and HLADR7 antigens are more often detected in patients with psoriasis.

Provoking factors include psycho-emotional stress, chronic infections (usually streptococcal infections), alcohol abuse, taking medications (lithium salts, beta-blockers, chloroquine/hydroxychloroquine, oral contraceptives, interferon and its inducers, etc.).

In psoriasis, the immunopathophysiological process is initiated through the presentation of antigen by dendritic antigen-producing cells and the subsequent stimulation of the release of IL12 and IL23 by T cells, resulting in the proliferation and differentiation of T lymphocytes into Th-1 and Th-17.

These subpopulations of T lymphocytes express genes responsible for the synthesis and subsequent release into tissues of a large number of different inflammatory mediators.

In particular, Th-1 predominantly stimulates immune responses through excessive release of IL-2, IFN-?, TNF-a. In turn, Th-17 is responsible in the body for both protection from various pathogenic agents (this action is realized through the production of IL21 and IL22) and tissue inflammation (respectively, through IL17A).

As a result of stimulation of tissue inflammation processes, IL17A-induced activation and hyperproliferation of keratinocytes occurs. The latter, acting on the feedback principle, themselves contribute to the further formation of pro-inflammatory cytokines and chemokines in the skin, which leads to acanthosis and disdifferentiation of epidermal keratinocytes.

Interval in weeks

General blood test 1

Liver function indicators 2

Urine pregnancy test

Cholesterol, triglycerides 4

Notes 1 Red blood cells, leukocytes, platelets. 2 Aminotransferases, alkaline phosphatase, gamma-glutamyl transpeptidase, bilirubin. 3 Sodium, potassium. 4 It is recommended to determine 2 weeks in advance. before treatment and on the day of therapy (on an empty stomach). 5 Only if indicated (muscle cramps).

1.4 Coding according to ICD 10

L40.0 – Psoriasis vulgaris (vulgar, plaque)

L40.1 – Generalized pustular psoriasis

L40.2 – Acrodermatitis persistent Allopo

Generalized pustular psoriasis of Zumbusch

L40.3 – Palmar and plantar pustulosis

L40.4 – Guttate psoriasis

L40.5 Arthropathic psoriasis (M07.0-M07.3*, M09.0*)

L40.8 – Other psoriasis

Flexor inverse psoriasis

Exudative psoriasis

1.6 Clinical picture

Patients complain of rashes and a feeling of skin tightness. Patients with psoriasis vulgaris may experience itching of varying degrees of intensity. Itching, often painful, is accompanied by exudative and seborrheic psoriasis.

Psoriasis vulgaris (vulgar, plaque) is characterized by the appearance on the skin of papular elements of a pink-red color with clear boundaries, prone to fusion and the formation of plaques of various shapes and sizes, covered with silver-white scales.

Plaques are located mainly on the scalp, the extensor surface of the elbow, knee joints, in the lumbar region, sacrum, but can be localized on any other areas of the skin.

In patients with obesity, diabetes mellitus, and thyroid dysfunction, there is increased exudation in the lesions, and grayish-yellow scale-crusts appear, tightly adjacent to the surface of the plaques, which is why the psoriatic triad is difficult to detect (exudative psoriasis).

When the rash is localized only on seborrheic areas of the skin (scalp, nasolabial and postauricular folds, chest and interscapular area), seborrheic psoriasis is diagnosed.

With seborrheic psoriasis, the scales usually have a yellowish tint, while on the head the peeling can be very pronounced, and the rashes can move from the scalp to the skin of the forehead, forming the so-called “psoriatic crown”.

Manifestation of psoriasis: stages of the disease

The disease can affect the skin on different scales. When small plaques appear on the skin, the patient independently copes with the treatment of psoriasis, following the recommendations of a specialist. This development option does not require taking potent drugs under the supervision of specialists.

But in the case of global damage to a large area of ​​the body, psoriasis begins to be treated in the hospital, and here it is necessary to involve the “heavy artillery” of medications and procedures.

Physician supervision is necessary as the disease progresses. So, the disease is characterized by three stages, which can flow from one to another.

Variants of the course that psoriasis suggests:

• stationary stage;
• progressive;
• regressing.

A treatment regimen, which involves medications and special procedures, is prescribed depending on the stage of the disease. It is necessary to get rid of psoriasis with the help of complex measures, therefore systematic therapy is used.

In stationary and progressive stages, psoriasis is treated in hospitals.

2. Diagnostics

The diagnosis is made by a dermatologist based on symptoms and medical history. Usually, psoriasis can be determined through an initial examination, but in some cases the disease may not show itself for a long time, and its manifestations are expressed in ordinary dry skin and slight flaking.

Then a diagnostic test is performed that reveals the presence of the disease. For psoriasis, histological diagnosis may be prescribed, which consists of examining material from the affected areas.

If psoriatic arthritis is suspected, radiography is performed.

• If necessary, differential diagnosis with other skin diseases is recommended, a histological examination of a skin biopsy from the lesion.

• If there are signs of joint damage, continuously relapsing and progressive arthritis, torpid to the therapy, consultation with a rheumatologist is recommended.

• When prescribing PUVA therapy, consultations with a therapist, endocrinologist, ophthalmologist, and gynecologist are recommended in order to exclude contraindications to PUVA therapy.

• When prescribing narrowband mid-wave ultraviolet therapy, consultations with a therapist, endocrinologist, or gynecologist are recommended to exclude contraindications to narrow-band mid-wave ultraviolet therapy.

• When prescribing therapy with genetically engineered biological drugs, consultations with a phthisiatrician are recommended during its implementation in order to exclude contraindications to therapy with genetically engineered biological drugs.

3.3 Other treatment

The treatment regimen includes both medication and physiotherapeutic procedures prescribed taking into account the individual characteristics of the patient.

With a progressive stage of the disease, immediate treatment in a hospital setting is required. During this period, means are used to stop the process of increasing the affected area.

• antihistamines (for example, Diphenhydramine, Pipolfen, Suprastin);
• sedatives (valerian, bromide, etc.);
• detoxification by injection (solutions: Unithiol 5%, sodium thiosulfate 30%, calcium chloride 10%);
• vitamins of groups A, B, C, D, E, folic, ascorbic acid.

After successfully stopping the progression, psoriasis enters the stationary stage. Inpatient treatment provides general restoration and regeneration of skin cells. The following methods of therapy are used:

• prescription of drugs: Pyrogenal, starting with a minimum injection dose of 5 mcg, Prodigiosan, administered intramuscularly at 30 - 35 mcg;
• ultraviolet irradiation of the entire body area or individual affected areas;
• baths with sea salt, pine needles;
• ointments, creams for external treatment;
• For guttate psoriasis, antibacterial drugs are prescribed.

In severe cases of the disease, when a significant percentage of affected cells are present on the patient’s skin, therapy is carried out using medications with a stronger effect.

The classic treatment regimen involves the use of:

• cytostatics (Azathioprine, Methotrexate),
• retinoids (Acitretin, Cyclosparin A),
• anticoagulants that help improve microcirculation, Heparin is usually used;
• detoxification carried out using plasmapheresis, hemosorption, hemodesis;
• PUVA therapy, carried out by the combined use of photosensitizing agents and ultraviolet irradiation.

After the expiration of hospital treatment, the patient continues to take medications prescribed by the doctor. The patient is also recommended a therapeutic diet.

It is worth remembering that a favorable emotional atmosphere will not only allow the patient to strengthen the nervous system, but will also contribute to a speedy recovery.

• For limited rashes, external therapy is recommended.

• Topical glucocorticosteroids are recommended:

hydrocortisone** 1% ointment for external use applied to skin lesions 2 times a day for 3–4 weeks.

Alclomethasone cream 0.05%, ointment 0.05% applied to skin lesions 2-3 times a day for 3-4 weeks.

triamcinolone ointment 0.1%, 0.025% for external use, apply to affected areas of the skin 2 times a day for 3–4 weeks.

apply mometasone** cream 0.1%, ointment 0.1%, lotion in a thin layer to the affected areas of the skin once a day for 3–4 weeks.

methylprednisolone cream 0.1%, ointment 0.1%, emulsion 0.1% for external use, apply a thin layer to the affected areas of the skin 1 time per day for 3-4 weeks.

apply hydrocortisone butyrate cream 0.1%, ointment 0.1% to the affected areas of the skin 1–3 times a day for 3–4 weeks.

betamethasone** cream 0.05%, 0.1%, 1%, ointment 0.05%, 0.1%, spray 0.05% applied to the affected areas of the skin 2 times a day for 3–4 weeks.

fluocinolone ointment for external use 0.025%, cream for external use 0.025% apply to the affected areas of the skin 2-4 times a day for 3-4 weeks.

fluticasone ointment 0.005% for external use, cream 0.05% for external use, apply to affected areas of the skin 2 times a day for 3–4 weeks

Apply clobetasol ointment, cream for external use 0.05% to the affected areas of the skin in a very thin layer once a day for 3–4 weeks.

Psoriasis of the feet.

How to recover quickly?

Local treatment

Vitamin D3 analogues

Phototherapy

UV-B phototherapy

Balneotherapy

Systemic therapy

Psoriasis is a chronic, non-contagious skin disease that occurs as a result of hereditary predisposition under the influence of various triggering factors: stress, infectious diseases, alcohol abuse and smoking...

It is characterized by the appearance of a characteristic rash on the skin in the form of areas of skin thickening (infiltration) with redness (erythema) and peeling.

The size, location and other characteristics of the rash can vary over a fairly wide range.

The rash may not cause subjective sensations, but if localized on the skin of the feet, it can crack and bleed, and in some cases become weeping and become infected.

Psoriatic arthritis can also sometimes develop.

Interesting statistics:

29% are forced to explain to others every day the reason for their skin condition

40% feel awkward when visiting a swimming pool, beauty salon or fitness center

46% – choose clothes and shoes that hide psoriatic rashes

49% face problems finding employment

5.5% have thought about suicide at least once due to illness

90% are disappointed in treatment

95% have at least once become victims of various healers or companies that offer dubious treatment technologies

Are you one of them? Then section How to recover quickly? for you.

How to recover quickly?

Treatment of psoriasis.

Analysis of the state of the problem of treating psoriasis in the post-Soviet space is depressing. Most doctors do not know modern treatment methods, and often participate in the scheme of selling some “innovative” SUPER method - from various devices to ointments and creams containing the excrement of extinct animals, the spirit of the pharaoh’s mummy and other dregs. By typing “psoriasis treatment” into any search site, you can see with your own eyes the amazing imagination of various scammers. And finding, for example, the latest American standards for the treatment of psoriasis is almost impossible.

Task 1. The right doctor. Doctor - dermatologist.

Quite a difficult task.

Sure signs of the “right” doctor:

— participation in international! conferences (look at the certificates on the wall),

- lack of offers on his part “only for you and only now, at the lowest price... SUPER remedy.”

- use of international assessment systems to select a treatment regimen for psoriasis - lesion area (BSA - Body Surface Area), psoriasis severity index (PASI - Psoriasis Area Severity Index) and index (DLQI - Dermatology Life Quality Index), reflecting the assessment of the quality of life by the patient himself . Ask your doctor how much your PASI and DLQI index have decreased after the course of treatment (according to modern standards, the criterion for adequate treatment is a decrease in the PASI index from 50 to 75%, a decrease in the DLQI index by 10 points, less than 5 points - you need to choose a different treatment method).

Task 2. Diagnostics. Do I have psoriasis?

To establish a diagnosis, it will be necessary to perform a series of examinations ( of course in the best certified laboratory) – general and biochemical blood test, skin microscopy. Additional methods are also possible.

Task 3. World standard of treatment.

The officially approved “therapeutic ladder” begins with local treatment (including balneotherapy), then phototherapy and general drugs (including immunobiological drugs) are added.

Local treatment.

The skin of the feet of people with psoriasis has significantly altered physicochemical characteristics, resulting in impaired skin barrier function and increased transcutaneous water loss. As a result, the skin becomes prone to drying out and cracking.

Goal of local treatment- moisturizing and preventing excess water loss from the skin. Modern creams may contain various additives and have additional exfoliating, mild anti-inflammatory, and antipruritic effects.

Corticosteroids (glucocorticoids, steroids) for local treatment of psoriasis of the feet are most often prescribed. As a rule, class 4 steroids (the most powerful) are used to treat foot psoriasis. It is enough to apply steroids 1-2 times a day. There are winning combinations of steroids with keratolytics, antibacterials and other agents.

They have:

- easy to use

- ideal for a short course of treatment and when it is necessary to achieve rapid remission (weakening or disappearance of the manifestations of the disease).

— over time they sometimes lose their healing effect

- in large doses and if used for too long, can lead to atrophy (thinning of the skin)

- when applied to large areas of the skin, there is certainty of absorption of steroids into the general bloodstream.

- It is necessary to take a break from time to time, for several weeks, and use other means.

Analogues of vitamin D3 are calcitriol and calcipotriol.

Drugs in this group help slow down and normalize the processes of skin cell division. They exist in the form of a cream, ointment, or lotion that is applied to the skin twice a day. Can be used in combination with other medications and phototherapy. The dose should not exceed 100g per week.

Phototherapy is the use of artificial sources of ultraviolet (UV) radiation. UV irradiation can inhibit the process of abnormally rapid division of skin cells.

Special lamps have been created that can be used to irradiate a patient with clearly measured doses of ultraviolet radiation, from several seconds to several minutes in one session. In the treatment of psoriasis, UV rays with different wavelengths, UVA or UVB, are used.

Photochemotherapy, or PUVA therapy- this is the use of UVA with a photosensitizer - psoralen, taken orally (Puva = psoralen + uva). It is recommended for patients with a large area of ​​skin damage and when other methods do not give the expected results. Using UVA alone without psoralen is not effective. But due to the need to take a photosensitizer (psoralen), this treatment method is not safe enough - the risk of malignant tumors (cancer) of the skin increases, and gastrointestinal disorders occur. Since psoralen can be retained in the lens of the eye, patients should protect their eyes from the sun. Previously, the method was widely used, but given the possible side effects, it is now used to a limited extent.

UV-B phototherapy- safer, does not require the use of a photosensitizer. Approved for the treatment of pregnant women and children. Sessions are held 3-5 times a week.

There are broadband UVB and narrowband UVB techniques. Narrowband UVB phototherapy is more specific and more effective, in which the skin clears faster and a longer remission occurs (weakening or disappearance of the manifestations of the disease). Special devices have been created for the treatment of plantar psoriasis.

Phototherapeutic treatment can be combined with medication and balneotherapy.

Balneotherapy– water-based treatments, including natural thermal springs, hot springs, mineral or sea waters. An example is the treatment of psoriasis at the Dead Sea, which is known for its healing properties. You can create a similar effect in artificial conditions and even at home using special ready-made compositions for foot baths.

Sodium chloride (salt) and sulfide (hydrogen sulfide) baths are most often used. They help improve blood circulation and the functional state of the central nervous system.

Team just for you StarLik(Kyiv, Donetsk) and certified travel partners can now offer special regular health tourism programs to the best rehabilitation, treatment, SPA centers around the world. Here you will get your feet in order for a long time.

In chapter Recommends StarLik We have collected only the best proven, certified products and drugs for the treatment of psoriasis. You can purchase them at the lowest price thanks to StrarLik in vivo technology you can at the lowest price in StarLik pharmacy.

Systemic therapy

Taking medications internally, or administered by injection (intravenously, intramuscularly or subcutaneously). Used for severe psoriasis. It is prescribed only by a doctor and is carried out under his supervision.

Drugs for the systemic treatment of psoriasis include: cytostatics (methotrexate), retinoids (acitretin), immunosuppressants (cyclosporine) and immunobiological drugs.

Immunobiological preparations

They are proteins that modify the immune response. These medications are a huge step forward in the treatment of psoriasis. Unlike methotrexate or cyclosporine, which have a broad spectrum of effects on the immune system, immunobiological drugs affect exclusively the parts of the immune system that cause psoriasis.

Prescribed only by a doctor. Immunobiological drugs include infliximab, etanercept, adalimumab, ustekinumab, etc. Unfortunately, they are much more expensive than many other drugs for systemic treatment of psoriasis, which limits their widespread use.

Task 4. Comfortable shoes and knitwear.

During an exacerbation, switch to wider and softer shoes, use special socks made of anti-allergenic materials sewn using seamless technology.

Task 5. Limiting physical activity on the feet.

During the acute period of illness, avoid exercises that involve loading your feet. Limit your use of the pool.

If you have any further questions, please consult with StarLik doctor(Kyiv, Donetsk) in your city or ask questions in the section consultations.