“Itchy Condition”
Today, most experts are inclined to believe that the disease is based on immunological disorders that occur for various reasons. It is well known that the development of psoriasis is associated with a genetic predisposition. A special group of genes has been identified, the presence of which increases the risk of developing pathology. Thus, psoriasis can be inherited. If both parents suffer from psoriasis, the risk of its transmission is up to 75%, and if the mother or father has the disease, up to 40%. But for the “launch” of the disease in a gene carrier, it is necessary to influence provoking factors, which include infections, metabolic disorders, stress factors, toxic effects, and others.
In psoriasis, there is a significant acceleration (7-8 times higher speed) of skin cell division. Newly formed cells are different from normal ones. A large number of abnormal cells and triggers the inflammatory process, which is supported by special substances – cytokines.
Psoriasis can occur in a person of any age, including a child, but most often the onset of the disease occurs between 16 and 25 years of age. It is characterized by a chronic progressive course with frequent exacerbations, and the process most often begins with skin rashes in the form of small, pinhead-sized, bright pink papules, the surface of which is covered with silvery-white scales. Gradually, they increase in size and can merge with each other, forming larger lesions – plaques. The plaques are clearly demarcated from the surrounding healthy skin, are bright pink or red in color, and are also covered with silvery-white scales. Rashes can cause severe itching (the very name of the disease comes from the ancient Greek “ψωριασις”, “psoriasis”, which translates as “itchy condition”. The skin of the scalp (62%) and nail plates are often affected. At the same time, all manifestations of psoriasis, in addition to physical suffering, cause significant psychological discomfort, patients are ashamed of their disease.
In addition, 5-12% of patients with psoriasis develop psoriatic arthritis, a chronic inflammatory process in the joints, a particularly severe form. The difficulty lies in the fact that articular symptoms do not always manifest themselves with extensive skin lesions. Joints can be affected already in the early stages of the disease, when the area of the lesion is relatively small, while there may be no subjective sensations. It is for this reason that the diagnosis of psoriatic arthritis is often made late, because at first the patient turns to a dermatologist with complaints of skin rashes. The dermatologist pays attention to “his” symptoms. As a rule, the patient gets to see a rheumatologist much later. The result is not very comforting: psoriatic arthritis is chronic pain, limited mobility, and in the most severe cases, disability of the patient.
Successful and timely started treatment leads to a decrease in the size of plaques or their complete disappearance.
Treatment: from x-ray to gene
The very first external remedies for the treatment of psoriasis appeared at the turn of the 18th-19th centuries. They were made on the basis of poisonous arsenic and were used almost until the middle of the twentieth century. Doctors also tried to use mercury, from the beginning of the 20th century, X-rays and even pure radium, discovered by Pierre and Marie Curie (the latter method, fortunately, was not widely used, since Maria herself died quite soon from aplastic anemia due to high doses of radiation). Other – not so radical – antipsoriatic drugs used at that time include products based on salicylic and pyrogallic acids, preparations containing tar, sulfur, naphthalan, grease, and so on. However, evidence-based methods for the treatment of psoriasis have appeared relatively recently.
Traditional external therapy
In the 50s of the last century, the first ointments based on synthetic retinoids were created – substances that are similar in structure to vitamin A. They have proven themselves well in clinical practice, but without side effects in the form of increased dryness, thinning and flaking of healthy skin did not work out.
The next step in the fight against psoriasis was hormonal drugs – glucocorticosteroids. These preparations are presented in the form of creams and ointments for external use. With an exacerbation of the disease, softening, moisturizing preparations with the addition of exfoliating agents (salicylic or lactic acids, urea) are often used; hormonal glucocorticosteroid drugs or a combination of glucocorticosteroids and calcipotriol or glucocorticosteroids with keratoplastic (exfoliating) agents.
Phototherapy has been one of the main treatments for psoriasis for a long time. First, in the form of natural solar insolation, and then with the use of special lamps that generate only rays of a certain spectrum and with a certain wavelength. Often in psoriasis, ultraviolet radiation is combined with the use of special drugs, photosensitizers that enhance the effect of sun exposure. The results of treatment are usually satisfactory, but with an overdose of UV rays, burns are not ruled out, and over time, the likelihood of developing skin neoplasms (melanoma, basal cell skin cancer, squamous cell skin cancer) may increase.
All these methods of treating psoriasis bring more or less relief to the patient: a decrease in the area of plaques, the intensity of itching. As a rule, they are used at the initial stage of the disease, when the area of skin plaques does not exceed 10% of the total skin area. But, unfortunately, all of them do not affect the very cause of the disease – immune disorders.
Systemic therapy
Back in the twentieth century, the first attempts were made to influence psoriasis from the inside. For this purpose, the latest at that time glucocorticosteroids in the form of tablets and injections were initially used. They were replaced in the 70s of the last century by drugs of the immunosuppressive class. Compared to traditional topical agents, they had a more pronounced effect, but their use was also associated with the risk of developing various side effects from the cardiovascular system, gastrointestinal tract, and others.
A big step forward in the treatment of psoriasis was the discovery in the early 2000s of the latest genetically engineered biological drugs that selectively block the key links of inflammation. They are administered subcutaneously or intravenously, immediately enter the bloodstream and quickly exert their effect. Today, for the treatment of moderate to severe psoriasis and psoriatic arthritis, two groups of these drugs are used: inhibitors (blockers) of tumor necrosis factor alpha and inhibitors (blockers) of other substances that support inflammation – interleukins. But this “medal” has a downside. Along with the high rate of onset of the effect, adverse reactions become more frequent. For example, the risk of infectious and other diseases increases. Therefore, before starting treatment and regularly during therapy, a thorough examination of patients is mandatory to exclude possible concomitant diseases, in particular tuberculosis (radiography, Mantoux test, etc. are performed). In addition, therapy with genetically engineered biological drugs is very expensive, and this is important given that the treatment will be long.
The latest discovery in this area was a targeted (from the English target – “target”) synthetic basic anti-inflammatory tablet drug. At the heart of its action are the so-called small molecules. They got this name because, due to their small molecular weight, they act intracellularly – so far no drug has penetrated so deeply! A feature of their action is the ability to block substances that cause immune inflammation. Today it is believed that they play a significant role in the occurrence and development of psoriasis and psoriatic arthritis. It is important that “small molecules” were appreciated not only by doctors, but also by the patients themselves, who noted an improvement in their condition.
It’s time to act!
It will be possible to talk about a complete victory over psoriasis only when the possibilities of genetic engineering are at such a level that they learn to “correct” genes – after all, as we remember, the disease is most often transmitted by heredity. But already today it is possible to take psoriasis under control and achieve a stable remission – to live without skin and joint manifestations. To do this, at the first suspicion of the presence of a disease, consult a doctor, strictly follow all the recommendations of a specialist.
In addition, a patient with psoriasis should:
- exclude alcoholic beverages, spices, smoked, pickled, canned foods from the diet;
- avoid even minimal skin injuries: exclude baths, saunas, use of hard washcloths;
- use specially selected skin care products, including soap, shower gel, shampoo;
- try to avoid prolonged exposure to the sun, exposure to direct sunlight.
And the last. Remember: often the therapy of psoriasis and psoriatic arthritis is ineffective, not because this or that drug does not work. The human factor comes to the fore: the treatment of any chronic diseases requires a long time and involvement in the process of the patient himself. But many people want a quick effect, stop following the recommendations of the attending physician, and as a result, instead of the long-awaited relief, they get an exacerbation of the disease. Today, fundamentally new opportunities have appeared in the arsenal of doctors and patients – everyone who is faced with the problem of treatment inefficiency or side effects of drugs should know about this. Perhaps the struggle for clear skin and a high quality of life begins right now!
The electronic article was prepared with the financial support of the representative office of Celgene International Holdings Corporation (USA) – hereinafter Celgene – in accordance with the internal policy and current legislation of the Russian Federation. Celgene, its employees or representatives did not take part in the writing of this article, are not responsible for the content of the article. The views of Celgene may not be those of the author of the article and the editors.
2018-RUS-061
Photo: archive of the press service
