psoriasis

from Wikipedia, the free encyclopedia
Psoriasis on the back and arms
Classification according to ICD-10
L40 psoriasis
L40.0 Psoriasis vulgaris
L40.1 Generalized pustular psoriasis
L40.2 Acrodermatitis continua suppurativa
L40.3 Palmoplantar pustular psoriasis
L40.4 Guttate psoriasis
L40.8 Other psoriasis
L40.9 Psoriasis, unspecified
ICD-10 online (WHO version 2019)
Psoriasis plaque : In a higher resolution, the silvery-whitish remains of the fallen skin layer are visible

Psoriasis or psoriasis ( ancient Greek ψωρίασις ; equated in antiquity with the ψώρα psóra " scabies ") is a non-contagious autoimmune disease that manifests itself primarily as an inflammatory skin disease (dermatosis) , and also as a systemic disease that often affects other organs primarily affects the joints and associated ligaments and adjacent soft tissues (see psoriatic arthritis ) , the eyes (see uveitis ) , the vascular system , the heart and the genitals. In addition, it can be associated with diabetes mellitus and strokes ; it shows itself mainly through very scaly patches of skin, often z. B. on the knees , elbows and scalp , often with severe itching and changes in the nails.

Around 125 million people worldwide suffer from the disease, in Germany around 2 million people (2013); it occurs at any age, but predominantly in the 2nd to 3rd decade of life (type I) , less often from the 5th decade of life (type II) . The etiology is probably multifactorial (hereditary disposition , autoimmune reaction ) and has not yet been conclusively clarified.

In 2004, October 29 was first declared World Psoriasis Day by the International Federation of Psoriasis Associations .

history

A scaly skin disease, which was probably psoriasis, was already described by the Greek doctor Hippocrates (approx. 460-370 BC). The term psoriasis was used for the first time by the doctor Galenus , who used it to describe dandruff in the eye and scrotum area . However, based on current research, this was probably eczema .

For a long time, psoriasis was not differentiated from the scabies caused by mites . Presumably psoriasis was also often confused with leprosy ; It is believed that many “ lepers ” did not suffer from leprosy but from psoriasis and other dermatoses. In the Old Testament, for example, "white leprosy" is mentioned, which presumably was psoriasis, and people suffering from it were excluded from the community there (as with leprosy) and up into the Middle Ages. At the end of the 16th century, psoriasis, whose symptoms were confused with those of syphilis and gonorrhea , was also considered a sexually transmitted disease.

Appearance

Psoriasis on the knees

Manifestation on the skin

Silvery-white epidermis that is soon shed
Again psoriatic plaque up to 1 cm in diameter

Those affected typically have monomorphic , reddish, mostly round, island-shaped, sharply demarcated and slightly raised foci. These efflorescences are found primarily on the scalp , elbows , kneecaps , around the navel , above the tailbone and knuckles and under the earlobes . In general, areas of the skin that are often stretched (such as the joints mentioned, but also e.g. the calves) or otherwise mechanically stressed (e.g. under the belt) are affected.

Rather uncharacteristic, because psoriasis does not scaly, but only with reddened skin patches, occurs in both men and women in the genital area.

The upper skin ( epidermis ) of a healthy person renews itself within 26 to 27 days. During this time, new skin cells are formed and the aged (keratinized) skin cells ( keratinocytes ) are almost invisibly rejected by the body. In healthy skin, the keratinocytes provide mechanical, microbial and chemical protection for the skin. The transcription factor STAT3 is normally only activated after a skin defect and then triggers the repair process by increasing the number of keratinocytes and activating the cutaneous T cells.

In psoriasis, on the other hand, the keratinization of the affected areas takes place both accelerated - the skin layer renews itself prematurely within only three to seven days - and increased ( hyperkeratotic ) and with loss of the stratum granulosum, its structure and function are impaired ( parakeratotic ). The reasons are the increased DNA synthesis and the increased mitotic activity of the basal cells of the epidermis . The STAT3 is activated even if there is no skin defect, and consequently unadjusted remodeling processes in the epidermis are ongoing.

In psoriasis, the aged skin cells form silvery, shiny, coarse lamellar scales due to the accelerated renewal , which have a sebum-like, silvery consistency reminiscent of candle wax (candle wax phenomenon). The underlying tissue, the lowest cell layer of the epidermis , the border to the dermis , has a strong blood supply due to the increased growth and therefore appears as a strong reddening under the easily removable scales . Even deeper cell layers are easily detached (phenomenon of the last membrane). If this thin membrane can be peeled off, this is almost always a sure sign of psoriasis. After removal, punctiform bleeding occurs (phenomenon of bloody dew, Auspitz phenomenon ).

The infiltration of neutrophils is also typical , which leads to microabscesses ("Munro abscess") under the horny layer.

Psoriasis vulgaris

  • Type I (60–70% of cases) Manifested before the age of forty, has a familial frequency and is more severe than type II. 95% of this form is associated with the histocompatibility antigen HLA-Cw 6 and HLA- Dr 7 and coupled with HLA-B 17 and HLA-B 57. All genes are on the short arm of chromosome 6 .
Psoriasis vulgaris on the elbow

The typical first manifestation of psoriasis vulgaris is guttate psoriasis, which often occurs after exposure to trigger factors such as drugs (β-blockers, lithium, antimalarial drugs, etc.) or a streptococcal infection. However, it can subside again or turn into a vulgaris. Localization sites of psoriasis vulgaris are the scalp (psoriasis capilitii), the intertriginous spaces, the flexor surfaces (psoriasis inversa), the palms and soles of the feet (psoriasis palmarum et plantarum), the genital and anal localization (with a rhagade in the anal notch as typical Sign applies).

  • Type II (30-40% of cases)

Late manifestation often only after the age of forty. It is usually associated with nail psoriasis or joint problems (psoriatic artrithis). The HLA coupling is only slight and there is no familial accumulation. Most of them are easier gradients.

Skin involvement with pustular formation and increased coupling with HLA-B27 , observed above all from the age of 50, rarely earlier.

The causes of this mostly generalized form of psoriasis are still largely unexplained. It is assumed that unusually large amounts of the neutrophil chemotactic interleukin -8 flow in, which could explain the mass migration of neutrophils into the stratum corneum. The influx leads to sterile pustules. In addition to IL-8, the tumor necrosis factor -α (TNF), which leads to cutaneous inflammatory reactions and systemic symptoms , is of major importance .

The clinical course is characterized by an acute attack of fever. Within a few hours, extensive erythema with pustules develop, first at the points of contact with the skin (e.g. under the breast) and later generalized, with pustules that can confluent in severe cases.

Within 24 hours, the number of leukocytes increases, the calcium content decreases, as does the albumin content in the blood plasma. In the further course there are always new attacks of fever and generalized pustules.

Generalized pustular psoriasis
This special form of psoriasis can be fatal without therapy including internal applications (see below) and is also triggered by cosmetic products (see below).
Psoriasis pustulosa palmaris et plantaris
  • Barber type
If the general condition is good, the pustules are only on the hands and feet.
Acrodermatitis continua suppurativa
  • Hallopeau type
The pustules are on the acres (these are: fingers, toes, hands, feet, nose, chin, eyebrow and zygomatic arches), especially on the fingers. Nail and hair loss are possible.

Genitals, anus

In this case, the groin and genitals themselves are particularly affected: in men the penis root , glans and scrotum , in women the pubic mound with the pubic hair , i.e. the vulva with the labia ; also the area of ​​skin between or around the genitals and anus . The symptoms are rather untypical for psoriasis because there are no characteristic scaling, but mostly with red, sharply defined foci.

Scalp

The scalp psoriasis occupies a special position: The hairy head is the most frequently affected skin area of ​​psoriasis in both juvenile forms and adults. According to the German Dermatological Society in the guideline on psoriasis of the hairy head, statistical information on the frequency of scalp involvement in psoriasis fluctuates between 50 and 80 percent. The scalp counts a. due to their sensitivity and the thick hair to the difficult to treat areas.

Manifestation on skin appendages

Pitting on a fingernail

If the scalp is severely affected, the hair follicles can be impaired, which, as a special form of island- shaped hair loss, results in alopecia psoriatica.

Changes to the nails of toes and fingers are sometimes the only symptom. Nail matrix psoriasis (pitting or dimple nails, "oil stains" or yellowish discolored oil nails ), nail bed psoriasis (distal onycholysis ) and subungual onychodystrophy ( Crumb nail, nail thickening ( onychauxis ), possibly also acroosteolysis .

Participation of other organs

With or without (substantial) involvement of the skin, psoriasis can also affect other organs:

Arthropathic psoriasis

→ Main article: Psoriatic arthritis : Inflammatory changes in the joints and associated ligaments and adjacent soft tissues, with and without simultaneous changes in the skin, and with and without overlap with Bechterew's disease with evidence of HLA-B27 .

eyes

Inflammations of the inside of the eye ( uveitis ) occur more frequently in psoriasis, are often associated with inflammations of the retina as well, and have other peculiarities compared to other forms of uveitis.

Cardiovascula

The data situation for a connection between psoriasis and vascular diseases and their consequences (heart attack, stroke) is inconsistent. There is also a higher incidence of classic vascular risk factors ( obesity , high blood pressure , sugar and lipid metabolism disorders ), but with a view to the systemic inflammation in psoriasis, one can assume an independent risk factor for arterial diseases of the cardiovascular system.

bone

A comparison between psoriasis patients and healthy people of comparable age and sex showed that psoriasis patients show increased bone proliferation with no different degrees of erosion.

Emotional distress

The emotional stress of psoriasis sufferers is generally greatly underestimated: According to recent studies, they are in the same range as those of heart attack patients. Many sufferers experience their illness as a severe impairment of their personal quality of life , they feel socially isolated, suffer from a lack of self-confidence and often also from depression .

The fact that the rate of alcohol abuse in psoriasis is significantly higher than that of the general population can be both a consequence and an aggravating non-specific irritation of the skin disease.

causes

Psoriasis on the left thigh

The etiology of psoriasis is believed to be multifactorial; The connection, extent and effect of hereditary disposition and autoimmune reaction as well as other possible triggers have not yet been conclusively clarified.

Hereditary disposition

Psoriasis is to a large extent hereditary , therefore familial accumulation has been observed, with occasional generations being skipped. To date, however, it is not known whether psoriasis is inherited as a dominant or recessive inheritance. It is assumed that it is triggered by the interaction of variants of different genes and environmental influences. The risk of an identical twin of an affected person also getting sick is 65–72%. The disease affects around two to three percent of the population in Central Europe , while the proportion in the United States is around four to five percent. In Eskimos , indigenous peoples of America , people of African descent and aborigines of Australia , psoriasis is almost non-existent; in Japan and the People's Republic of China the prevalence is between 0.025 and 0.3%, most common among Kazakhs (up to 12%). Psoriasis does not break out in all hereditary symptoms; In addition to the hereditary disposition , further, as yet unknown factors must probably be added.

The fact that in hereditary diseases actually disadvantageous genes are retained for thousands of years is being explained by other selection advantages of those affected. For example, it is postulated that people prone to psoriasis suffer less from skin infections because they have more defensins (antibacterial proteins contained in the cells of the stratum corneum of the skin ).

Immune system malfunction

It is assumed that it is an autoimmune T-cell-mediated immune reaction, in which the immune system recognizes the body's own tissue as foreign and attacks it. A pro-inflammatory environment develops in the affected tissues . In psoriasis, the protein psoriasin is increased .

Surprisingly, an Italian study found a prevalence of 18 percent with latent tuberculosis infection among a good 400 people with psoriasis. Whether the infection is a risk factor for psoriasis or whether both infection and psoriasis are favored by the same defect in the immune system must be further investigated.

Diagnosis

PASI score

The severity of the disease is mainly determined for the evaluation of therapy results with the PASI score .

Phenomena

  • "Candle" phenomenon: By scratching e.g. B. with a wooden spatula on the psoriasis focus, the loosely adhering, silvery-white scales fall off, which is reminiscent of the scraping of a wax candle.
  • Phenomenon of the “last skin”: If you continue scratching, a lamellar thin skin can be removed.
  • "Auspitz" phenomenon / phenomenon of "bloody dew" (= phenomenon of punctiform hemorrhages ): After removing the parakeratotic material and the last membrane, punctiform hemorrhages occur.

Differential diagnoses

The following important information is missing from this article or section:

There is no reference to atopic eczema; even more useful information about differential diagnosis is missing (it only says “difficult”).
Help Wikipedia by researching and pasting it .

The differential diagnosis of psoriasis depends on the form of manifestation. Here is an overview based on the Fritsch textbook:

Manifestations Differential diagnosis Remarks
Single stove Eczema plaque, dermatomycosis , chronic discoid lupus erythematosus , Bowen's disease , superficial basalioma , extramammary Paget's disease , pagetoid reticulosis Single foci can be mistaken for eczema, a fungal disease or precursors to a skin cancer disease.
Guttate psoriasis seborrheic eczema , pityriasis rosea, pityriasis lichenoides, lichen planus , subacute cutaneous lupus erythematosus , syphilis II In this form there are several polycyclic, partly confluent foci that can be mistaken for eczema. Pityriasis lichenoides is a rarer autoimmune disease, as is the more common lupus erythematosus. Stage II syphilis can mimic almost any skin disease.
Plaque-type psoriasis Nummular eczema, parapsoriasis en plaques, mycosis fungoides , subacute cutaneous lupus erythematosus The plaque type can also be confused with eczema and an autoimmune disease. Parapsoriasis is a poorly defined group of psoriasis-like diseases. Mycosis fungoides is a skin infiltration with malignant lymphocytes .
erythrodermic psoriasis Eczematic erythroderma , pityriasis rubra pilaris, congenital ichthyosiforme

Erythroderma, Sézary syndrome , erythrodermic mycosis fungoides

The full-body shape of psoriasis can be confused with extensive eczema and spiny lichen (pityriasis rubra pilaris). In Sézary syndrome, the skin is partially infiltrated by malignant lymphocytes .
Psoriasis capillitii Seborrheic head eczema, tinea amiantacea, microsporia The scalp can also be simulated by eczema or special fungal diseases.
intertriginous psoriasis intertriginous eczema, candidiasis Infestation between the fingers and toes must be differentiated from eczema or fungal disease.
palmoplantar psoriasis chronic hand or foot eczema, palmoplantar mycosis, Sézary syndrome The manifestation on the palms of the hands or the soles of the feet can be similar to eczema, a fungal disease.
genital psoriasis Reiter's disease , erythroplasia , syphilis II Reiter's disease is a complex reaction to an infection (for example chlamydia ). The erythroplasia is triggered by papillomaviruses and can become malignant.
with joint manifestation Reiter's disease

In principle, the differential diagnosis should be left to an experienced dermatologist. In guttate psoriasis with several polycyclic, sometimes confluent, foci, there is a possibility of confusion with eczema or Reiter's disease: → Main article: reactive arthritis

The full picture with the triad of joint inflammation (arthritis), conjunctivitis (conjunctivitis) and inflammation of the urethra (urethritis) is probably triggered by an autoimmune reaction after bacterial infection, even if this is not always remembered. If there are visible changes in the skin near the inflamed joints that resemble those of psoriasis, Reiter's disease is a differential diagnosis to psoriatic arthritis.

Course, triggering or aggravating factors

The disease progresses differently in each patient: in some it appears to heal and occurs only once in a lifetime (around 25%), in others, on the other hand, phases alternate with strong and little or no activity of the disease.

Many sufferers report serious physical or psychological stressful situations as an initial trigger factor, such as B. a severe flu-like infection, an operation or even drastic private experiences such as the death of a close relative. Women in particular often have strong hormonal changes, such as those that occur. a. occur in pregnancies , for the first time an outbreak and a "psoriasis flare" result. The fact that psoriasis often breaks out for the first time during puberty could also belong in this context.

Most often the disease only shows up between the ages of 20 and 30 (Type I, see above). In individual cases, psoriasis already occurs in childhood and then represents an additional and mostly underestimated psychological burden for the child. Especially in autumn and winter it comes because of the additional skin stresses from dry heated air and wet and cold climatic conditions and probably also because of less UV radiation leads to flare-ups.

In addition, psoriasis can be triggered by numerous medications such as beta blockers , ACE inhibitors , lithium salts, antimalarials, interferons , tetracyclines , terbinafine , NSAIDs and folic acid or the course of the disease can be made worse.

Risk factors are also cosmetic preparations used in everyday life, especially if they dry out the skin (e.g. lotions containing alcohol) or irritate it chemically, such as shaving foam , hairspray and hand washing preparations. Even cosmetic products that are actually supposed to alleviate psoriatic symptoms can lead to their deterioration and even dangerous generalized pustular psoriasis, such as the numerous shampoos that contain zinc pyrithione .

Non-specific stimuli such as injuries, friction, operations, sunburns or the like are also observed as trigger factors for psoriasis . Psoriasis is therefore one of the diseases in which the Koebner phenomenon can be demonstrated. Obesity , alcohol abuse and stress can also make psoriasis worse.

treatment

On the occasion of World Psoriasis Day 2013, the German Psoriasis Association announced that, according to estimates by experts, around a quarter (24%) of those suffering from psoriasis no longer go to a doctor due to dissatisfaction with the treatment. A lack of knowledge among doctors and patients about the extent and therapies of the disease led to late, incorrect or inadequate treatments and were no longer acceptable.

Based on the understanding of psoriasis as a genetically co-conditioned disease and the fact that gene therapy is not yet available, other types of treatment cannot be expected to cure, but only to alleviate the symptoms. In addition, as with all diseases with a phased course and spontaneous improvement, it is difficult to distinguish the effectiveness of treatment methods with regard to this relief from the placebo effect on the one hand and spontaneous improvement ( remission ) on the other . This applies to treatments based on both medical and alternative medicine . Depending on the severity of the disease and the involvement of possible organs, the treatment is graded:

nutrition

In some cases there is a link between psoriasis and celiac disease . The renunciation of foods with the adhesive protein gluten , which is necessary in the case of celiac disease, can then also alleviate the psoriasis symptoms.

Psycho-mental approaches

Since psoriasis often worsens due to negative psychological influences, treatments that prevent stress and / or change attitudes towards the disease can have positive effects on psoriasis. Self-help groups for people with psoriasis not only help to find a suitable treatment method for their own psoriasis, they also give those affected the certainty that they are not alone in the world with the disease. Overall, acceptance is an important factor in dealing with psoriasis.

The often reported successes with outsider methods can possibly also be attributed to such psychological factors. Patients who are susceptible to such scientifically not recognized methods can also benefit indirectly by supporting their psyche.

External applications

This article or the following section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.

In the case of clinically less severe skin manifestations, one usually limits oneself to external applications ( topical therapy ). With most treatment methods, the patient has to be prepared for a longer period of weeks or even months. The basic therapy consists of the application of active ingredient-free ointments and ointments with 3–10% urea or salicylic acid. Although this recommendation is in the S3 guideline and in many dermatology textbooks, there are no major randomized studies on its effectiveness.

  • Urea (Urea pura) - is used for care and treatment in the form of additives in oil, cream and ointments . The microscopic effect of a local urea treatment was examined in a small series. The thickness of the cornea could be reduced by 29%. The rate of division of the epidermal cells decreased by 51%.
  • Salicylic Acid - Essentially used to shed dandruff. The guideline of the German Dermatological Society on psoriasis of the hairy head states that systemic intake can lead to salicylic acid intoxication. This is especially possible in the case of pronounced extensive inflammatory changes or in children. However, with modern measures, desquamation before the actual treatment can now usually be dispensed with. Since this substance is also anti-inflammatory, it is also used directly for treatment with a relatively mild effect.
  • Dithranol (also known as cignolin) - slows down cell division and is very effective. However, this method is extremely complex to treat. Older preparations also had other disadvantages such as the brown coloration of the surrounding healthy skin, but also of many objects that came into contact with the preparation, such as clothing, bed linen and wash basins. There are modern preparations on the market today that can significantly reduce the side effects described above. For example, with the minute therapy, in which dithranol is only applied to the diseased areas for a few minutes and then washed off.
  • Corticoids - synthetic active ingredients that are modeled on the human hormone in the adrenal cortex . Strong corticoids such as clobetasol or betamethasone quickly reduce the inflammatory symptoms. Because of the side effects, corticoids should only be used for a short time and only on small areas of the skin. They are not suitable for treating large areas of skin. Corticoid ointments are best suited for the scalp . One effect that is often caused by these preparations is "skin atrophy" (thinning of the skin), the veins then shimmer through the skin.
    The tolerance can be influenced favorably by applying cortisone as a fixed combination with calcipotriol . In a study in which patients with scalp psoriasis had used the fixed combination of calcipotriol and betamethasone (in lipo-gel form) for 52 weeks, none of the patients experienced the dreaded skin atrophy - the thinning of the skin. Due to its good tolerability and high effectiveness, this fixed combination is recommended as initial therapy in the guidelines for medical treatment of scalp psoriasis.
  • Coal tar - Has been used for a long time to treat chronic skin conditions. Slows down cell division and relieves itching. However, the tar substances used here are now considered to be carcinogenic, which is why they are only used to a very limited extent or known products have already been withdrawn from the market. Occupational exposure to coal tar can increase the incidence of bladder cancer. This could not be proven for dermatological applications.
  • Vitamin B12 ( cyanocobalamin ) in avocado oil - ointment base is available as a non-pharmacy-only medical product for the treatment of psoriasis (psoriasis). So far only a small study has been published. Large clinical studies on the treatment with B 12 ointment are not yet available.
  • Vitamin D - derivatives - are synthetic substances that are modeled on a hormone that plays an essential role in the control of the immunological and regenerative processes of the skin. They reduce the division activity of the skin cells. The calcipotriol or tacalcitol used are those vitamin D derivatives which reduce the risks of vitamin D ( hypercalcemia ) many times over.
    These drugs can also have dangerous side effects if overdosed; but in general they are well tolerated. In many studies, vitamin D analogues have been administered with a corticoid with great success . A common treatment method is the combination with UV light therapy .

Bath and light therapies

Light therapy can be carried out in the dermatologist's office or, if you have purchased the appropriate equipment, at home. Sunlight also provides relief, but exposure to artificial light of a certain wavelength is more beneficial.

Different forms and combinations are used:

Bath / mud therapy

Bath therapy with sulfur-containing natural fango and volcanic water, as offered in the Argentine Andes in the Copahue thermal baths , can bring relief, but not cure. There have also been positive experiences with bathing therapies in the Blue Lagoon ( Bláa Lónið ) in Iceland, as well as those at the Dead Sea in Israel.

Balneo- / balneophototherapy

The balneophototherapy mainly as " Sole -Photo therapy" known. This method is intended to simulate the conditions at the Dead Sea . Between 60 and 90% of patients respond well to very well to this type of treatment. The patient first bathes in a solution containing a lot of brine for about 20-30 minutes, and then briefly - if possible with skin that is still wet. d. H. to be irradiated with an intense UVB light source in the range of a few minutes. A Cochrane Review on balneophototherapy was published on May 5, 2020. The authors evaluated the study data from patients with psoriasis vulgaris. The salt bath combined with UVB showed advantages over UVB treatment alone (main result). The primary endpoint was a reduction in the Psoriasis Area and Severity Index ( PASI ) by at least 75% (PASI-75). This endpoint was reported by only two of the eight included studies. Both studies had the same sponsor and both studies had a high risk of bias. Therefore, the certainty of evidence was considered low.

Fish therapy

This is carried out with reddish sucking barbel (Garra rufa , also kangal or nibbling fish) : The patients bathe for three weeks for about two hours a day with about 200 sucking barbs in special therapy tubs. The fish (kangal fish) remove the skin flakes from the affected patient. The patients then receive a short UV radiation in the solarium and skin care creams. A well-known place for this is the "Kangal thermal spring" near the Turkish village of Kavak. Treated patients report a significant improvement in their findings on the facility's commercial website. Treatment in this hot spring has so far been reported in two small clinical studies with positive results, but its significance is limited due to the retrospective design and the lack of control groups. Since 2000, the fish for this therapy have also been available from breeders in Germany.

Laser therapy

The excimer laser is one of the latest developments in laser therapy . It is a xenon chloride gas laser. It generates monochromatic light with a wavelength of 308 nm. The laser works in the UV narrowband spectrum. In contrast to the fanned out cone of light in light cabins, the laser generates a bundled beam. With the small optical window of the laser head, it is possible to apply a therapeutically high dose of radiation to diseased skin areas within a short period of time without exposing the surrounding healthy skin to radiation. The laser is particularly suitable for treating small, stubborn foci of inflammation on the skin. The laser has proven itself in the treatment of various diseases that respond to UV therapy. It is mainly used for psoriasis and vitiligo. The required therapy time is significantly lower compared to conventional light cabins due to the high irradiance of the laser. Regions of the skin that are difficult to reach, such as folds of the skin or bends of the joints, can be reached more easily than with therapy in light cabins. Depending on the sensitivity of the diseased skin area, the therapeutically necessary dose can be specifically adjusted.

PUVA

This long-known method ( P soralen + UVA ) is available in three forms for external use (as a cream or bath) and internal use (using tablets). The active ingredients are psoralens (e.g. methoxsalen), which are contained in preparations such as psoralen or meladinins . These increase the skin's sensitivity to light and thus increase the effectiveness of UVA rays. The PUVA therapy presumably leads to a photo-inactivation of the hyperreactive T cells, since psoralen, a furocoumarin , enters into molecular binding reactions to nucleic acids and protein structures. Long-term use of PUVA can cause irregular pigmentation, light-typical aging of the skin with telangiectasia (fine veins in the skin) and decreasing elasticity. In young patients, the possibility of later skin cancers must also be considered. The PUVA is recommended in the guideline "Therapy of psoriasis vulgaris" after weighing up successes and risks.

Narrow spectrum ultraviolet radiation

The narrow spectrum - UVB therapy is after the irradiation devices with 311  nm named light wavelength. Psoriasis reacts most sensitively in the range between 310 and 313 nm, which is why 311 nm radiation is now the method of choice for whole and partial body radiation, e.g. B. with a light comb . Due to the lower erythema effect , the tolerance is better than with broadband UVB and SUP lamps. This therapy is often combined with topical treatments to further increase its effectiveness.

Selective ultraviolet phototherapy (SUP)

A combination of UVA and UVB. It works quickly and intensively, but must be optimally adapted to the skin conditions of the person in order to avoid sunburn. However, this applies to all radiation therapies.

Blue LED light therapy

This new light therapy makes use of blue light with a wavelength of 453 nanometers (nm). This light range belongs to the visible light spectrum and is therefore free from ultraviolet radiation (UV radiation). Light-emitting diodes (LEDs) are safe, energy-efficient and long-lasting light sources. Studies have shown that the blue LED light has anti-proliferative properties that can reduce the overgrowth of certain skin cells (keratinocytes) in psoriasis. The inflammation in affected skin, by the inactivation of T cells is reduced. According to clinical studies, these effects lead to an alleviation of the symptoms of the psoriasis lesions, such as flaking, redness and thickness.

Electrotherapy

Electrotherapy with weakly dosed interference current for treatment was further developed at the Karlsruhe Research Center, where treatment successes could be demonstrated in a smaller study. The treatment is practicable and well tolerated. For treatment, the psoriatic areas must be covered with electrodes. Hands, feet, or elbows can also be treated in tubs filled with tap water. The treatments must be carried out regularly twice a day for five minutes until the infestation has healed or has significantly improved. Depending on its severity, this can take up to twelve weeks. Since the treatments have to be carried out regularly, they are usually carried out by the patient himself. Treatment requires special therapy equipment that can be bought or borrowed. Several studies are currently ongoing. Although analgesic effects have been described in psoriatic arthritis, no influence on the course of the disease has been observed.

Internal applications

Internal applications (systemic therapy) are indicated for moderate to severe cases of the skin and involvement of other organs. In view of the fact that psoriasis is an autoimmune disease (see above), i.e. an inflammatory, systemic disease with the additional risk of associated co-morbidities, systemic treatment clearly plays the greater role. Cosmetic (topical) treatment cannot be a satisfactory solution for a systemic disease. Recent data suggest that early systemic therapy not only improves psoriasis itself, but also reduces the cardiovascular risk associated with psoriasis.

The following list is based on the frequency of prescriptions in Germany according to the German Psoriasis Register :

Fumaric acid ester

A mixture of different fumaric acid esters ( fumaric acid dimethyl ester and fumaric acid monoethyl ester salts) has been available as a drug under the trade name Fumaderm ® since 1994. Treatments with this drug are used for moderate to severe infestation, with a decrease in the severity of the disease by an average of 50–80%. According to the recommendation of the German S3 guideline for the treatment of psoriasis vulgaris, fumaric acid esters are particularly suitable for long-term therapy. Another advantage of therapy with fumaric acid esters is the low level of drug interactions. Fumaric acid dimethyl ester has an immunomodulatory effect (anti-inflammatory) and is the antipsoriatic drug with the longest experience in use (namely since 1959). As the inflammation goes down, the dandruff also goes down.

The most important adverse drug reactions are transient gastrointestinal complaints, diarrhea , colicky abdominal pain, and hot flashes. The number of white blood cells in the blood can also decrease (leuco- / lymphocytopenia ). If the number of white blood cells drops sharply, the dose must be reduced or therapy interrupted. If therapy is continued despite a severely reduced number of white blood cells, there is a risk of opportunistic infections such as progressive multifocal leukoencephalopathy (PML) , which can be fatal. Doctors therefore check the blood count at regular intervals. There is no scientific evidence of a DMF-associated risk for PML. The advantageous risk-benefit ratio of Fumaderm ® in the oral treatment of moderate to severe psoriasis, especially for long-term maintenance therapy, was highlighted in the relevant guidelines for the therapy of psoriasis. The effects on psoriatic arthritis have not been adequately studied, but there is evidence of efficacy and current clinical practice uses fumaric acid esters in patients with plaque psoriasis and mild psoriatic arthritis. Fumaric acid esters are the most frequently prescribed systemic psoriasis therapies in Germany.

Methotrexate

When used in low doses (up to 25 mg / week), methotrexate (MTX, numerous generics ) is the most commonly used drug for the internal treatment of psoriasis worldwide. In Germany it is the second most used. It suppresses the immune system. Adverse drug effects affect the liver, kidneys and the blood-forming system of the bone marrow. For a long time it was believed that MTX is particularly effective in psoriatic arthritis, but a randomized placebo-controlled study published in 2012 could not show such an effect.

Biologicals

There are two types of biologicals : the TNF blockers adalimumab ( Humira ® ), infliximab ( Remicade ® , biosimilars) and etanercept (Enbrel ® ) and the p40 interleukin 12/23 inhibitor ustekinumab ( Stelara ® ), respectively. the monoclonal antibody secukinumab ( Cosentyx ® from Novartis), which neutralizes interleukin-17A. These are biotechnologically produced substances that either belong to the group of monoclonal antibodies (adalimumab, infliximab, secukinumab and ustekinumab) or to the group of fusion proteins (etanercept). These substances are used in patients for whom the classic systemic therapies (methotrexate, ciclosporin, fumaric acid ester) or light therapy are not possible or are inadequately effective. There is evidence that in psoriatic arthritis, the TNF-α antagonists can prevent the joint damage from progressing. TNF blockers in particular increase the risk of infection during therapy, as well as the risk of opportunistic infections such as PML . Particularly severe peeling of the skin can occur with ustekinumab. Since adalimumab suppresses the immune system, the risk of developing opportunistic infections is also increased here. Adalimumab is the third most used in Germany for the treatment of psoriasis. The three proteins adalimumab, etanercept and infliximab are - from an economic point of view - particularly successful drugs and are therefore so-called blockbusters . But they are also used in other indications (e.g. psoriatic arthritis , rheumatism and Crohn's disease .)

Further biologicals are z. B. ixekizumab ; in addition, numerous are in clinical testing .

Apremilast

The phosphodiesterase inhibitor apremilast ( Otezla , Celgene ) has been approved for the treatment of moderate to severe chronic psoriasis since January 2015. Apremilast is the first oral PDE4 inhibitor to be approved for this indication and is used to treat patients in whom other systemic therapies have not responded or were not tolerated. The substance has also been approved for the treatment of psoriatic arthritis in adults.

Retinoids

The vitamin A derivatives such as acitretin are often combined with UV radiation, but there is insufficient evidence of synergistic effects of this combination therapy. It is important that these substances can lead to a deformity of the child during pregnancy in women up to two years after treatment.

Corticoids

The tablets or syringes used here have a short-term soothing effect. However, a setback (a so-called rebound phenomenon ) and other serious side effects can also occur. Internal therapy of psoriasis with corticoids is no longer recommended.

Ciclosporin

The immunosuppressive substance cyclosporine is approved for the treatment of the most severe, therapy-resistant forms of psoriasis. Long-term therapy (longer than a maximum of one to two years) is not indicated due to the potential side effects such as kidney damage and high blood pressure, but also due to the possibility of an increased cancer risk.

Surgical therapy options

The removal of the tonsils appears to improve a good proportion of patients with guttate psoriasis, vulgar psoriasis, or palmoplantar pustular psoriasis. This is indicated by case studies, case series and a randomized controlled trial. Most of the patients were Japanese.

Treatment of nail psoriasis

There is currently no approved treatment method for nail psoriasis. However, the fixed combination of calcipotriol and betamethasone has proven itself in off-label use . This is also underpinned by study results that show a significant reduction in nail psoriasis and positive effects on hyperkeratosis and onycholysis.

Alternative medical treatment methods

The survey of some psoriasis sufferers showed that they mainly use herbs and diet rules, as well as methods of traditional Chinese medicine , mostly in addition to medical procedures. Some research suggests that acupuncture treatment is effective for psoriasis and other skin conditions. However, there is currently no reliable evidence of effectiveness beyond a placebo effect. Conversely, skin stimuli such. B. through acupuncture needles due to the Koebner phenomenon lead to psoriasis plaques.

In homeopathy , too, users repeatedly report successes. So far, however, there is no reliable evidence of an effectiveness of homeopathy in psoriasis beyond the placebo effect.

In 2014 an Ayurvedic cream was tested with the ingredients turmeric, neem, dyer's root and sweet indrajao. The test persons claim that itching is reduced immediately and skin redness and swelling are substantially reduced.

See also

literature

  • S3 guideline therapy of psoriasis vulgaris of the German Dermatological Society. In: AWMF online (as of 2011)
  • S1 guideline psoriasis of the hairy head of the German Dermatological Society. In: AWMF online (as of 2009)
  • E. Christophers, U. Mrowietz: Psoriasis. In: Otto Braun-Falco et al. (Ed.): Dermatology and Venereology. 5th edition. Springer Verlag, Berlin 2005, pp. 476–497.
  • JH Blume: Treatment options for psoriasis vulgaris. In: skin. 1/2005, October 11, 2005; arzt-baden-wuerttemberg.de (PDF).
  • Gernot Rassner: Dermatology: Textbook and Atlas. 9th edition. Elsevier, Urban & Fischer, Munich 2009, ISBN 978-3-437-42763-3 .
  • Heinrich Schlange-Schöningen , G. Saalmann: The psoriasis. History and therapy from ancient times to the present. Herford 1998.
  • P. Altmeyer, R. Hartwig, U. Matthes: The effect and safety profile of fumaric acid esters in oral long-term therapy in severe therapy-resistant psoriasis vulgaris. In: The dermatologist . Volume 47, No. 3, March 1996, pp. 190-196.
  • S. Dübel (Ed.): Handbook of Therapeutic Antibodies. Vol. III. Wiley / VCH, Weinheim 2007.
  • Ulrich Mrowietz, Kristian Reich: Psoriasis - new findings on pathogenesis and therapy . In: Deutsches Ärzteblatt . 106th year, no. 1–2 , 2009, pp. 11-19 ( aerzteblatt.de ).

Web links

Commons : Psoriasis  - Collection of pictures, videos and audio files

Individual evidence

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  2. ↑ Psoriasis (overview) - Department of Dermatology - Altmeyers Encyclopedia. Retrieved October 28, 2017 .
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  6. ↑ Sensitive areas - Psoriasis Forum Berlin e. V. Accessed July 12, 2018 .
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