Certain aspects of combined therapy of severe psoriasis.
K.N.Suvorova, I.M.Korsunskaya, A.Yu.Putintsev.
Pediatric and Adolescent Dermatology and Venereology Section, Chiar of Pediatric Infectious Diseases,
Psoriasis is one of the most widespread forms of dermatosis. In various countries its prevalence ranges from 0.1 to 3%, while the share of psoriasis patients among those with dermatologic and venereologic diseases is 12 to 15%. Recently there has been a certain increase in the incidence of this dermatosis, severe drug-resistant forms of psoriasis, such as psoriatic erythrodermia, arthropathic psoriasis, exudative psoriasis becoming more prevalent.
Psoriasis is a chronic dermatosis of multifactor nature genetic factors dominating in its development. The search for psoriasis genetic markers has confirmed that, apart from the HLA-system, dominant forms of psoriasis are linked with the distal part of the 17th chromosome. An important role in psoriasis pathogenesis also belongs to factors the effect of which on cutaneous processes is probably mediated by immune status impairments and various biochemical defects.
Immunological changes associated with psoriasis consist in decreased absolute and relative T-lymphocyte count in circulating blood mostly due to a decrease in the subpopulation of T-helpers. Histochemical examination of biopsy samples from psoriatic foci using monoclonal antibodies revealed that dermal infiltration consists mostly of T-lymphocytes, while B-lymphocytes are only present in individual samples as isolated cells. Most T-lymphocytes infiltrating the derma belong to the subpopulation of T-helper cells. Expression of the HLA-DR-complex on some keratinocytes also indicates a change in their immunological phenotype. According to modern conceptions this reflects the ability of HLA-DR-keratinocytes to activate epidermal T-lymphocytes as well as to produce cytokines, some of which are capable of inducing hyperproliferation of epithelial cells.
Analysis of metabolic disorders in psoriasis patients using the standard set of biochemical blood tests has demonstrated that in at least 80% of exudative psoriasis, psoriatic erythrodermia and arthropathic psoriasis cases inflammatory biochemical serum syndrome is present.
As a lot of patients with severe, predominantly exudative forms of psoriasis are treated in V.G.Korolenko municipal Clinical Hospital No. 14, Glutoxim was included in the complex therapy of this group of patients.
Glutoxim belongs to thiopoietins, a new class of drugs possessing immunomodulating and systemic cytoprotective effects. It acts differently on normal cells, where it stimulates proliferation and differentiation, and on transformed ones, where it induces apoptosis.
The following parameters were taken into account when prescribing the drug: erithrodermal eruptions, torpidity of disease development on traditional therapy as well as changed biochemical parameters of the blood (AsAT, AlAT, GGT, APh, thymol test) which were more frequent in alcohol abusing men.
25 patients (9 women and 16 men) aged from 19 to 72 were observed. The study group included 15 patients with exudative psoriasis (7 patients), arthropathic psoriasis (6 patients) and erythrodermal course of dermatosis. 3 of the study group patients has elevated transaminase activity. The control group included 10 patients with similar forms of psoriasis.
As basis therapy, all patients received disintoxicating and hyposensibilizing drugs, 2 patients were on methotrexate (15 mg intramuscularly once a week). Steroid ointments were used as local therapy. Glutoxim was administered daily for 10 days as intramuscular injections of 1 ml of 10% solution.
Patients of the study group demonstrated a marked decrease of skin infiltration at sites of eruption as early as on day 3 of therapy; by the end of therapy residual infiltration was minimal and persisted only along the patch circumference. Skin edema decreased only by the end of therapy. Itching subsided considerably in all patients receiving Glutoxim.
In the 10 patients of the control group no regress of psoriatic eruption was registered for 10 days.
According to repeated biochemical blood tests, in 3 patients of the study group transaminases decreased to normal values.
Example. Patient B., male, 59 years old. Diagnosis: arthropathic psoriasis with exudative skin manifestations. At admission to the Dermatology department of V.G.Korolenko Municipal Clinical Hospital No. 14 the patient had monomorphic rash in the form of papules and patches on forearms, thighs and torso merging into irregular infiltrated edemic foci covered with off-white scaly crust. Biochemical blood parameters: cholesterol — 5.8 mM/l, total bilirubin — 20.5 uM/l, conjugated bilirubin — 7.9 uM/l, urea — 7.42mM/l, AsAT — 56.4 U/l, AlAT — 24.0 U/l, GGT — 69.5 U/l, thymol turbidity test — 2.5. After 3 days of Glutoxim administration infiltration and skin edema reduced considerably, peeling practically disappeared, itching diminished. The repeated biochemical blood test indicated a decrease in transaminase activity: cholesterol — 5.5 mM/l, total bilirubin — 9.6 uM/l, urea — 4.10 mM/l, AsAT — 17.5 U/l, AlAT — 24.0 U/l, GGT —51.8 U/l, thymol turbidity test — 0.5.
Glutoxim was well tolerated by all patients of the study group. No adverse reactions were observed.
Thus, the use of Glutoxim in psoriasis ensures faster and more complete regression of the disease symptoms; its hepatoprotective effect is primarily manifests itself in normalization of transaminase activity, which makes it possible to use Glutoxim as part of complex therapy of severe psoriasis. Further studies of the possibility of using this drug in psoriasis are required.
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