PSORIASIS

From Big Medical Encyclopedia

PSORIASIS (psoriasis; grech, psora skin disease, crusts; synonym: psoriasis vulgaris, vulgar psoriasis, scaly deprive) — the widespread chronic dermatosis which is characterized by the shelled papular enanthesis.

The item was known at the time of Hippocrates under the names lepra and psora, and also alphos and lichen. A. Tsels mentioned alphos (psoriasis) of nails. R. Willan distinguished diskoidny and figured psoriasis. In 1841 F. Gebra specified that it is not independent diseases, but a wedge, kinds of psoriasis. Wilson (W. J. E. Wilson) called psoriasis alfozisy, and the term «psoriasis» designated the shelled forms of eczema.

The item — one of the most widespread dermatosis. According to Yu. K. Skripkin (1979), sick P.' number makes 3 — 10% of total number of patients with skin diseases. Men and women are ill P. equally often. The disease can be shown at any age, however is more often during puberty. Quite often P. has family character.

The etiology and a pathogeny

Exist various theories of an origin of P. (infectious, exchange, neurogenic, hereditary, immune), however there is no uniform concept.

Infectious theory is the oldest. A. M. Krichevsky (1957), A.F. Ukhin (1963), A.A. Studnitsin (1971), Kuta (And. Kuta, 1960) suggested about the virus nature of P. V to blood serum and in sick P.' skin complement-linked and virus neutralizing antibodies, pretsipitina, agglutinins and antigenic complexes were revealed. Lipshyutts (V. of Lipsc.fci.utz), and after Y. Kirle acidophilic little bodies inclusions, similar to virus little bodies found in cells of basal and acanthceous layers of epidermis in sites of fresh psoriasis rashes. The elementary particles of a pentagonal form including a nucleotide were found in macrophages of a derma (see. Nucleic acids), and in lymphocytes of blood — the electronic and dense particles having looking alike virions. On chorion allantois of a chicken germ and fabric cultures the cytopathic effect of «a virus of the psoriasis» got from blood serum, scales of psoriasis elements was observed, wet P. Odnako's patients many researchers, e.g. A. Ya. Prokopchuk (1954), Korichchati (1959), G. N. Gnuzdev (1971), do not confirm the virus nature of P. since identification of the activator and P.'s reproduction in an experiment were not crowned with success and never P.'s transfer from the sick person to healthy even was noted at hemotransfusions.

Exchange theory emergence P. is based on the numerous observations testimonial of various disbolism at patients with psoriasis. At such patients note a disproteinemia, a qualitative and quantitative change of content in blood of free amino acids, nucleoproteids, thiol connections, including glutathione, biogenic amines, residual nitrogen, a gaptoglobin, transferrin, properdin. In blood serum the maintenance of glikozaminoglikan and ceruloplasmin increases that demonstrates disturbance of biosynthetic function of a liver. Radical concentration in skin at P. exceeds their contents in skin of the healthy person on average three times. In process of recovery this difference disappears. Fluctuations of concentration of microelements, the vitamins participating in oxidation-reduction processes are observed. Results of a research of tissue respiration at P. demonstrate development of the hypoxia having an adverse effect on the course of psoriasis. In skin, especially in psoriasis elements, synthesis of a glycogen increases that is confirmed by increase in energy balance with strengthening of enzymatic activity of a succinatedehydrogenase, a lactate dehydrogenase, cytochrome oxydase, acceleration of a development cycle of cells of epidermis. Change of lipidic exchange stimulates keratinization (see).

Neurogenic theory. A. G. Polotebnov considered that P. represents a symptom of vasculomotor neurosis. P. V. Nikolsky considered P. as secretory and vasculomotor neurosis. Many researchers point to an important etiological and pathogenetic role at P. of a psychological injury. Sodora (L. Szodoray, 1955) revealed at P. increase in maintenance of acetylcholine in nerve terminations of skin and so-called executive bodies that allowed it to consider P. as skin reaction, a cut neurogenic mechanisms are the cornerstone. Sharp (J. Sharpy, 1950), Reyss (F. Reiss, 1956) consider P. an adaptation disease. N. K. Bogolepov, etc. (1976) by means of elektroentsefalografichesky researches revealed at sick P. disturbances of a functional condition of formations of a trunk of a brain on the basis of change of bioelectric activity of a brain. Dependence between extent of changes of EEG at P. is established and vegetovascular frustration, such as fluctuations of the ABP, headaches, a hyperhidrosis, etc. Some researchers consider the neurosis-like states noted at sick P. as a result, but not an etiology since various forms P. can cause dysfunction of the autonomic nervous system and psychological disturbances in the form of neurosis-like states. The pathogeny of dysfunctions of a nervous system at P. is connected with action on limbic system of the changed afferent impulsation from the angry skin receptors. Vegetative dysfunction at P. has the sympathetic or parasympathetic nature, sometimes happens mixed (see. Autonomic nervous system ). Various disturbances of a vegetative and effector innervation at P. are usually observed at a long current of a dermatosis, a thicket in the progressing its stage.

Hereditary theory it is actively developed in 70 — 80 20 century. Results of clinical and genetiko-statistical trials of G. B. Belenky (1970), B.N. Mordovtseva (1971) confirm a certain role of genetic factors in emergence of the Item. Concerning a mode of inheritance of P. of opinion are contradictory. Assume autosomal and dominant inheritance with incomplete penetrance of genes, the multifactorial nature of P. is not excluded (see. Hereditary diseases ).

Immune theory. Have a certain value in P.'s pathogeny immunol. disturbances. Sick P.' skin in the progressing stage of a disease has sharply changed reactivity and supersensitivity that leads to emergence on places mechanical, chemical, physical and other irritations of the rashes characteristic of P. — isomorphic reaction of irritation, or Kebner's phenomenon (see. Kebnera phenomenon ). At P. decrease in level of a bradikininogen in blood, change of a ratio of number T - and V-lymphocytes, their ability to a contact sensitization is revealed, increase in content of immunoglobulins of classes O, A, E at preservation of datum level of IgM is noted; antibodies to antigens of cells of horn and granular layers of epidermis are found, antibodies to kernels of cells of epidermis are found in extracts from lymphocytes and neutrophils; by means of a direct method of an immunofluorescence (see) in epidermis of psoriasis elements the deposits of immunoglobulins, cell-bound immune complexes, antibodies and a complement promoting developing of microabscesses of Munro (small accumulations of leukocytes) are revealed. There is an assumption that development of primary psoriasis center is promoted by injury of epidermis owing to autoimmune aggression.

Involvement in process of joints gives the grounds to assume a possibility of development of P. as a general disease (see. Arthritises ).

Patogistologiya

In epidermis at P. lengthening and puffiness of nipples of a derma note a parakeratosis (see), an acanthosis (see) in the field of interpapillary shoots in combination with thinning of basal and acanthceous layers over nipples, what the wedge, Auspitts's phenomenon is connected with. In basal and acanthceous layers intracellular hypostasis, in a corneous layer and under it — Munro's microabscesses is sharply expressed. In surface layers of a derma the trichangiectasia, and also lymphocytic and histiocytic infiltration is observed. Changes of nerve fibrils in psoriasis rashes are not specific.

Clinical picture

Fig. 1. The patient with psoriasis (and — an anterior aspect — the back view): multiple enanthesis of the person, breast, back, upper extremities. Fig. 2. Patient with psoriasis: primary elements of rash — sharply delimited multiple roundish papules on skin of a side surface of a breast, a stomach, a front surface of a shoulder. Fig. 3. Sick with psoriasis (the progressing stage): rashes are located mainly in the field of a prelum of skin with a belt (Kebner's phenomenon), the left breast is raised. Fig. 4. The patient with psoriasis (the regressing stage): skin of a back surface of a body, a neck and hands is covered turned pale, in the central part with the sunk-down plaques. Fig. 5. The patient with psoriasis (sits, having forced elbows to the knees): large, old, drain plaques on extensor surfaces of skin of forearms and shins.

The item can suddenly begin with emergence of multiple rashes (tsvetn. fig. 1, and, b). Rashes can be single and be located within limited sites. Primary elements of rash at psoriasis are sharply delimited roundish papules (see) pink color (tsvetn. fig. 2) size about an edge or a head of a pin. The surface of papules is usually covered with silver-white scales. At the beginning psoriasis rashes of an infiltrirovana so slightly that at a palpation infiltrate is not probed. Gradually the sizes of rashes and stratification of scales increase, infiltration amplifies. The following triad of signs is characteristic of psoriasis rashes: the phenomenon of a stearin spot — at a poskablivaniye of rashes their surface reminds a stearin spot; a phenomenon of a terminal film — after from a surface of a rash all scales are scratched out, the thinnest gentle translucent plenochka opens; at disturbance of an integrity of this plenochka by its careful poskablivaniye there are dot bleedings — Auspitts's phenomenon, or a phenomenon of blood dew, according to A. G. Polotebnov.

Distinguish three stages of development of psoriasis rashes: progressing, stationary and regressing. For the progressing stage emergence of new rashes, saturated rich colors of papules, merge of papules, signs of their centrifugal growth — the bright pink not shelled indistinct rim around papules (Pilnov's symptom), Kebnera a phenomenon (see), an itch is characteristic (tsvetn. fig. 3). In stationary stage process as if calms down, there are no signs of its progressing, and regress both. In the regressing stage color of rashes turns pale, infiltration of plaques decreases, rashes resolve since the center (tsvetn. fig. 4), forming ring-shaped figures, or from the periphery with formation of a pseudo-atrophic rim of Voronov in the form of a whitish border. On site the resolved rashes there are depigmented sites — a pseudoleukoderma (a psoriasis leukoderma). There is no itch, Kebner's phenomenon is absent. Sometimes at the same patient it is possible to observe emergence of fresh rashes at simultaneous permission of old.

Fig. 6. Patient with psoriasis: psoriasis plaques on a pilar part of the head are plentifully covered with scales, on skin of a back drain papular rashes. Fig. 7. Sick with exudative psoriasis: on skin of a back, buttocks, hands the edematous, covered with crusts plaques are visible. Fig. 8. Hands of the patient with artropatichesky psoriasis: joints are deformed, edematous, nail plates are thickened (onikholizis). Fig. 9. Foot of the patient with pustular psoriasis: against the background of psoriasis plaques pustules are visible. Fig. 10. Sick psoriasis erythrosis: drain, extensive sites of defeat — Infiltrirovan's skin, bright red color with a peeling. Fig. 11. Right hand of the patient psoriasis: on a palm with transition to area of a radiocarpal joint skin of an infiltrirovan, bright red color with partially exfoliated corneous layer.

Favourite localization of P. — extensor surfaces of extremities, hl. about river in the field of elbow and knee joints (tsvetn. fig. 5), pilar part of the head (tsvetn. fig. 6), trunks. The perverted localization — damage of skin on bends of extremities, skin folds is possible (under mammary glands, in inguinal, axillary area).

Depending on the size of separate rashes vulgar P. can be tear-shaped or monetovidny. At merge of plaques there can be figured centers, various on outlines, which are often reminding the map; in other cases ring-shaped and serpiginozny plaques are formed. Occasionally rashes are located preferential in the field of mouths of follicles of hair — follicular P. Inogda rashes happen universal (e.g., at a psoriasis erythrosis).

Depending on character of a course of process, its sharpness, defeat of other bodies and systems allocate various wedge, forms vulgar P. Ostro quite often proceeds the exudative Item. At this form along with a typical peeling as a result of impurity of exudate education cheshuykokorochek yellowish or grayish color is observed (tsvetn. fig. 7), very seldom at the same time on a surface arise vegetations. Sometimes cheshuykokorkovy stratifications have a conic, ustritseobrazny appearance.

Often seborrheal P. meets, at Krom of a rash are located on so-called seborrheal sites (on a face, a breast, a back in interscapular area, a pilar part of the head). Rashes of yellowish color, without characteristic silver-white scales, phenomena of a terminal film and dot bleeding are less expressed, than at a usual form of vulgar

P. K to severe forms of P. belong artropatichesky Item. (see. Arthritises ) and pustular P. (tsvetn. fig. 8 and 9), and also psoriasis erythrosis. Pustular P.'s combination to artropatichesky is quite often observed. Distinguish two types of pustular psoriasis: a) pustular, or purulent, Tsumbush's psoriasis, at Krom pustular rashes arise at already available P.; primary elements at the same time, apparently, are the bubbles or bubbles which are quickly turning into purulent rashes, contents of pustules are always sterile; b) the pustular psoriasis of Barber which is localized only on palms and soles; in other places at the same time there can be typical psoriasis rashes, sometimes process generalizutsya.

Psoriasis erythrosis meets mostly as the complication developing as a result of irrational therapy of P. or as a result of any other adverse influences: some pharmaceuticals, excessive insolation (at summer type P.), etc. More often happens at men, usually does not occur at children. Skin becomes red color, on it there is a plentiful large and melkoplastinchaty peeling (tsvetn. fig. 10). Patients complain of feeling of tightening of skin, an itch. The psoriasis erythrosis can sometimes be combined with the artropatichesky Item.

Psoriasis of palms (tsvetn. fig. 11) and soles meets preferential at the age of 30 — 50 years, is more often at the persons doing manual work. Distinguish blyashechno-fan-shaped, circular, horn and calloused forms.

Nails of the patient with psoriasis: characteristic pointed defeat of nail plates in the form of a thimble.

Item of nails (an onychia psoriasis), according to J. Heller, occurs on average at 9% of sick Items. Nails are surprised preferential on hands. At artropatichesky P., according to Wright (Y. Wright, 1959), nails are surprised by 3 times more often than at P. without damage of joints. Primary P. of nails meets seldom. Pointed defeat of plates of nails in the form of a thimble (fig.) is most characteristic. More severe defeat of a matrix of a nail leads to considerable changes of a nail plate: to an onikholizis (the nail plate separates from a bed since free edge, near to-rogo the yellowish-brown border is formed), to discoloration, a configuration, thickness and consistences of the affected nail. The surface of a nail plate at the same time becomes hilly, the plate is thickened, gains grayish-yellow color. Further deformation and destruction of a nail can lead to its atrophy or a hypertrophy — an onychogryphosis (see Nails).

Seldom meet warty and papillomatous forms P., their malignancy is in some cases possible.

Extremely seldom meeting belongs to acute forms violent Item., at Krom in the field of the centers of defeat along with typical papular elements bubbles and bubbles appear.

Item of mucous membranes, for the first time described in 1882 by A. I. Pospelov, meets seldom; usually is followed by a typical enanthesis. Lips, a hard palate, language are surprised, cheeks, eyelids, a conjunctiva and a cornea of eyes, a tympanic membrane, an urethra and a bladder are more rare.

P.'s current can be various. Sometimes insignificant rashes remain decades, hl. obr. in the field of elbow and knee joints or on a pilar part of the head. Quite often P. flows hard for many years, especially at a psoriasis erythrosis or at patients with artropatichesky P. U of many patients in warm season of manifestation of P. decrease, and quite often and completely disappear (winter type P.), at some sick P. becomes aggravated in summertime (summer type P.). Quite often later seeming a wedge, recovery on skin of Wood who «recovered» in beams of a lamp it is possible to see the shining rashes which at usual lighting remain imperceptible — so-called invisible psoriasis. Remissions at P. last sometimes decades.

Psychological disturbances at sick P. consist of neurotic frustration and reaction of the personality to a disease. More often at P. there are neurotic frustration connected with damages of skin. Various options of the relation to a disease are defined by severity of P. and features of the identity of the patient. So, at single rashes only reaction of adaptation is noted, and at widespread rashes, erythrodermic, exudative, artropatichesky forms neurotic states are more often observed. Features of reaction to P. to some extent depend also on premorbidal lines of the personality. People quiet, balanced have a proper response of adaptation, and at people with existence of premorbidal alarming and hypochondriac traits of character reaction to a dermatosis is more often noted patol. Neurotic states at sick P. are shown in the form of a neurotic syndrome (see the Neurasthenia), K-ry can be asthenic, astenodepressiviy or asthenohypochondriac type. The clinic of neurotic states at sick P. is quite often combined with numerous vegetative frustration in the form of lability of the ABP, disturbances of a cordial rhythm, dysfunctions of bodies went. - kish. path.

The diagnosis

the Diagnosis is made on the basis by a wedge, pictures and (in doubtful cases) data gistol, researches.

Differential diagnosis is carried out with pink it is deprived (see. Deprive pink ), tear-shaped a parapsoriasis of m (see), papular a syphilide of ohms (see Syphilis), seborrheal eczema (cm). Pustular P. sometimes should be differentiated with a superficial streptoderma (see Impetigo); warty P. — with warty red flat is deprived (see. Deprive red flat ) and a warty tuberculosis cutis (see. Tuberculosis extra pulmonary ); exudative P. — with seborrheal and microbic eczema, a superficial candidiasis (see Candidiasis) and a streptoderma; artropatichesky P. — with a pseudorheumatism (see); pustular psoriasis of Tsumbush — with a superficial streptoderma, microbic eczema and a subhorn pustular dermatosis of Sneddon — Wilkinson (see. Subcorneal pustular dermatosis). The psoriasis erythrosis should be distinguished from red scaly hair depriving of Deverzhi (see. Deverzhi disease ), Wilson's erythroses — Brock (see the Erythrosis), a limfadenichesky erythrosis (see. Lipomelanotichesky reticulosis ), etc.

Treatment

At the choice of a method of treatment it is necessary to consider a stage of a disease. At the progressing O. apply hl. obr. sedatives (drugs of bromine), neuroleptics — Frenolonum, levomepromazinum (Tisercinum), thioridazine (sonapaks), tranquilizers (Elenium, Seduxenum, etc.), at the expressed neurangiosis — cinnarizine (Stugeronum), etc., anti-inflammatory drugs, vitamins, novocaine, etc. In the stationary and regressing P.'s stages appoint vitamins A, B1, B6, B12, B15, folic to - that, redoxons, PP, D2, lipotropic means, pyrogenal. At artropatichesky P., a psoriasis erythrosis, exudative and pustular P., except the transferred funds, in the absence of contraindications use corticosteroids (Prednisolonum, Triamcinolonum, dexamethasone); at pustular P. antibiotics are sometimes effective. From immunodepressive means most often appoint a methotrexate. According to indications carry out sanitation of the available centers of an infection, use endocrine drugs, microelements, at peripheral vasomotor spasms and infiltrative old psoriasis plaques vazodilatator are shown (komplamin, nigeksin, etc.). The diet with restriction of animal fats is recommended.

Medicinal therapy needs to be carried out in a complex with physical therapy. Systematic heat baths, in warm season — sea or river bathings and solar radiations are shown (are contraindicated at a summer form P.). General irradiations UV rays (see. Ultraviolet radiation) have the hyposensibilizing effect on sick P.' skin, it is useful to lead them to the periods of remission of the Item. At P.'s treatment

the photochemotherapy — radiation by long-wave UV rays in a combination with furocoumarins, so-called PUVA therapy was widely adopted (see. Ultraviolet radiation). Study use of a method of hemosorption. For the purpose of normalization of function of century of N of page use of diadynamic currents on area of sympathetic nodes is reasonable (see. Impulse currents ). In the absence of contraindications the dignity is recommended. - hens. treatment (Sochi — Matsesta, Pyatigorsk, Sernovodsk, Talgi and other resorts with hydrogen-sulfide waters, and also the resort of Naftalan). Stay in the southern resorts contraindicated sick summer type P. progressing, exudative and pustular P.

Mestno at the progressing P. indifferent ointments, e.g. apply 1 — 2% salicylic ointment. At P.'s current, chronic, not inclined to aggravations, appoint salicylic and mercury ointments, tsignolin, chrysarobin in pastes and ointments (it is impossible to apply on face skin and a pilar part of the head because of a possibility of development of conjunctivitis), sernodegtyarny ointments, Rybakov's ointment (from fatty solid oil), etc. Use also ointments with cytostatics, a papaverine, corticosteroids.

At artropatichesky P., and also in the presence of old psoriasis plaques improvement from mud procedures (see Mud cure), a fonoforeza using corticosteroids is sometimes observed.

Any of the means which are applied to topical treatment P., even in case of successful action, does not prevent possible palindromias. However elimination of rashes often leads to long remission, and in some cases to treatment.

The forecast

the Forecast for life favorable. An exception are severe forms of artropatichesky P. at which the invalidism and even death of the patient is possible. The forecast concerning duration of a disease and a possibility of treatment is extremely individual; perhaps spontaneous treatment. Seldom or never on psoriasis plaques the epithelioma develops, is more often basal and cellular (see. Bazalioma ).

Prevention

Prevention consists in the prevention and timely elimination of disturbances of functions of various bodies and systems of an organism promoting emergence of the Item. At the same time normalization of the psychological status, observance of the mode of work, rest, food is of great importance. For prevention of a recurrence the general treatment of sick P. it is necessary to continue a nek-swarm time after disappearance of rashes. Sick P.' medical examination

the Bibliography

Bogolepov N. K. is reasonable., Aristova R. A. and Fedorov S. M. Kliniko-elektroentsefalo-graficheskiye researches at psoriasis, Vestn. dermas, and veins., No. z, page 11, 1976; Grebenyuk V. N. Patomimii, in the same place No. 9, page 28, 1978, bibliogr.; Zadorozhny B. A. Psoriaz, Kiev, 1973, bibliogr.; Kalamkaryan A. A., Frolov E. P. and V. N. Mordvinians. Current state of a problem of psoriasis and task of its development, Vestn. dermas, and veins., No. 7, page 3, 1979, bibliogr.; Box of sou of N of V. F. Psoriasis and metabolism, Minsk, 1975, bibliogr.; Marzeeva G. I., Trofimova JI. I. and Kirsanova M. M. Effektivnost of a photo of chemotherapy at a psoriasis erythrosis, Vestn. dermas, and veins., No. 5, page 8, 1982, bibliogr.; Psoriasis, under the editorship of S. I. Dovzhansky, Saratov, 1976, bibliogr.; Chistyakova I. A. Photochemotherapy of psoriasis, Vestn. dermas, and veins., No. 1, page 36, 1978; Bolgert M. Importance et rôle des facteurs patologiques dans le psoriasis, Bull. Acad. nat. Med. (Paris), t. 158, p. 578, 1974; Bra un-Falco O. u. Pet-z about 1 d t D. Zur Histotopas von Enzymen des energieliefernden Stoffwechsels in der Epidermis bei Psoriasis vulgaris, Arch, klin. exp. Derm., Bd 230, S. 223, 1967; Cyclic nucleotides in disease, ed. by B. Weiss, p. 79, Baltimore, 1975; Danda J. Problematika prvnich projevu u lupenky, Cs. Derm., sv. 56, s. 335, 1981, bibliogr.; Novotny F. Podil autoimu-nity na patogenezi psoriâzy, ibid., sv. 48, s. 340, 1973; Parrish J. A. a. o. Photochemotherapy of psoriasis with oral methoxsalen and longwave ultraviolet light, New Engl. J. Med., v. 291, p. 1207, 1974; W a h b an A. Psoriasis, Int. J. Derm., v. 20, p. 108, 1981.

B. A. Zadorozhny; S. M. Fedorov (not BP.), V. V. Vladimirov (tsvetn, fig.).

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