Detailed scheme of treatment at the Institute of psoriasis. Clinical guidelines: Psoriasis International protocol for the treatment of psoriasis

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Psoriasis, unspecified (L40.9)

Dermatovenereology

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development
No. 18 of the Ministry of Health of the Republic of Kazakhstan dated September 19, 2013

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.

I. INTRODUCTION

Protocol name: Psoriasis
Protocol code:

Code (codes) ICD X:
L40 Psoriasis:
L40.0 Psoriasis vulgaris;
L40.1 Generalized pustular psoriasis;
L40.2 Acrodermatitis persistent (allopo);
L40.3 Pustulosis palmar and plantar;
L40.4 Guttate psoriasis;
L40.5 Psoriasis, arthropathic;
L40.8 Other psoriasis;
L40.9 Psoriasis, unspecified

Abbreviations used in the protocol:
DBST-diffuse connective tissue diseases;
BR - Reiter's disease;

SFT - selective phototherapy;
UFT - narrow band phototherapy;
PUVA - therapy - a combination of long-wave ultraviolet (320-400 nm) irradiation and taking photosensitizers inside;
INN - international non-proprietary name;
ml - milliliter;
Mg - milligram;
ASAT - aspartate aminotransferase;
ALT - alanine aminotransferase;
ESR - erythrocyte sedimentation rate;
UAC - general analysis blood;
OAM - general urinalysis.

Protocol development date: May 2012
Patient category: adults and children with characteristic clinical manifestations - a monomorphic papular rash of pinkish-red color, covered with silvery-white scales.
Protocol user: dermatovenereologist of the skin-veins dispensary.

Classification

Clinical classification

Psoriasis is divided into the following basic forms:
- Vulgar (common);
- Exudative;
- Psoriatic erythroderma;
- Arthropathic;
- Psoriasis of the palms and soles;
- Pustular psoriasis.

Allocate 3 stages of the disease:
- Progressive;
- Stationary;
- Regressive.

Based on prevalence:
- Limited;
- Common;
- Generalized.

Types depending on the season:
- Winter (exacerbation in the cold season);
- Summer (exacerbation in the summer season);
- Indefinite (exacerbation of the disease is not associated with seasonality).

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of diagnostic measures

The main diagnostic measures (mandatory, 100% probability):
1. Complete blood count in the course of treatment
2. General analysis of urine in the dynamics of treatment

Additional diagnostic measures (probability less than 100%):
1. Determination of glucose
2. Determination of total protein
3. Determination of cholesterol
4. Determination of bilirubin
5. Definition of ALAT
6. Definition of ASAT
7. Determination of creatinine
8. Determination of urea
9. Immunogram level I and II
10. Histological examination skin biopsy (in unclear cases)
11. Consultation of a therapist
12. Physiotherapy consultation

Examinations that must be carried out before planned hospitalization (minimum list):
1. Complete blood count
2. Urinalysis
3. Biochemical blood tests: AST, ALT, glucose, total. bilirubin.
4. Precipitation microreaction
5. Examination of feces for helminths and protozoa (children under 14 years old)

Diagnostic criteria

Complaints and anamnesis
Complaints: skin rashes, itching of varying intensity, peeling, pain, swelling in the joints, restriction of movement.
Medical history: start first clinical manifestations, season, duration of the disease, frequency of exacerbations, seasonality of the disease, genetic predisposition, the effectiveness of previous therapy, concomitant diseases.

Physical examination
pathognomonic symptoms:
- psoriatic triad during scraping ("stearin stain", "terminal film", "blood dew");
- Koebner's symptom (isomorphic reaction);
- the presence of a growth zone;
- sizes of elements;
- characteristics of the location of the scales;
- psoriatic lesions of the nails
- state of the joints.

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

Instrumental research: not specific.

Indications for expert advice(in the presence of concomitant pathology):
- therapist;
- neuropathologist;
- rheumatologist.

Differential Diagnosis

Differential Diagnosis:

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

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals:
1. Stop the severity of the process.
2. Reduce or stabilize the pathological process (lack of fresh rashes) on the skin.
3. Remove subjective feelings.
4. Maintain your ability to work
5. Improve the quality of life of patients.

Treatment tactics

Non-drug treatment:
- mode 2;
- table number 15 (limit: the intake of spicy dishes, spices, alcoholic beverages, animal fats).

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

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

Note: This protocol uses the following classes of recommendations and levels of evidence
A - strong evidence of the benefit of the recommendation (80-100%);
B - satisfactory evidence of the benefits of the recommendations (60-80%);
C - weak evidence of the benefits of the recommendations (about 50%);
D - satisfactory evidence of the benefits of the recommendations (20-30%);
E - convincing evidence of the futility of recommendations (< 10%).

List of Essential Medicines(mandatory, 100% probability) - drugs of choice.

Pharmaco- logical group	INN of the drug	Release form	Dosage	Multiplicity of application	Note
Immunosuppress- active agents (Cytostatics), including anti-cytotoxic new funds	Methotrexate	ampoules Tablets	10-30 mg 2.5 mg	1 time per week for 3-5 weeks Doses and regimen of appointment is selected individually.	Methotrexate has been approved for the treatment of psoriasis without any of the double-blind, placebo-controlled trials that are currently mandatory. Clinical guidelines were developed by a group of dermatologists in 1972, determined the main criteria for prescribing methotrexate for psoriasis.
	Cyclosporine (level of evidence B-C)	Concentrate for solution for infusion, capsules	(1 ml ampoules containing 50 mg each); capsules containing 25, 50 or 100 mg of cyclosporine.		Cyclosporine concentrate for intravenous administration 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 isotonic sodium chloride solution or 5% glucose solution. The initial dose is usually when injected into a vein 3-5 mg / kg per day, when taken orally - 10-15 mg / kg per day. Next, doses are selected based on the concentration of cyclosporine in the blood. The determination of the concentration must be made daily. For the study, a radioimmunological method is used using special kits. The use of cyclosporine should only be carried out by physicians with sufficient experience in immunosuppressant therapy.

	Infliximab (level of evidence - B)	powder for solution	100 mg	5 mg/kg according to the scheme
	Ustekinumab (level of evidence - A-B)	bottle, syringe	45mg/0.5ml and 90mg/1.0ml	45 - 90 mg according to the scheme	It is used for medium-severe forms of psoriasis, with an area and severity of skin lesions of more than 10-15%. Selective inhibitor of pro-inflammatory cytokines (IL-12, IL-23)
	Etanercept* (level of evidence - B)	Solution for subcutaneous administration	25 mg - 0.5 ml, 50 mg - 1.0 ml.	Etanercept 25 mg twice a week, or 50 mg twice a week for 12 weeks, followed by 25 mg twice a week for 24 weeks	It is used mainly in 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 THCS leads to skin irritation. Combination with TGCS may reduce the incidence of this effect. Dose-dependent side effects include hypercalcemia and hypercalciuria.
Glucocortico- steroid 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, minimize the risk of adverse events. The effectiveness of treatment will increase with complex therapy with root protectors
Strong (III)	Betamethasone	ointment, cream	0,1%	1-2 times a day	Local application of TGCS can cause the appearance of striae and skin atrophy, and these side effects more pronounced against the background of the use of highly active drugs and occlusive dressings.
	Methylpredni- ash 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
Weak (I)	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 supporting the efficacy 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 period) placebo-controlled efficacy studies local application activated zinc pyrithione for mild and moderate papulo-plaque psoriasis

List of additional medicines(probability less than 100%)

Pharmacologists cal group	INN of the drug	Release form	Dosage	Multiplicity of application	Note
Antihistamine- drugs*	cetirizine	tablets	10 mg	1 time per day No. 10-14	To provide a pronounced anti-allergic, antipruritic, anti-inflammatory and anti-exudative action.
	Chloropyramine	tablets	25 mg	1 time per day No. 10-14
	Diphenhydramine	ampoule	1%	1-2 times a day No. 10-14
	Loratadine	tablets	10mg	1 time per day No. 10-14
	clemastine	tablets	10 mg	1-2 times a day No. 10-14
Sedatives*	Valerian extract	tablets	2 mg	3 times a day 10 days	If the pathological process on the skin is accompanied by anxiety of the state of mind and body associated with anxiety, tension and nervousness
	Dry extract (obtained from rhizomes with roots of valerian officinalis, lemon balm herb, herb St. Guaifenesin	bottle	100 ml	5 ml 2 times a day
	Peony elusive rhizome and roots	bottle	20-40 cap	2 times a day for a course of therapy
	Peony elusive rhizome and roots	bottle
Sorbents*	Dioctahedral- cue smectite	sachet	3 gr.	1 sachet 3 times a day for 10 days
Sorbents*	activated carbon	tablet	0.25 gr.	1 time per day 7-10 days
Desensitized sedatives*	Sodium thiosulfate	ampoules	30% - 10.0 ml	1 time per day for 10 days
	calcium gluconate	ampoules	10% - 10.0 ml	1 time per day for 10 days
	Magnesium sulfate solution	ampoules	25% - 10.0 ml	1 time per day for 10 days
Drugs correcting microhemorrhagic disorders circulation*	Dextran	vials	400,0	1 time per day №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 for 1.5 months
	Thiamine	ampoules	5%-1.0 ml	1 time per day 10-15 days
	Pyridoxine	ampoules	5%-1.0 ml	1 time per day 10-15 days
	Tocopherol	capsules	100mg, 200mg, 400mg	3 times a day 10-15 days
	cyanocobolamin	ampoules	200mcg/ml, 500mcg/ml	1 time per day every other day No. 10
	Folic acid	tablets	1mg, 5mg	3 times a day 10-15 days
	Vitamin C	ampoules	5%-2.0 ml	2 times a day for 10 days
Glucocortico- steroids*	Betamethasone	Suspension for injection	1.0 ml	1 time in 7-10 days
	Hydrocortisone	Suspension for injection	2,5%	dose and frequency are determined individually	according to the indications, depending on the severity
	Dexamethasone	tablets ampoules	0.5 mg; 1.5 mg 0.4% - 1.0 ml	dose and frequency are determined individually	according to the indications, depending on the severity
	Prednisolone	tablets ampoules	5 mg 30 mg/ml	dose and frequency are determined individually	according to the indications, depending on the severity
	Methylpredni- zolon	Tablets, Lyophilisate for solution for injection	4 mg; 16 mg 250, 500, 1000 mg	dose and frequency are determined individually	according to the indications, depending on the severity
Potassium and magnesium supplements*	Potassium magnesium aspartate	tablets	-	1 time per day	for the entire course of hormone therapy
Drugs that improve peripheral circulation*	Pentoxifylline	ampoules	2% - 5.0 ml	1 time per day 7-10 days
Drugs that improve peripheral circulation*	Deproteinized hemoderivat from the blood of calves	ampoules	5.0 ml	1 time per day 10-15 days
Means that contribute to the restoration of microbiological intestinal balance*	1. Germless water substrate of metabolic products of Escherichia coli DSM 4087 24.9481 g 2. germ-free aqueous substrate of metabolic products of Streptococcus faecalis DSM 4086 12.4741 g 3. germ-free aqueous substrate of metabolic products Lactobacillus acidophilus DSM 4149 12.4741 g 4. germ-free aqueous substrate of metabolic products Lactobacillus helveticus DSM 4183 49.8960 g.	bottle	100.0 ml	20-40 drops 3 times a day for 10-15 days
	Powder Lebenin	capsules		3 times a day 21 days
	Saccharomycetes Boulardii	capsules	250 mg	3 times a day for the entire course of treatment
	Freeze-dried bacteria	bottle capsules	3 and 5 doses	3 times a day for the entire course of treatment
	Sterile concentrate metabolic products of the intestinal flora	drops	30 ml, 100 ml	20-60 drops 3 times a day
Hepatoprotect- tori*	Ademetionine	ampoules (lyophilizate for preparation. solution), tablets	400 mg	When taken orally, the daily dose is 800-1600 mg. With intravenous drip (very slowly) or intramuscular injection, the daily dose is 400-800 mg. The duration of treatment is set individually.	According to indications, mainly if there is a concomitant liver pathology.
	Essential phospholipids	capsules	300 mg
	Smoky extract, milk thistle	capsules	250 mg	1 capsule 3 times a day for the entire course of treatment
	Ursodeoxycholic acid	capsules	250 mg	1 capsule 3 times a day for the entire course of treatment
Immunomodu- Lators*	Levamisole	tablets	50 - 150mg	1 time per day in courses of 3 days with a 4-day break	Predominantly at the revealed violations of the immune status. In order to normalize immunity.
	Liquid extract (1:1) from grass pike soddy and ground reed grass)	dropper container	25ml, 30ml, 50ml.	according to the scheme: 1 week - 10 drops x 3 r / d 2 weeks - 8 drops x 3 r / d 3 weeks - 5 drops x 3 r / d 4 weeks - 10 drops x 3 r / d
	Sodium oxodihydroacridinyl acetate	tablets 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*	Pheebs	ampoules	1.0 ml	s / c 1 time per day for a course of 10 injections
External Therapy*	CycloPyroxolAmine	shampoo	1,5%	Rub onto damp scalp until foam is formed. Leave the foam for 3-5 minutes, rinse. Repeat procedure 2nd time	During the relapse every other day. In stationary and regression stage 1 time per week
	Ketoconazole	shampoo	2%	1-2 times a day	Mainly in the stationary and regression stages
Corneopro- tectors	PalmitoylEthanolAmin preparations based on Derma-Membrane-Structure (DMS)	Cream, Lotion	17% 31%	Adjuvant therapy during remission: apply to skin whole 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 use of TGCS, helps prolong remission.

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

Other treatments

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

Surgical intervention - no reason.

Preventive actions:
- a diet poor in carbohydrates and fats, enriched with fish, vegetables;
- elimination of risk factors;
- treatment of concomitant pathology;
- courses of vitamin therapy, herbal medicine, adaptogens, lipotropic agents;
- hydrotherapy;
- Spa treatment;
- root protectors (to restore the integrity of the stratum corneum, help prolong remission);
- emollients (mainly in the interrecurrent period - to restore the hydrolipidic layer).

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

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

Hospitalization

Indications for hospitalization, indicating the type of hospitalization:
1. Progression of a disease resistant to therapy (planned).
2. Acute joint damage, erythroderma (planned).
3. The severity and severity of the course (planned).
4. Torpid course of the disease (planned).

Information

Sources and literature

Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
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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, GR 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, SL Karvonen, L Kemeny, I Kopp, C Leonardi, M Maccarone, A Menter, U Mrowietz, L Naldi, T Nijsten, JP Ortonne, HD 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. Clinica Dermatologica, Ospedali Riuniti, 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 of Corneoprotectors in Dermatology, 2012, pp. 25 – 28 (56).

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of developers:
1. Eshimov A.E. - Ph.D. Director of the Research Institute of Dermatovenereology of the Ministry of Health of the Republic of Kazakhstan
2. Abilkasimova G.E. - Ph.D. chief physician Research Institute of Dermatovenereology of the Ministry of Health of the Republic of Kazakhstan
3. Ashueva Z.I. - Researcher of the Research Institute of Dermatovenereology of the Ministry of Health of the Republic of Kazakhstan
4. Dzhulfaeva M.G. - Senior Researcher of the Research Institute of Dermatovenereology of the Ministry of Health of the Republic of Kazakhstan
5. Dorofeeva I.Sh. - Researcher of the Research Institute of Dermatovenereology of the Ministry of Health of the Republic of Kazakhstan
6. Kuzieva G.D. - Researcher of the Research Institute of Dermatovenereology of the Ministry of Health of the Republic of Kazakhstan
7. Abdrashitov Sh.G. - MD senior researcher of the Research Institute of Dermatovenereology of the Ministry of Health of the Republic of Kazakhstan
8. Berezovskaya I.S. - Head of the Dermatological Department of the Research Institute of Dermatovenereology of the Ministry of Health of the Republic of Kazakhstan
9. Baev A.I. - Ph.D. Deputy Director for Science of the Research Institute of Dermatovenereology of the Ministry of Health of the Republic of Kazakhstan

Reviewers:
1. G.R. Batpenova - Doctor of Medical Sciences, Chief Freelance Dermatovenereologist of the Ministry of Health of the Republic of Kazakhstan, Head of the Department of Dermatovenereology of JSC "MUA"
2. Zh.A. Orazymbetova - d.m.s., head. course Kazakh-Russian Medical University
3. S.M. Nurusheva - d.m.s., head. Department of the Kazakh National Medical University. S.D. Asfendiyarov

No conflict of interest

Indication of the conditions for revising the protocol: Updating the protocols should be carried out as proposals are received from users of the protocol and registration of new medicines in the Republic of Kazakhstan.

Attached files

Attention!

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It refers to skin diseases that are difficult to treat and has a chronic course. V mild stage can be treated as an outpatient in a hospital. With a burdened history, if more than 30% of the skin is affected, treatment is carried out in the Central clinical hospital(TsKB). Successful therapy is carried out only in the Central Clinical Hospital, which have departments based on psoriasis institutes. Psoriasis institutes study in detail the etiology of the development of dermatological problems in patients and treat them using a wide range of methods. When each patient chooses the most suitable therapy options for himself, remission occurs faster and lasts a longer time. The Moscow Institute specializes in the treatment of psoriasis at different stages and uses various methods for this.

Treatment scheme at the Psoriasis Institute

The Psoriasis Institute offers treatment for patients with moderate and severe disease development in a hospital setting. The history of the development of the disease is carefully studied, the patient undergoes a medical examination. After compiling a complete clinical picture, the patient receives high-quality treatment that is relevant for a 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 medical and physiotherapy treatment. Standards of drug therapy:

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

Institute of Psoriasis and MOH Russian Federation prefers the combined method of treatment of psoriasis, in combination with drug therapy with physiotherapy. Physiotherapy treatment at the Institute of Psoriasis is carried out with the help of:

photochemotherapy;
PUVA baths;
selective phototherapy.

The recommendations of 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 bring him into remission. But all clinical picture can vary depending on the degree of development of psoriasis and the individual characteristics of the human body, and it is difficult to determine how long the therapy will last, even in the same clinical cases.

Medical treatment

Medical therapy 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 a 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.

Anticoagulants slow down the rate of blood clotting, due to which cell growth is inhibited, the process of progression of rashes stops. On the basis of coagulants there are ointments, creams, injections.
Detoxifiers help bind and remove toxins from the patient's body, which are formed due to the death of epidermal cells. Treatment with detoxifiers takes place intravenously.
Retinoid preparations 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 treatment in the hospital and after discharge.
Cytostatics help prevent cell division, this stops rashes and reduces the location of an existing rash on the body.

Fact! With the help of data 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 various powers, it is possible to reduce the size of rashes, prevent the progression of psoriasis, improve skin condition, and eliminate itching. In medical practice, UV irradiation is carried out by several types of rays.

Alpha ultraviolet rays. This type of UV irradiation is used in combination with special preparations called 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 dose of radiation in this particular place.
Beta ultraviolet cure. This type of UV treatment for psoriasis is based on studying the characteristics of the skin of a particular patient and determining the minimum dose of radiation for him. The minimum dose of UV beam is directed to a small area of the skin surface, the dose is subsequently increased several times, expanding the area of the irradiated surface.

For the treatment of psoriasis with ultraviolet rays, various installations are used. A variety of UV installations make it possible to treat psoriasis at a variety of localization sites and in various positions of the patient, both in the supine and standing positions, to provide both general and local UV effects on the affected foci of skin areas. UV cabins, bathrooms, local installations are used. How long UV irradiation sessions should last, their duration and number, 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 with the help of photochemotherapy. This method is used to treat psoriasis vulgaris, exudative, erythrodermic and pustular psoriasis. The method of treatment consists in long-wave UV exposure to inflammation foci, taking photosensitizers inside, which increase the effectiveness of exposure to UV radiation on the body. UV rays have a positive effect on the skin in psoriasis, they relieve the inflammatory process, activate the synthesis of melanin in the skin, and have an immunostimulating effect. In the process of exposure to UV rays on the skin, photosensitizers are concentrated in the epidermis. After 3 hours, the 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 Methoxsalen or Ammifurin is taken orally;
UV irradiation of the place of localization of rashes is carried out with a power of 0.25-1 J/cm;
the UV dose is gradually increased by 0.5 J/cm.

Clinical indicators of analyzes after passing the UV session determine the duration of the patient's treatment. How many days the patient will need to undergo photochemotherapy depends on the test results, which determine the recommendations of the attending physician. One course of treatment for a patient is 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 resembles UV photochemotherapeutic treatment and includes UV exposure to the foci of localization 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 in patients such adverse reactions like nausea, kidney failure, gastrointestinal disorders. PUVA bath provides only local exposure to photosensitizers, which is gentle on the body. The procedure for treating psoriasis with a PUVA bath is as follows:

The patient takes a bath with photosensitizers for 15-25 minutes, which are solutions of Ammifurin or Mitoxalen. An alcoholic 3% solution of Ammifurin is diluted with water, 1:3, respectively, by body weight, but not more than 180 mm per bath. Mitoxalen is available 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.
Local or general UV irradiation of the patient, with a radiation power of 0.25-1 J/cm.
Rest, sleep.

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

Important! The number of procedures that are 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 carried out both for the treatment of patients and for the prevention of psoriasis in remission.

selective phototherapy

A medical study of the indicators of analyzes and observations of the Institute of Psoriasis for patients shows that selective phototherapy increases the resistance of remission by up to 80%. Selective phototherapy is performed for patients with 30% skin lesions, with manifestations of psoriasis medium degree and in severe forms of the course of the disease, with a vulgar and exudative form of psoriasis. Conducting selective phototherapy is the impact of combined UV radiation, medium-wave and long-wave ultraviolet rays. The method of selective phototherapy varies in intensity:

The first direction is the impact of the 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, and allergic reactions on the skin. The treatment protocol determines the duration of the procedure and the number of sessions.
According to the second method, it is supposed to carry out UV radiation in a certain dose for the entire period of therapy. A standard phototoxic dose of medium and long wavelength UV radiation is administered throughout the course of treatment. UV radiation of a single power is treated for several days, repeating 2-3 courses with interruptions.

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

Recommended
Expert Council
RSE on REM "Republican Center
health development"
Ministry of Health
and social development
Republic of Kazakhstan
dated November 30, 2015
Protocol No. 18

Protocol name: Psoriasis.

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

Abbreviations used in the protocol:
ALT - alanine aminotransferase
ASAT - aspartate aminotransferase
BR Reiter's disease
DBST-diffuse connective tissue diseases
Mg - milligram
ml - milliliter
INN - international non-proprietary name
KLA - complete blood count
OAM - general urinalysis
PUVA - therapy - a combination of long-wave ultraviolet (320-400 nm) irradiation and taking photosensitizers inside

ESR - erythrocyte sedimentation rate
SFT - selective phototherapy
UFT - narrow band phototherapy

Protocol user: dermatovenereologist of the skin-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:
progressing;
· stationary;
regressive.

Based on prevalence:
limited;
common;
generalized.

Depending on the season of the year, types:
winter (exacerbation in the cold season);
summer (exacerbation in the summer season);
indefinite (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, restriction 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 (“stearin stain”, “terminal film”, “blood dew”);
Koebner's symptom (isomorphic reaction);
the presence of a growth zone;
the dimensions of the elements;
Characteristics of the location of the scales;
psoriatic lesions of the nail plates;
condition of the joints.

List of diagnostic measures

The main diagnostic measures (mandatory, 100% probability):
Complete blood count in the course of treatment
General analysis of urine in the dynamics of treatment

Additional diagnostic measures (probability less than 100%):
Determination of glucose
Determination of total protein
Determination of cholesterol
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)
Therapist's consultation
Physiotherapist's consultation

Examinations that must be carried out before planned hospitalization (minimum list):
· general blood analysis;
· general urine analysis;
· biochemical analyzes blood: AST, ALT, glucose, total. bilirubin.;
Precipitation microreaction;
Examination of feces for helminths and protozoa (children under 14 years of age).

Instrumental research: not specific

Indications for expert advice(in the presence of concomitant pathology):
· therapist;
a neuropathologist;
rheumatologist.

Differential Diagnosis:

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

Treatment goals:

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

Treatment tactics.

Non-drug treatment:
Mode 2
Table number 15 (limit: the intake of spicy dishes, spices, alcoholic beverages, animal fats).

Medical treatment.

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

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

Note: This protocol uses the following classes of recommendations and levels of evidence
A - strong evidence of the benefit of the recommendation (80-100%);
B - satisfactory evidence of the benefits of the recommendations (60-80%);
C - weak evidence of the benefits of the recommendations (about 50%);
D - satisfactory evidence of the benefits of the recommendations (20-30%);
E - convincing evidence of the futility of recommendations (< 10%).

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

Pharmacological group	INN of the drug	Release form	Dosage	Multiplicity of application	Note
Immunosuppressive agents (Cytostatics), including anti-cytokine agents	Methotrexate	ampoules, syringe Tablets	10, 15, 25, 30 mg 2.5 mg	1 time per week for 3-5 weeks Doses and regimen of appointment is selected individually.	Methotrexate has been approved for the treatment of psoriasis without any of the double-blind, placebo-controlled trials that are currently mandatory. Clinical guidelines were developed by a group of dermatologists in 1972, which determined the main criteria for prescribing methotrexate for psoriasis.
	Cyclosporine (level of evidence B-C)	Concentrate for solution for infusion, capsules	(1 ml ampoules containing 50 mg each); 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 isotonic sodium chloride solution or 5% glucose solution. The initial dose is usually when injected into a vein 3-5 mg / kg per day, when taken orally - 10-15 mg / kg per day. Next, doses are selected based on the concentration of cyclosporine in the blood. The determination of the concentration must be made daily. For the study, a radioimmunological method is used using special kits. The use of cyclosporine should only be carried out by physicians with sufficient experience in immunosuppressant therapy.

	Infliximab (level of evidence - B)	powder for solution	100 mg	5 mg/kg according to the scheme
	Ustekinumab (level of evidence - A-B)	bottle, syringe	45mg/0.5ml and 90mg/1.0ml	45 - 90 mg according to the scheme	It is used for medium-severe forms of psoriasis, with an area and severity of skin lesions of more than 10-15%. Selective inhibitor of pro-inflammatory cytokines (IL-12, IL-23)
	Etanercept* (level of evidence - B)	Solution for subcutaneous administration	25 mg - 0.5 ml, 50 mg - 1.0 ml.	Etanercept 25 mg twice a week, or 50 mg twice a week for 12 weeks, followed by 25 mg twice a week for 24 weeks	It is used mainly in 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 THCS 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, minimize the risk of adverse events. The effectiveness of treatment will increase with complex therapy with root protectors
Strong (III)	Betamethasone	ointment, cream	0,1%	1-2 times a day	Local application of TGCS can cause the appearance of striae and skin atrophy, and these side effects are more pronounced against the background of 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
Weak (I)	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 supporting the efficacy 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 period) placebo-controlled studies of the efficacy of topical application of activated zinc pyrithione in mild to moderate papulo-plaque psoriasis.

List of additional medicines (less than 100% probability)

Pharmacological group	INN of the drug	Release form	Dosage	Multiplicity of application	Note
Antihistamines*	cetirizine	tablets	10 mg	1 time per day No. 10-14	To provide a pronounced anti-allergic, antipruritic, anti-inflammatory and anti-exudative action.
	Chloropyramine	tablets	25 mg	1 time per day No. 10-14
	Diphenhydramine	ampoule	1%	1-2 times a day No. 10-14
	Loratadine	tablets	10mg	1 time per day No. 10-14
	clemastine	tablets	10 mg	1-2 times a day No. 10-14
Sedatives*	Valerian extract	tablets	2 mg	3 times a day 10 days	If the pathological process on the skin is accompanied by anxiety of the 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, herb St.	bottle	100 ml	5 ml 2 times a day
	Peony elusive rhizome and roots	bottle	20-40 cap	2 times a day for a course of therapy
Sorbents*	activated carbon	tablet	0.25 gr.	1 time per day 7-10 days
Desensitizing drugs*	Sodium thiosulfate	ampoules	30% - 10.0 ml	1 time per day for 10 days
	calcium gluconate	ampoules	10% - 10.0 ml	1 time per day for 10 days
	Magnesium sulfate solution	ampoules	25% - 10.0 ml	1 time per day for 10 days
Preparations correcting disorders of microcirculation*	Dextran	vials	400,0	1 time per day №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 for 1.5 months
	Thiamine	ampoules	5%-1.0 ml	1 time per day 10-15 days
	Pyridoxine	ampoules	5%-1.0 ml	1 time per day 10-15 days
	Tocopherol	capsules	100mg, 200mg, 400mg	3 times a day 10-15 days
	cyanocobolamin	ampoules	200mcg/ml, 500mcg/ml	1 time per day every other day No. 10
	Folic acid	tablets	1mg, 5mg	3 times a day 10-15 days
	Vitamin C	ampoules	5%-2.0 ml	2 times a day for 10 days
Glucocorticosteroids*	Betamethasone	Suspension for injection	1.0 ml	1 time in 7-10 days
	Hydrocortisone	Suspension for injection	2,5%	dose and frequency are determined individually	according to the indications, depending on the severity
	Dexamethasone	tablets ampoules	0.5 mg; 1.5 mg 0.4% - 1.0 ml	dose and frequency are determined individually	according to the indications, depending on the severity
	Prednisolone	tablets ampoules	5 mg 30 mg/ml	dose and frequency are determined individually	according to the indications, depending on the severity
	Methylprednisolone	Tablets, Lyophilisate for solution for injection	4 mg; 16 mg 250, 500, 1000 mg	dose and frequency are determined individually	according to the indications, depending on the severity
Drugs that improve peripheral circulation*	Pentoxifylline	ampoules	2% - 5.0 ml	1 time per day 7-10 days
Means that help restore the microbiological balance of the intestine*	1. Germless water substrate of metabolic products of Escherichia coli DSM 4087 24.9481 g 2. germ-free aqueous substrate of metabolic products of Streptococcus faecalis DSM 4086 12.4741 g 3. germ-free aqueous substrate of metabolic products Lactobacillus acidophilus DSM 4149 12.4741 g 4. germ-free aqueous substrate of metabolic products Lactobacillus helveticus DSM 4183 49.8960 g.	bottle	100.0 ml	20-40 drops 3 times a day for 10-15 days
	Powder Lebenin	capsules		3 times a day 21 days
	Freeze-dried bacteria	bottle capsules	3 and 5 doses	3 times a day for the entire course of treatment
	Freeze-dried bacteria	bottle capsules	3 and 5 doses	3 times a day for the entire course of treatment
Hepatoprotectors*	Smoky extract, milk thistle	capsules	250 mg		According to indications, mainly if there is a concomitant liver pathology.
Hepatoprotectors*	Ursodeoxycholic acid	capsules	250 mg	1 capsule 3 times a day for the entire course of treatment
Immunomodulators*	Levamisole	tablets	50 - 150mg	1 time per day in courses of 3 days with a 4-day break	Predominantly at the revealed violations of the immune status. In order to normalize immunity.
	Liquid extract (1:1) from grass pike soddy and ground reed grass)	dropper container	25ml, 30ml, 50ml.	according to the scheme: 1 week - 10 drops x 3 r / d 2 weeks - 8 drops x 3 r / d 3 weeks - 5 drops x 3 r / d 4 weeks - 10 drops x 3 r / d
	Sodium oxodihydroacridinyl acetate	tablets 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*	Pheebs	ampoules	1.0 ml	s / c 1 time per day for a course of 10 injections
External Therapy*	CycloPyroxolAmine	shampoo	1,5%	Rub onto damp scalp until foam is formed. Leave the foam for 3-5 minutes, rinse. Repeat procedure 2nd time	During the relapse every other day. In stationary and regression stage 1 time per week
	Ketoconazole	shampoo	2%	1-2 times a day	Mainly in the stationary and regression stages
Root protectors	PalmitoylEthanolAmin preparations 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 use of TGCS, helps prolong remission.

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

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 magnetotherapy, balneotherapy, heliotherapy.

Surgical intervention - no reason

Indicators of treatment efficacy and safety of diagnostic and treatment methods:
Significant improvement - regression of 75% of rashes and 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).
acuteness and severity of the course (planned).
torpid course of the disease (planned).

Preventive actions:
a diet low in carbohydrates and fats, enriched with fish, vegetables
elimination of risk factors
treatment of comorbidities
courses of vitamin therapy, herbal medicine, adaptogens, lipotropic agents
hydrotherapy
· Spa treatment.
Root protectors (to restore the integrity of the stratum corneum, help prolong remission).
emollients (mainly in the interrecurrent period - to restore the hydrolipid layer)

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

Minutes of the meetings of the Expert Council of the RCHD MHSD RK, 2015< >List of used literature: 1. "Skin and venereal diseases". Guide for doctors. Edited by YUK 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. Studnitsyn. Moscow, 1983. 4. Rational pharmacotherapy of skin diseases and sexually transmitted infections. Guide for practicing physicians. // Under the editorship of A.A. Kubanova, V.I. Kisina. Moscow, 2005. 5. European Guidelines for the Treatment of Dermatological Diseases Ed. HELL. Katsambasa, T.M. Lottie. // Moscow Medpress inform 2008.-727 p. 6. "The therapeutic guide to dermatology and allergology." P. Altmayer 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 papular-plaque psoriasis. Results of a randomized, placebo-controlled study of ANTHRACIT. 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 AcadDermatol. 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, HôpitalL "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, GR 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, SL Karvonen, L Kemeny, I Kopp, C Leonardi, M Maccarone, A Menter, U Mrowietz, L Naldi, T Nijsten, JP Ortonne, HD 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. Clinica Dermatologica, Ospedali Riuniti, 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 of Corneoprotectors in Dermatology, 2012, pp. 25 - 28 (56).

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

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

Before prescribing medication for psoriasis, a dermatologist must collect a complete patient history, prescribe all the necessary tests and familiarize yourself with the list of medications already taken by the patient. Any treatment regimen for psoriasis involves the exclusion of the maximum number of risk factors. This is especially important if medical treatment of psoriasis is planned, because excessive exposure to chemical elements on the body can lead to very serious immune diseases, and even cancer, instead of a skin disease.

Standards for the treatment of psoriasis: mandatory research before prescribing therapy

The US National Department of Health has issued a directive that every patient must undergo appropriate monitoring before starting drug therapy. The Hungarian psoriasis treatment regimen also implies that the patient is given a minimum set of tests before starting systemic therapy. Despite the fact that European and American directives are not valid in post-Soviet countries, domestic clinics also carry out mandatory liver function tests, a complete blood count (including platelet count, hepatitis virus and immunodeficiency detection). The psoriasis treatment protocol also implies that patients should be periodically checked for infections and malignancies while taking medication.

Who is the nsp psoriasis treatment program for?

If patients have serious infections that require antibiotic therapy, then therapy with natural preparations is prescribed, a large range of which is offered by NSP. Since the Hungarian scheme and other official treatment programs are aimed at correcting the immune system in the diagnosis of psoriasis, it is important to use all approaches to prevent the development of severe complications. Some therapy protocols also contain recommendations for the use of vaccines in patients suffering from posterior plaques and receiving medication. After all, standard vaccinations, including against pneumococci, hepatitis A and B, influenza, tetanus, diphtheria, can aggravate the patient's condition. That is why it is preferable to complete the full course of vaccination before starting therapy. The administration of other vaccines should also be avoided under any circumstances.

26 Sep 2016, 23:57

Treatment of psoriasis mummy
effective treatment psoriasis medicine is still unknown, which is explained by the lack of knowledge about the true causes of the development of dermatosis. That is why the treatment of pathology involves a complex ...

Psoriasis refers to diseases that do not have a viral or fungal nature, so it is not transmitted through the air, household items or through personal contact with the patient. Prerequisites for the onset of the disease are hereditary, psychological, physiological factors.

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

Initially, the external manifestations of scaly lichen 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 - itching and inflammation - are eliminated. The products also help to improve the condition of the skin, make it elastic. Together with local drugs, a number of procedures are prescribed - physiotherapy, ultrasound, herbal medicine, electrosleep, the PUVA method, phototherapy, laser therapy, cryotherapy.
Usage hormonal drugs. They are used only in extreme cases, they allow you to quickly eliminate the symptoms of psoriasis, but have a significant minus - a negative impact on other human organs.
Biologics (monoclonal antibodies, GIP) help immune system body to cope with the manifestations of the disease.
An important role is played by the appointment of vitamin complexes with the mandatory inclusion of vitamin D.

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

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 those. It was introduced into wide medical practice in 2005.

This method of therapy is based on the idea of protection human body from endotoxins. According to the hypothesis, they penetrate the walls of the intestine, affecting 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. Such treatment helps to protect the body from the appearance of cytotoxins that provoke the development of skin disease.

The Hungarian psoriasis treatment regimen includes several stages:

Focusing. This period, which is equal to 24 days, is needed to carry out a number of diagnostic measures with a detailed study of the patient's analyzes. The purpose of the stage is to detect infections, fungi, pathogenic microorganisms in the body.
Medical 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 in the afternoon.
Additional activities. With an advanced stage, the doctor may prescribe several injections (gluconate or calcium chloride).
A strict diet with the use of vitamins of group D, B12.

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

How is the Duma technique used for psoriasis?

This method of treating the disease involves the use of food, medicines, 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 in the morning with the use of herbal decoction (St. The day is strictly divided into morning, lunch, evening and night.

In the morning, a mandatory shower with tar soap is provided. 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, one of the probiotics should be consumed (Bifikol, Kipacid, Linex, Probifor). The morning ends with a light fruity lunch.

For lunch and dinner, the medication should be repeated. At night, an herbal bath is taken from a decoction of chamomile and calendula. At about 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 psoriasis drugs. Accordingly, from their products, the company's specialists created their own method for getting rid of skin disease, which was called the NSP Psoriasis Treatment Program.

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

After 3 weeks, patients, if necessary, are connected to Calcium Magnesium Chelate, Eight, Omega-3. The course of therapy with these drugs allows you to achieve excellent performance in the condition of patients.

Protocol for the treatment of psoriasis at the Dead Sea

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

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