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Psoriasis and biological drugs

Autor: prof dr Ivana Binić    


Psoriasis (lat. Psoriasis vulgaris) is a chronic, recurrent, inflammatory skin disease with frequency of 1 to 3% in the general population. Both sexes can have the disease; although it usually begins in the early youth, it can be manifested later in life.

Genetic factor and psoriasis

It is known that predisposition for the disease is inherited, but the real cause of it isn’t still clear. Psoriasis is a relatively frequent disease, while the seriousness of illness can vary. The major characteristic is the appearance of red areas, covered with silvery-whitish lamellas. This can be localized, but the changes can also take larger areas of the body, and sometimes even the entire body. Although the disease often takes the head, it does not cause the loss of hair; when the changes withdraw, there aren’t any scars. Psoriatic process can also take the joints, and then we should talk of psoriatic arthritis.

The major process that happens in the normal skin is the process of keratinization, when the cells of the skin (keratinocytes) mature, and, from the basal layer they slowly go to the layers of the epidermis, when they are invisibly removed from the surface. This process normally lasts for 28 days. In psoriasis, the process of keratization happens several times faster, keranocytes don’t mature normally, and as a consequence, there is the thickening of the areas taken by psoriasis, and the forming of squama (lamella, layers). Unfortunately, there is no drug which is completely efficient.

Forms of disease

According to the percentage of the area taken by psoriasis, the disease can be divided into mild forms - 5% of skin is taken; temperate forms - 10% of the skin is taken; heavy forms-more than 10 % of the skin is taken by the disease. It is necessary to mention that this cannot be the only criteria, since sometimes, when a smaller area is taken, this can also be a heavy form if the localization of changes is such. Here, we can mention pustulous psoriasis (appearance of pustule) of palms and soles, which makes numerous daily activities of the patient difficult, regardless of the fact that less than 5% of the skin is taken by the disease.

Psoriasis and the quality of life

Psoriasis has a great influence on the patient’s life quality; their disease is visible, and due to that, they are sometimes unable to take part in various activities, which are normal and done by other people without any thinking about them-swimming in the pool, going to the gym, shopping, going to work, etc. There is a great number of depressive and anxious patients, which was proved in a lot of researches.

The course of the disease is unpredictable

The course of the disease cannot be completely predicted.  In some patients, the disease remains localized forever; in some of them, it can inexplicably withdraw; but, in some patients, it can take the whole body. Stress and anxiety, skin injuries, different infections and hormone disbalance can influence the appearance of the disease. There are probably other factors that influence the disease, but they are not yet discovered. It hasn’t been proved that bad food influence the disease, so there is no adequate diet; yet, greater alcohol taking can worsen the changes on the skin. It should be mentioned that UV radiation (sunbathing) can improve psoriatic changes, but not in all patients.

The aim of therapy is to reduce the diseased area of the skin

The aim is also to achieve a control over the disease, to reduce the diseased area of the skin, and to achieve and  maintain remission of the disease as long as possible; it is also important that the side effects of the therapy be mimimal, and finally, that the life quality of these patients be improved.

All the patients need treatment, no matter if it is a control of acute deterioration or maintaining of remission.  Local therapy is usually the first choice in case of a milder form of disease. In that case, local drugs are used; they contain active substances such as: synthetic analogs of D vitamin, corticosteroids, drugs of tar, salicylates and derivates of the acid A vitamin. The next therapeutic option is phototherapy in which the artificial sources of light, with specific wavelength, are used. Sometimes, these lamps (they can be UVA or UVB lamps) are combined with substances which are called photosensitiers (local and systematic), because of better effects.

There are different models and they are used in accordance with the percentage of the diseased are on the skin. Potential danger can be in the form of burns, cataract (if protection of eyes is not adequate), photoalergic reactions, skin maturing and even skin cancer. The third possibility in the therapy of psoriasis (mild to heavy forms of psoriasis) is in the form of oral drugs. Those are immunosuppressants, antimetabolites and retinoids. Although their therapeutic effect can be satisfying, their use can be followed by serious side effects such as kidney damage, liver damage, heart damage and malignancies. Therefore, it is necessary to estimate the need for the use of these drugs.

Immune system disorder

New scientific discoveries about immunopathogenesis of this disease explain psoriasis as an immune system disorder, but not as a primary skin disease. Because of that, science has developed a new group of biological drugs which affect the specific components of immune response, change it and stop the process of disease. They can be offered to the patients as a more secure and efficient therapeutic option in comparison with traditionally used immunosuppressants. Before the use of biological drugs has started, some of them were successfully used in the treatment of other illnesses, such as: rheumatoid arthritis, ancylosis spondylitis, Chron’s disease, ulcerative colitis.

In the USA and Europe, there are five drugs from this group which are approved for the treatment of psoriatic arthritis and mild form to heavy plaque psoriasis. They certainly don’t represent the primary choice of the psychotherapeutist, but they are indicated in patients with more severe clinical feature.

One of the drugs (etanercept-Embrel®) for the treatment of psoriasis is present in our country too, but it is not on the positive list for this disease. It is an expensive drug, so everyone cannot have it. All in all, the era of biological drugs represents a certain progress in the treatment of psoriasis and they give a new hope to the group of people who fight every day against this disease. As these are relatively new drugs, it would be necessary to make instructions for their use and make efforts that they are put on the positive list for a certain number of patients, so that this kind of therapy could be applied in a planned and systematic way, with the greatest benefit for the patients.

Ivana Binic, PhD, MD

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