I often hear patients ask: "Doctor, why is psoriasis so difficult to treat? I have used a lot of drugs and physical therapy, and the skin lesions improved, but they recurred not long after. Are there any new drugs now?" .
The answer is: "Yes, there are new systemic drugs such as biological agents, and there are also new topical drugs." However, how to choose treatment and how to combine treatment to achieve the best effect requires a full assessment of the patient's condition. , develop individualized plans.
Traditional treatments for psoriasis include topical drugs, phototherapy, systemic drugs, etc. Currently, commonly used external drugs include glucocorticoids, retinoic acid, vitamin D3 derivatives, etc., and systemic drugs include retinoic acid. , methotrexate, cyclosporine and other drugs.
Traditional treatments have shortcomings such as slow onset of effect, easy relapse, many adverse reactions, and poor compliance. In recent years, biological treatment has become one of the main treatments for psoriasis. It is widely used in the treatment of severe and severe psoriasis. It has played an active and effective role in treating refractory and special types of psoriasis.
The biological agents currently approved for marketing in my country and already used clinically for the treatment of psoriasis include:
1. Tumor necrosis factor alpha (TNF-α) inhibitor: enamel Xip, infliximab, adalimumab;
2. Interleukin 12/23 (IL-12/23) inhibitor: ustekinumab;
3. Interleukin 23 (IL-23) inhibitor: guselkumab;
4. Interleukin 17A (IL-17A) inhibitor: secukinumab, elxumab Chiclizumab.
Most of the approved indications for biological agents in my country are adults with moderate to severe plaque psoriasis or those who are not satisfied with the efficacy of other systemic treatments such as cyclosporine, methotrexate or PUVA, or have contraindications. Moderate to severe plaque psoriasis in adults who cannot be tolerated, so most of the patients who use biological agents in China are plaque psoriasis patients;
Although the efficacy of different biological agents varies, overall after treatment The response rate is relatively high. Most patients can reach PASI75 or PASI90 in 12 to 16 weeks. However, there are still a few patients who cannot obtain satisfactory treatment effects through a single biological agent treatment plan or at a certain stage. The treatment effect can only reach PASI75 or even below PASI50. , then other treatment methods need to be combined.
In the early stage of treatment, combined with external medications, the condition can be improved more quickly. During the treatment process, when some skin lesions are stubborn or recurring, they can also be combined with external medications;
Multiple clinical studies have shown that biological Preparations combined with topical glucocorticoids, retinoic acid or vitamin D3 derivatives can improve the efficacy;
Especially in the early stages of plaque psoriasis treatment or when the response rate is not high, topical halomethasone emulsion can be used Cream, tazarotene betamethasone cream, and calcipotriol betamethasone ointment can promote thinning of plaques and reduction of scales, with faster onset of action and better efficacy. After the plaques are thinned, calcipotriol is used externally. Maintenance treatment with alcohol ointment can further promote the rapid removal of skin lesions.
Studies have proven that the combined application of etanercept, adalimumab, infliximab and ustekinumab with narrow-band mid-wave ultraviolet rays can further improve the efficacy;
However, given that this combination is not necessary for most patients, and the simultaneous use of biological agents such as TNF?α inhibitors and ultraviolet therapy cannot completely exclude the increased risk of skin malignancies, it is not recommended to combine biological therapy with ultraviolet light. Phototherapy is used as a routine treatment option.
The combination of biological agents such as etanercept and methotrexate can improve the efficacy, and the combination of biological agents such as infliximab and methotrexate can reduce the production of anti-drug antibodies (ADA);
For those who are not satisfied with the efficacy of biological agents alone or whose long-term maintenance efficacy is unstable, acitretin can be used in combination;
The combined use of biological agents with other immunosuppressants such as cyclosporine is not recommended.
Patients who are already taking methotrexate and acitretin before the application of biological agents can continue to be treated with combined biological agents without stopping the medication. After the condition improves or is controlled, the traditional drugs will be gradually reduced or discontinued. .
The development of biological treatments for psoriasis is very rapid. With the continuous accumulation of clinical experience and the continuous emergence of new biological agents, we need to develop suitable individual treatments based on the patient's condition, psychological, economic situation and other comprehensive factors. ization plan.
If biological treatment fails to achieve satisfactory results, it can be combined with traditional drugs to treat psoriasis to achieve the best results and maximize patient benefit.
Author: Wang Ping, Fifth People’s Hospital of Hainan Province