| disease | Psoriasis |
| alias | Psoriasis, Oxhide Lichen (Neurodermatitis), Psoriasis |
Psoriasis, commonly known as "psoriasis," is referred to as "psoriasis" in traditional Chinese medicine. It is a common chronic, recurrent, inflammatory skin disease characterized by the appearance of varying sizes of papules, erythema, and surfaces covered with silvery-white scales, with clearly defined borders. It commonly occurs on the scalp, extensor surfaces of the limbs, and the back. It is more prevalent in men than in women. The condition tends to recur or worsen in spring and winter, while it often alleviates in summer and autumn.
bubble_chart Etiology
The exact disease cause of this condition is not yet fully understood. In recent years, most scholars believe it is related to genetic factors, infections, metabolic disorders, immune dysfunction, endocrine disorders, and other factors.
1. Genetic Factors Clinical observations indicate that this disease often has a familial history and a genetic predisposition. Foreign reports suggest that 30–50% of cases have a familial history, with some even emphasizing rates as high as 100%. Domestic reports indicate a familial history in about 10–20% of cases. Regarding the mode of inheritance, some propose autosomal dominant inheritance with incomplete penetrance, while others suggest autosomal recessive inheritance or X-linked inheritance. If one parent has psoriasis, the incidence rate in their offspring is three times higher than that of children from healthy parents. If both parents have psoriasis, the incidence rate in their offspring is even higher.
In recent years, a significant correlation has been found between human leukocyte antigens (HLA) and psoriasis. Foreign reports indicate that psoriasis patients have a significantly higher frequency of HLA-B13 and HLA-B17 antigens, though some also report increased frequencies of HLA-B3, HLA-CT7, and HLA-W6. In Chinese psoriasis patients, besides the significantly higher frequencies of HLA-B13 and HLA-B17 antigens compared to the normal group, the gene frequencies of HLA-DR7, HLA-A19 are also elevated, while those of HLA-BW35, HLA-DR9, HLA-C7, and HLA-DQ are reduced. Currently, it is believed that psoriasis is controlled by multiple genes and is also influenced by environmental factors.
2. Infections Clinical practice has demonstrated that the onset of psoriasis is related to upper respiratory tract infections and tonsillitis. About 6% of psoriasis patients have a history of throat infections. We have observed that many cases of psoriasis in children are closely associated with tonsillitis. For example, one mother and her three children simultaneously developed acute tonsillitis, and after the condition was controlled, three of them developed psoriasis. Such patients respond well to antibiotic treatment. After tonsillectomy, skin lesions may significantly improve or disappear, indicating that infection is an important factor in the onset of psoriasis.Some scholars believe that the onset of this disease is related to viral infections. Some have confirmed the presence of eosinophilic inclusion bodies in prickle cells, while others deny their existence. Some have inoculated guinea pigs, resulting in skin lesions similar to this disease, and inclusion bodies were found in their tissue sections. However, the incidence rate was only 7.5%. Others have conducted experimental inoculations on chicken embryos, achieving a success rate of 86.7%. The nuclei of cells in this disease show vigorous division, and deoxyribonucleic acid (DNA) levels increase. Therefore, the viral theory seems to have some basis, but so far, no virus has been successfully cultured.
Recently, domestic researchers such as Liu Zhengyu have studied the relationship between human cytomegalovirus (HCMV) infection and the onset of psoriasis. They tested serum HCMV-specific antibodies (IgM, IgA) and urinary HCMV-DNA positivity rates in 86 psoriasis patients. The results showed that the active HCMV infection rate in psoriasis patients was significantly higher than in the control group, and the urinary HCMV-DNA positivity rate was also significantly higher, indicating that active HCMV infection exists in psoriasis patients and that the onset of the disease is related to HCMV activation.
However, it is worth noting that some scholars believe the ratio of cAMP to cGMP is crucial in determining epidermal cell proliferation and differentiation. The proliferation, incomplete differentiation, and glycogen accumulation in the epidermal cells of psoriasis patients are attributed to low cAMP and high cGMP, though this has not been fully confirmed.
4. Immune Dysfunction The relationship between psoriasis and immunity has long been widely emphasized. Clinically, immunosuppressants such as methotrexate (MTX), ethylenimine, and cyclosporine A have shown significant efficacy in treating this condition. Psoriasis patients exhibit various local or systemic immune abnormalities, and the disease is highly associated with the expression of HLA-B13 and B17 antigens, suggesting it is also an immune-related disorder. However, the exact immune pathogenesis of psoriasis remains unclear. A prevalent view is that psoriasis is an epidermal proliferative disease caused by activated T cells. The dermis of psoriatic lesions contains infiltrated activated T cells, which release gamma-interferon, inducing epidermal cells to synthesize tumor necrosis factor, interleukin-8, interleukin-6, and other cytokines. These attract neutrophil infiltration in the epidermis, leading to dermal vasodilation and skin inflammation. Moreover, interleukin-6 and interleukin-8 released by monocytes and epidermal cells further promote epidermal cell proliferation, resulting in the coexistence of abnormal epidermal hyperplasia and skin inflammation in psoriatic lesions. The initiating factors for T-cell activation in psoriasis lesions require further study and may involve infections, trauma, or neuropsychiatric factors.
5. Endocrine Disorders The relationship between psoriasis and hormones has long been recognized. The disease is associated with pregnancy, childbirth, lactation, and menstruation. Clinically, some psoriasis patients experience alleviation or remission of rashes during pregnancy. Chuzch observed that 38% of 43 patients had lesion remission during pregnancy. In a domestic study by Liu Chenghuang et al., 6.2% of 169 psoriasis cases were linked to endocrine factors, with 5 cases showing improvement or cure during pregnancy but worsening postpartum. Xu Yanchun et al. reported that plasma estradiol levels in 19 female psoriasis patients aged 12–45 were significantly higher than in the control group, while progesterone levels were notably lower. They suggested that elevated estradiol and reduced progesterone levels might trigger or worsen lesions in female patients aged 12–45. However, some women experience aggravated or worsened lesions during pregnancy, and there are reports of certain efficacy using long-acting contraceptives for treatment. In summary, psoriasis appears to have a connection with endocrine changes.
6. Other Factors Psychological trauma, physical injury or surgery, humidity, changes in hemorheology, as well as physicochemical factors and drug stimuli, also play a role in the onset of psoriasis in some patients.
bubble_chart Pathological Changes
The pathological changes of psoriasis vulgaris are hyperkeratosis and parakeratosis of the epidermis. Small abscesses composed of neutrophils can be seen in the areas of parakeratosis, known as Munro's microabscesses. The granular layer is significantly reduced or absent. The spinous layer is thickened. The epidermal ridges extend, with their lower ends widened, and may merge with adjacent epidermal ridges. The dermal papillae are elongated and club-shaped, with thinning of the overlying spinous layer. The capillaries within the papillae are dilated and congested, leading to the clinical manifestation of Auspitz's sign. Surrounding areas show infiltrates of lymphocytes and neutrophils, among others.
The pathological changes of psoriatic arthritis are the same as those of psoriasis vulgaris described above and will not be repeated here.
The pathological changes of erythrodermic psoriasis are primarily characterized by more pronounced inflammatory reactions, with significant edema in the upper dermis, while other features are largely similar to those of psoriasis vulgaris.
The pathological features of pustular psoriasis and acrodermatitis continua are the formation of larger intraepidermal pustules, known as Kogoj's pustules, mainly in the upper epidermis. The pustules are primarily filled with neutrophils, and other changes are generally similar to those of psoriasis vulgaris, though parakeratosis and epidermal ridge extension are less severe.
The pathological changes of palmoplantar pustulosis consist of unilocular intraepidermal pustules containing large numbers of neutrophils and a few monocytes, with infiltrates of lymphocytes, histiocytes, and neutrophils in the superficial dermis.
bubble_chart Clinical Manifestations
According to the clinical and pathological features of psoriasis, it can generally be divided into six types: vulgaris, arthritis, pustular, palmoplantar pustulosis, erythrodermic, and acrodermatitis continua.
1. **Psoriasis Vulgaris** is the most common clinically, often with an acute onset and rapid spread throughout the body. The initial lesions are usually red or brownish-red papules or maculopapules. Over time, these expand into brownish-red patches covered with dry scales. The borders are well-defined, and adjacent lesions may merge.
The scales of this condition are silvery-white and gradually thicken. Scraping off the scales reveals a translucent thin membrane, known as the **"membrane phenomenon."** Removing this membrane leads to pinpoint bleeding, called **Auspitz's sign**. Both the membrane phenomenon and Auspitz's sign are specific for diagnosing psoriasis. In some patients, the scales become thick and hard, resembling oyster shells, which can restrict skin movement. On joint surfaces, these thick, hard scales are prone to cracking, causing painful fissures (rhagades).
The lesions of psoriasis vulgaris vary widely. Some rashes appear as scaly droplets, termed **guttate psoriasis**; fine scaly lesions at the follicular sebaceous gland openings are called **follicular psoriasis**; if the scales resemble oyster shells, it is termed **rupioid psoriasis**; irregular, map-like lesions are called **geographic psoriasis**; the most common clinical presentation is discoid or coin-shaped lesions, referred to as **discoid or nummular psoriasis**.
Psoriasis vulgaris can occur anywhere on the body but is most common on the extensor surfaces of the limbs, particularly the elbows and knees, often symmetrically, as well as the sacral region. Scalp involvement is also frequent, either alone or alongside systemic lesions. Scalp lesions have clear borders, with hair appearing in tufts but without alopecia areata. Nails (fingers and toes) may also be affected, showing a "thimble-like" pitted surface, loss of luster, thickening, or a yellowish-gray discoloration. The nail plate may separate from the nail bed, with the free edge crumbling or lifting. In rare cases, lesions may appear on the lips, penis, or glans.
Psoriasis vulgaris can be divided into **three stages** based on lesion progression:
(1) **Progressive Stage**: Old lesions persist while new ones continue to appear. Lesions show obvious infiltration and inflammation, often surrounded by a red halo, with thick scales. In the **initial stage**, mechanical skin stimuli such as needle pricks, cuts, burns, or surgical incisions may induce typical psoriatic lesions in the surrounding skin within 7–14 days. This is called **artificial psoriasis (Psoriasis factitia)**, also known as the **isomorphic response (Köebner phenomenon)**.
(2) **Stationary Stage**: Lesions remain largely unchanged for an extended period, with few new rashes appearing. Inflammation decreases, and the condition stabilizes.
(3) **Regressive Stage**: Inflammation subsides, and lesions shrink or flatten, leaving hypopigmented white spots or hyperpigmented patches. The disease tends to recur. Some patients initially exhibit seasonal patterns, with worsening in winter and remission or clearance in summer. Later, the condition may persist chronically. A few patients remain in long-term remission after clinical recovery.
Patients often experience varying degrees of **cutaneous pruritus**. Recent international reports indicate that some psoriasis patients exhibit pathological changes in internal organs, including **occlusive vasculitis, pulmonary abnormalities, hepatic steatosis and focal necrosis, keratoconjunctivitis**, and, in male patients, alterations in semen quantity and quality. Internal organ involvement in psoriasis patients should be carefully considered during treatment.
2. Psoriatic arthritis (Psoriasis arthropathica), also known as psoriasis nature of disease arthritis. In addition to skin rashes, this type of psoriasis can also involve joint lesions, with joint symptoms often improving or worsening simultaneously with skin damage. However, patients generally develop rashes first, followed by joint symptoms. Any joint can be affected, including large joints like the elbows and knees, as well as small joints such as those between fingers (toes). Spinal joints and sacroiliac joints may also be involved. Symptoms may include joint swelling, pain, limited mobility, and even deformities, resembling manifestations of wind-dampness arthritis. Destructive bone changes may lead to mutilating deformities, termed mutilating psoriatic arthritis. Severe psoriatic arthritis is often accompanied by persistent high fever and accelerated erythrocyte sedimentation rate (ESR), though wind-dampness factors are typically negative. The rash may also present with changes similar to pustular psoriasis. X-rays may reveal joint alterations in some patients resembling rheumatoid arthritis, including localized bone decalcification, joint space narrowing, varying degrees of joint erosion, and soft tissue swelling. The disease follows a chronic course, often persisting for years without remission.
3. Pustular Psoriasis (Psoriasis pustulose)
This type of psoriasis is rare and often occurs acutely without obvious triggers. Initially, large areas of inflammatory erythema appear, followed rapidly by the emergence of dense, sterile, superficial pustules ranging from needle-sized to foxtail millet-sized, pale yellow or yellowish-white in color. The surface often has fine, thin scales, and adjacent erythematous patches may merge, forming annular or gyrate patterns. The edges frequently exhibit more small pustules. A few patients may experience rapid generalized redness and swelling with countless sterile pustules within a short period. Patients often present with systemic discomfort, starting with shivering followed by high fever, exhibiting a remittent fever pattern, along with a burning sensation in the skin. Joint swelling and pain may occur. After a few days, the pustules dry and accumulate into crusts. The condition may naturally alleviate, revealing lesions typical of psoriasis vulgaris. However, after several days, sudden flare-ups may recur, with the condition repeatedly worsening and improving. Patients are often at risk due to secondary infections, systemic exhaustion, or liver and kidney injuries, which can be life-threatening.
Pustular psoriasis can manifest anywhere on the body. The most common sites are flexural surfaces, which rapidly proliferate before spreading to the entire body. Occasionally, the oral mucosa and nails (fingers or toes) may also be affected. Patients often exhibit fissured tongue, thickened and cloudy or fragmented nails, and subungual debris or pustules.
4. Palmoplantar Pustulosis (Pasfulosis palmaris et plantaris) Palmoplantar pustulosis includes palmoplantar pustular psoriasis (Pustular psoriasis of the palma and soles) and pustular bacterid.
(1) Palmoplantar Pustular Psoriasis Some consider this a localized form of pustular psoriasis, predominantly affecting the palms and soles. Lesions commonly appear on the thenar and hypothenar eminences of the palms and the metatarsal arch. They may also extend to the dorsal aspects of the fingers or toes. Initially, symmetrical erythema appears, soon followed by multiple sterile pustules that do not protrude. These pustules, located within the epidermis, gradually enlarge and merge, drying and crusting within one to two weeks. After the crusts shed, small scales appear, but new pustules emerge, leading to a recurrent cycle. Nails may become discolored or deformed, appearing cloudy, thickened, and ridged, accompanied by pain. Atypical psoriatic lesions or patches of pustular psoriasis may appear elsewhere on the body. Some patients exhibit fissured tongue.
(2) Pustular Bacterid Lesions often begin in the center of the palms or soles, gradually spreading across the entire palm or sole and sometimes extending to the sides of the hands or feet. Initially presenting as vesicles, they quickly transform into sterile pustules. After a few days, the pustules dry and form brown scales. Once the scales shed, new pustules reappear, perpetuating the cycle for years. The skin of the metatarsus may become red, thickened, and scaly. Some patients experience localized cutaneous pruritus and pain, with negative bacterial cultures from the pustules.
(3) Stage of Regression The inflammation of the lesions largely subsides, with the rash shrinking or flattening. Hypopigmented white spots or hyperpigmented patches may remain. The condition is prone to recurrence. Some patients initially exhibit a clear seasonal pattern, with worsening lesions in winter and remission or resolution in summer, but may later become chronically unhealed. A few patients remain free of recurrence for long periods after clinical recovery.
Patients experience varying degrees of cutaneous pruritus. Recent international reports indicate that some psoriasis patients exhibit pathological changes in internal organs. Psoriasis may be associated with occlusive vasculitis, pulmonary abnormalities, hepatic steatosis and focal necrosis, keratoconjunctivitis, and altered semen quality and quantity in male patients. Internal organ damage in psoriasis patients should be carefully considered during treatment.
2. Psoriatic Arthritis (Psoriasis arthropathica) Also known as psoriasis nature of disease arthritis. In addition to skin rashes, this type of psoriasis can also involve joint lesions. Joint symptoms often improve or worsen simultaneously with skin lesions. However, patients generally develop skin rashes first, followed by joint symptoms. Any joint can be affected, including large joints like the elbows and knees, as well as small joints such as those between the fingers (toes). Spinal joints and sacroiliac joints may also be involved. Symptoms can include joint swelling, pain, limited mobility, and even deformities, resembling the manifestations of wind-dampness arthritis. Destructive changes in the bones may lead to mutilating deformities, known as arthritis mutilans. Severe psoriatic arthritis is often accompanied by persistent high fever and an elevated erythrocyte sedimentation rate (ESR), but rheumatoid factor is typically negative. The skin rash may also exhibit changes similar to pustular psoriasis. X-rays may reveal joint changes in some patients that resemble rheumatoid arthritis, including localized bone decalcification, narrowing of the joint space, varying degrees of joint erosion, and soft tissue swelling. The disease follows a chronic course and often persists for years without remission.
3. Pustular Psoriasis (Psoriasis pustulose)
This type of psoriasis is rare and often occurs acutely without obvious triggers. Initially, large patches of inflammatory erythema appear, rapidly followed by dense, sterile, superficial pustules ranging from needle-sized to foxtail millet-sized, pale yellow or yellowish-white in color. The surface is often covered with fine scales, and adjacent erythema may merge, forming annular or gyrate patterns. The edges frequently exhibit more small pustules. A few patients may experience rapid generalized redness, swelling, and countless sterile pustules in a short period. Patients often present with systemic discomfort, starting with shivering followed by high fever (remittent fever), a burning sensation in the skin, and swollen, painful joints. After a few days, the pustules dry and accumulate crusts. The condition may spontaneously remit, revealing plaques of plaque psoriasis, but sudden exacerbations can recur periodically. Repeated cycles of remission and relapse may lead to life-threatening complications due to secondary infections, systemic exhaustion, or liver/kidney injury.
Pustular psoriasis can involve any part of the body. The flexural surfaces are most commonly affected initially, followed by rapid generalization. Occasionally, the oral mucosa and nails may also be involved. Patients often exhibit fissured tongue, thickened, cloudy, or brittle nails, and subungual debris or pustules.
4. Palmoplantar Pustulosis (Pustulosis palmaris et plantaris) Palmoplantar pustulosis includes pustular psoriasis of the palms and soles (Pustular psoriasis of the palma and soles) and pustular bacterid (Pustular bacterid).
(1) Pustular Psoriasis of the Palms and Soles Some consider this a localized form of pustular psoriasis, predominantly affecting the palms and soles. Lesions commonly appear on the thenar and hypothenar eminences of the palms and the plantar arch. They may extend to the dorsal aspects of the fingers or toes. Initially, symmetric erythema develops, quickly followed by multiple sterile pustules that remain flat and intraepidermal. These pustules gradually enlarge and coalesce, drying into crusts within 1–2 weeks. After desquamation, fine scales appear, but new pustules soon recur in cycles. Nail involvement may lead to discoloration or dystrophy, with thickening, cloudiness, and ridging, accompanied by pain. Atypical plaque psoriasis or generalized pustular psoriasis lesions may occur elsewhere on the body. Some patients exhibit fissured tongue.
(2) Pustular Bacterid Lesions typically begin in the center of the palms or soles, gradually spreading to the entire surface and sometimes the lateral aspects of the hands or feet. Initially presenting as vesicles, they rapidly transform into sterile pustules. After a few days, the pustules dry into brown crusts, which shed, only for new pustules to reappear. This cycle may persist for years, leading to erythematous, thickened, scaly skin on the palms and soles. Some patients experience localized cutaneous pruritus and pain. Bacterial cultures of the pustules are negative.
5. Erythrodermic Psoriasis (Erythrodermic psoriasis) Also known as psoriatic erythroderma (Erythrodema psoriaticum), this condition often results from inappropriate treatment or other factors converting pre-existing plaque psoriasis or pustular psoriasis into erythroderma. Common triggers include the use of highly irritating topical medications during the progressive stage of psoriasis or abrupt discontinuation of certain immunosuppressive drugs, leading to rapid exacerbation. Examples include systemic corticosteroids, with flare-ups occurring during dose reduction.
Initially, erythema appears at the original psoriatic skin lesions and rapidly expands into large patches, eventually affecting more than two-thirds of the body with diffuse erythematous infiltration, swelling, and a large amount of bran-like scales. Patchy areas of normal "skin islands" may appear, and the scalp may have thick, dirty, scaly crusts. The hands and feet may exhibit "glove" or "sock"-like skin peeling. The nails become cloudy, thickened, or deformed. This condition may be accompanied by fever, general malaise, superficial lymphadenopathy, and an elevated white blood cell count. After the erythroderma is cured, psoriatic lesions reappear. The course of this disease is prolonged, and recurrence is common after treatment.
6. Acrodermatitis Continua This condition is also known as Dermatitis Repens. Acrodermatitis continua is characterized by sterile pustules, leading some to consider it the same disease as pustular psoriasis. Others regard it as a subtype of pustular psoriasis, though differing opinions exist, arguing it should be classified as an independent disease. In this book, it is described as a type of psoriasis.
The disease predominantly affects middle-aged individuals, often triggered by trauma. Initially, sterile small pustules appear on the sides of a single finger or toe. Within a few days, the pustules dry and form crusts, which later shed, leaving behind smooth, red erosions. However, new pustules soon reappear, and the lesions gradually expand, potentially affecting the entire finger, toe, dorsum of the hand, or foot. It rarely becomes systemic or spreads to distant areas. The condition primarily involves the extremities of the hands and feet, occasionally affecting the oral mucosa. Nail involvement is relatively common, manifesting as turbidity, loss of luster, deformation, or even severe nail loss. Sterile small pustules may repeatedly emerge on the nail bed. The course is chronic and marked by recurrent episodes.
bubble_chart Treatment Measures
There is currently no satisfactory treatment for this disease, with most approaches only achieving short-term effects and unable to prevent recurrence.
1. General Therapy First, establish the patient's confidence and stabilize their emotions. Eliminate factors that may trigger the onset of the disease. Actively control infections. Spicy foods and alcohol are prohibited, and patients in the stage of progress should avoid using highly irritating topical medications.
2. Systemic Treatment For any type of generalized psoriasis, systemic treatment should be the primary approach. The principle of systemic treatment is to choose drugs with minimal side effects and long recurrence cycles. During medication, regularly monitor liver and kidney function as well as changes in blood counts.
(1) Immunosuppressants
1) Methotrexate (MTX) An antifolate antineoplastic drug, it is one of the earlier cytotoxic agents used to treat psoriasis. Effective for all types of psoriasis, it is suitable for arthritis-type, erythrodermic, pustular, and generalized plaque psoriasis, especially when other treatments fail. Its primary mechanism is inhibiting DNA synthesis, thereby preventing DNA production and suppressing nuclear mitosis. Dosage methods vary, but the current general recommendation is 15mg per week, with a maximum dose of 50mg per week. It can be administered orally, intramuscularly, or intravenously. This Yaodui has significant toxic reactions on the liver, potentially causing extensive hepatic fibrosis and cirrhosis. It also suppresses the hematopoietic system, primarily reducing white blood cell counts and affecting platelets, with severe cases leading to pancytopenia. Therefore, liver function and blood counts should be regularly monitored during treatment. Additionally, strict selection of indications is necessary. This drug is contraindicated in patients with liver or kidney dysfunction, anemia, leukopenia, and pregnant women.
2) Ethylenediamine Also known as Yiman 154 or diketazine, it primarily inhibits intracellular DNA synthesis, thereby suppressing cell growth. The usual adult dosage is 300–400mg daily, divided into 2–3 oral doses. Significant efficacy is typically observed after 3–4 weeks, with an effective rate of 58–88%. Its main side effect is bone marrow suppression, leading to decreased white blood cells and platelets. Recent reports have linked this drug to leukemia, necessitating regular blood count monitoring during use. To mitigate leukopenia, adjunctive medications like batyl alcohol or leucogen may be used. A drawback of this drug is its tendency to cause relapse after discontinuation. To prevent recurrence, a low-dose maintenance regimen can be adopted post-remission, such as reducing diketazine to 100mg daily or even 100mg every other day, which can significantly reduce relapse rates. If relapse occurs after stopping diketazine, re-administration is often less effective than initial use, requiring higher doses.
3) Hydroxyurea It has confirmed efficacy for refractory and pustular psoriasis, alleviating pustules, fever, and toxic symptoms in generalized pustular psoriasis. Its primary mechanism is inhibiting DNA synthesis. The dosage is 0.5g per dose, 2–3 times daily for adults, with a treatment course of 4–8 weeks. Toxic reactions mainly include leukopenia and thrombocytopenia, with relatively minor liver toxicity.
4) Cyclosporin A (CyA), as a new-generation immunosuppressant, has been increasingly used to treat various types of psoriasis since Mueller first reported its significant efficacy in treating severe psoriasis in 1979. The mechanism of CyA in treating psoriasis is not yet fully understood. Currently, there have been many reports in China on the use of CyA for severe psoriasis. The initial dosage is 5mg/(kg·d), administered orally in two divided doses, and gradually reduced after efficacy is observed. Common adverse reactions include gastrointestinal reactions, lack of strength, urinary tract irritation, and elevated blood pressure. Since the immunosuppressive effect of CyA is reversible, relapse is likely after discontinuation. Currently, studies abroad have explored the parenteral use of CyA for psoriasis, primarily through intralesional injections and occlusive dressings. Due to its high cost, CyA is not suitable for widespread use. Sandimmun Neoral is a novel microemulsion formulation of cyclosporin A, demonstrating excellent therapeutic and alleviating effects on erythrodermic, pustular, and arthritic psoriasis.
(2) Corticosteroids Although corticosteroids have shown good efficacy in treating various types of psoriasis, systemic use of this medication is generally not recommended at present. This is because higher doses and prolonged use can lead to severe side effects. Additionally, tapering or discontinuing the medication may result in severe psoriasis relapse or progression to pustular psoriasis. Corticosteroid preparations may be considered in the following scenarios: when erythrodermic psoriasis persists uncontrollably; when generalized pustular psoriasis causes high fever and distressing symptoms unmanageable by other medications; or when acute psoriatic arthritis severely damages joints. Typically, prednisone 60mg daily or an equivalent dose of other corticosteroid preparations is used. Close monitoring for side effects is essential.
(3) Vitamin Therapy
1) Vitamin C Intravenous injection or infusion of 3g vitamin C daily for one month as a treatment course. Some believe vitamin C can elevate cAMP levels in psoriatic lesions, inhibiting epidermal cell proliferation and exerting therapeutic effects.
2) Retinoids A group of vitamin A derivatives, commonly used aromatic retinoids such as etretinate show excellent efficacy for pustular psoriasis. The usual dose is 0.5–1mg/kg. Major side effects include teratogenicity and liver damage, making it contraindicated in women of childbearing age and those with liver dysfunction.
(4) Antibiotics Clinically, many psoriasis patients have achieved satisfactory results with antibiotic therapy. Examples include: benzathine penicillin 800,000U intramuscularly once daily for 15 days as a course; erythromycin 0.75–0.9g for adults added to 5% glucose solution for intravenous infusion once daily for 15–30 days as a course. Tianjin Changzheng Hospital has reported satisfactory outcomes using intravenous infusions of erythromycin, lincomycin, fosfomycin, and cefoperazone for plaque psoriasis. Thiamphenicol may be tried for pustular psoriasis, administered orally at 0.25–0.5g three times daily or intramuscularly at 0.4g twice daily.
(5) Immunomodulators For psoriasis patients with compromised immune function, immunomodulators such as thymosin factor D injections (10mg intramuscularly every other day) may be tried, with mild side effects. Levamisole (150mg/day, taken for 3 days per week with 4 days off) can also be used, typically for 1–3 months. Transfer factor is another option. All have shown some therapeutic efficacy.
(6) Traditional Chinese Medicine (TCM) Treatment In TCM, psoriasis is referred to as "Bai Bi." TCM attributes its pathogenesis primarily to excessive blood-heat toxicity or blood deficiency with wind-dryness. There are numerous TCM treatment methods and effective formulas. The dermatology department of Tianjin Changzheng Hospital employs pattern identification and treatment based on the disease mechanism, utilizing heat-clearing, blood-activating, and blood-nourishing methods.
The heat-clearing method treats blood-heat type psoriasis (corresponding to the progressive stage), focusing on clearing heat and cooling blood. Prescription: Unprocessed Rehmannia Root, Scrophularia Root, Hangshao, Imperatae Rhizoma, Arctium Fructus, Anemarrhena, Schizonepeta, Saposhnikovia Root, Cimicifuga Rhizome, Liquorice Root, etc. The author treated 98 psoriasis cases with this formula, achieving an 84.7% overall efficacy rate. Recent studies on its water-decocted concentrated extract demonstrated direct inhibition of keratinocyte proliferation and IL-6 production, validating its therapeutic mechanism.
The blood-activating method treats blood-stasis type psoriasis (corresponding to the stationary stage), focusing on promoting blood circulation and resolving stasis. Prescription: Glabrous Greenbrier, Sanleng, Ezhu, Carthamus, Red Peony Root, Tail of Chinese Angelica, Liquorice Root.
The blood-nourishing method treats blood-deficiency wind-dryness type psoriasis (corresponding to the stationary stage with prolonged duration). Prescription: Prepared Rehmannia Root, honeycomb, Chinese Angelica, Shouwu, Peony Root, Asparagus Root, Ophiopogon Tuber, Polyghace Seche, Liquorice Root.
In addition, preparations of Chinese medicinals such as Sichuan Lovage Rhizome injection or Mailuoning can also be used for treatment. For example, 200mg of Sichuan Lovage Rhizome can be added to 5% glucose solution for intravenous drip, once daily for 30 days as one treatment course. Alternatively, 20mL of Mailuoning can be added to 5% glucose solution for intravenous drip, once daily for 30 days as one treatment course, both of which have certain therapeutic effects.
3. Topical Medication Methods For localized rashes, topical medications can be selected for treatment. The principle is to primarily use keratolytic agents and cytostatic agents. In the stage of progress, strongly irritating topical medications should not be used to avoid inducing erythroderma.
（1）Anthralin It can inhibit the proliferation of epidermal cells and has certain efficacy in the topical treatment of psoriasis. Clinically, 0.1–1% anthralin ointment, paste, or emulsion is commonly used. The main side effect is skin irritation, and it should not be applied to rashes in the genital area. Anthralin preparations can also darken the skin and stain clothing.
（2）Corticosteroids They have anti-mitotic effects. Clinically commonly used ones include fluocinolone acetonide and clobetasol ointment or cream, which have good short-term efficacy for psoriasis. The main side effects include skin atrophy, hypertrichosis, and telangiectasia with long-term topical use.
（3）Calcipotriol It is an active metabolite of vitamin D2 and an analog of calcitriol. It was the world's first new drug for psoriasis launched in 1991. This Yaodui has a strong regulatory effect on keratinocyte differentiation and proliferation. Calcipotriol ointment (50μg/g) is effective and safe for treating grade I or grade II psoriasis.
（4）Methotrexate Cream Methotrexate (MTX) has confirmed efficacy in treating psoriasis, but its side effects are significant. Zhang Guoyi et al. abroad treated 54 cases of refractory psoriasis with 0.1% methotrexate cream while monitoring serum MTX concentrations. The methotrexate treatment group had an effective rate of 83.3%, with no detectable MTX in the serum and no significant systemic side effects. The results indicate that topical 0.1% methotrexate cream is effective in treating psoriasis.
4. Other Therapies Depending on the condition, appropriate options include mineral baths, Chinese medicinals baths, tar bath-ultraviolet triple therapy, and photochemotherapy.
Based on the clinical manifestations of this disease, especially the characteristics of the rash and the features of histopathology, the diagnosis is generally not difficult. However, it should be differentiated from the following diseases.
1. Seborrheic dermatitis: The edges of the lesions are indistinct, with mild basal infiltration. The scales on the rash are bran-like, and there is no Ausspitz sign. Seborrheic dermatitis on the scalp is often accompanied by alopecia areata, and the hair does not appear in tufts.
2. Pityriasis rosea: The lesions mainly occur on the trunk and proximal limbs, with the long axis of the rash aligned with the skin lines. The scales are fine and thin. The course is short, and recurrence after healing is rare.
3. Lichen planus: The lesions mostly occur on the limbs, presenting as purple-red, polygonal, flat papules with a waxy sheen. Wickham's striae may be visible. Oral lesions are common, and there is often varying degrees of cutaneous pruritus. The histopathology is distinctive.
4. Pityriasis rubra pilaris: The lesions mostly occur on the extensor surfaces of the limbs. In the early stage, they are follicular keratotic papules, and in the advanced stage, follicular keratotic papules can still be seen around the patchy lesions. Particularly, the follicular keratotic papules on the first phalanges are characteristic of this disease. The lesions are covered with fine scales that are difficult to peel off. It is often accompanied by hyperkeratosis of the palms and metatarsus.
5. Parapsoriasis: The lesions are covered with fine scales, without multilayered scales, no thin membrane phenomenon, no Auspitz sign, and mostly no subjective symptoms.
