The Development of Practice Guidelines for the Treatment of Severe Plaque Form Psoriasis

Abstract

To develop and introduce evidence-based guidelines for the selection of 5 commonly used treatment modalities-UV-B, photochemotherapy, methotrexate, acitretin, and cyclosporine-for adult patients with severe plaque form psoriasis. Patients and Setting: Patients, residents, and dermatologists from the Department of Dermatology of the Academic Medical Center of the University of Amsterdam, Amsterdam, the Netherlands, were involved in this process. Design: The development process started with a questionnaire to evaluate how patients with severe psoriasis were treated. A systematic literature review was set up to provide evidence-based estimates of effectiveness, adverse effects, and dropout rates. In 2 meetings, the opinion leaders and intended users discussed the results of the questionnaire and systematic review as well as the clinical considerations in the treatment choices. Guidelines were then made regarding the sequence of selection of 5 modalities in the concept of rotational therapy. These guidelines were introduced. Their use was analyzed for 6 months. Results: Before the guidelines, there was no uniform approach. In the systematic review, 665 studies concerning the treatments were found. Exclusion rates were high. No studies of methotrexate therapy could be included. Photochemotherapy showed the highest average proportion of patients with clearance (70% [6947/9925]) and good response (83% [8238/9925]), followed by UV-B (67.9% [620/ 913]) and cyclosporine (64% [1030/1609]) therapy. In the second internal meeting, the following sequence for the treatments was defined: UV-B, photochemotherapy, methotrexate, acitretin, and cyclosporine. In 78% (69/88) of patients treated after the introduction, the guidelines were followed to determine the treatment choice. Conclusions: Guidelines for treating severe plaque form psoriasis can be successfully developed, introduced, and implemented and were considered to improve clinical care.

The Grounds of Claritromycin Use in the Treatment of Psoriasis

“…Однако, очевидно, что это влияние было опосредованным, поскольку в чистых культурах кератиноцитов не проявлялось, а сказывалось только в смешанных культурах с CD4 + лимфоцитами, где пролиферативная актив ность кератиноцитов была увеличена, а степень дифференцировки снижена. Механизм влияния кларитромицина на пролиферацию и дифферен цировку кератиноцитов, вероятнее всего, связан с подавлением синтеза цитокинов лимфоидными клетками, что подтверждается исследованиями ряда авторов [8,9,11,12].…”

“…Большинство приме няемых в настоящее время средств для лечения этой патологии (глюкокортикоиды, иммунодеп рессанты) обладают мощным иммуносупрессив ным эффектом, но они направлены практически на все звенья иммунитета, вызывая осложнения и побочные эффекты [11]. В последние годы при стальное внимание исследователей в качестве пре паратов, способных подавлять функции некоторых иммунокомпетентных клеток, привлекли антиби отики макролидного ряда.…”

Psoriasis and Pregnancy

“…32 Treatment strategies for the management of psoriasis in nonpregnant patients have been published and were used as general guidelines for selection of the therapies presented below. [32][33][34][35] The management of psoriasis involves an orderly progression through the available treatments; drugs with the least desirable side-effect profiles are utilized only when safer options have been tried and proven ineffective. 35 Convenience, efficacy, and cost are also important considerations.…”

“…[32][33][34][35] The management of psoriasis involves an orderly progression through the available treatments; drugs with the least desirable side-effect profiles are utilized only when safer options have been tried and proven ineffective. 35 Convenience, efficacy, and cost are also important considerations. When developing a treatment approach, it is important to educate patients about realistic expectations.…”

“…75 Methoxsalen is pregnancy category C and should be given to pregnant females only in cases where it is clearly needed. 45 Pregnancy and inadequate use of contraception in fertile women are both considered by Spuls et al 35 absolute contraindications to PUVA treatment. Stern and Lange found no evidence that exposure of men and women to PUVA at the time of conception or during early pregnancy affected outcomes; however, the study was unable to detect modest increases in risk.…”