Psoriasis: treatment with phototherapy and cryosauna

Natalia Sachuk, chief physician of the Farmosa Medical Center, dermatovenerologist, trichologist, dermato-oncologist, cosmetologist, member of the All-Ukrainian Academy of Dermatovenerology, Association of Psoriasis, Association of Preventive and Anti-Edging Medicine, member of the Society of Trichologists of Ukraine, member of the All-Ukrainian Association of Dermatovenerologists and Cosmetologists of Ukraine

This disease is characterized by a chronic course with periods of exacerbations and remissions. Psoriasis accompanies a person throughout his life, negatively affects life activity and ability to work, and therefore is a big socio-economic problem.

Treatment of psoriasis is a difficult task for both the patient and the doctor. The main mission of the treatment of this complex disease is the accessibility and ease of tolerability of procedures, prolongation of remission and reduction of treatment time. Complex effective methods of external therapy for psoriasis consist of the use of anti-inflammatory, keratolytic, antiproliferative, antiexudative, antipruritic and antimicrobial effects of external drugs. Physiotherapeutic techniques work in the same direction.

Clinically, psoriasis is characterized by a monomorphic rash in the form of papules covered with silvery scales, as well as changes in various organs and systems. The main primary morphological element in the case of the papular-plaque form is a pink-red papule of an inflammatory nature, prone to peripheral growth, covered with silvery scales. Psoriasis is characterized by a triad of phenomena during scraping: the phenomenon of stearin stain, psoriatic film, and edema bleeding. There are stages: a progressive stage, a stationary stage and a regression stage, which are characterized by their own characteristics of the rash.

Favorite localization of rashes is the extensor surfaces of the limbs, the lumbar and coccygeal areas, and the scalp. The rash is characterized by symmetry, although any area of the skin, nail plates, joints, and internal organs can be affected.

Clinically, rarer forms of psoriasis are also distinguished, such as:

• psoriasis of large folds (intertriginous psoriasis) – observed in people with diabetes, obesity, children and the elderly, involving large folds;
• psoriasis of the palms and soles associated with trauma to these areas;
• exudative form of psoriasis, in which the psoriatic elements are saturated with exudate and there is no phenomenon of stearin spots, the rash changes until blisters appear;
• rupoid psoriasis, with the presence of massive layers of dirty gray scales on the surface of the papules;
• Zimbusch pustular psoriasis ⎼ develops as a secondary process after vulgar psoriasis, up to the appearance of large elements of “purulent lakes”;
• Barber's pustular psoriasis is a very rare and severe form, affecting the palms and soles, up to large pustular elements and erosions.

Treatment of psoriasis depends on the stage and form, as well as the clinical course of the disease, so it is very important to correctly collect a complete history, identify provocateurs in the form of stress and various infections (mycoses, cytomegalovirus and streptococcal infections, etc.), carefully conduct an examination and complete examination patient.

Treatment is aimed primarily at neutralizing the inflammatory process in the skin, taking into account the stage, form of the disease, age and gender of the patient, prevalence and presence of concomitant diseases. This is a lot of work for the doctor and the patient, which must result in long-term remission. Therefore, after completion of treatment of the acute stage of the process, drug treatment is supplemented with physiotherapy.

Among the causes of psoriasis, a certain allergic status of the patient is very common, especially drug allergies, so it is important to limit the use of pharmaceuticals in the hospital stage. Physiotherapeutic treatment methods usually include ultraviolet irradiation of different wavelengths, local combined ultraviolet and infrared irradiation, magnetic therapy and others. One of the most common methods is PUVA therapy, but it has significant limitations in diseases of the kidneys, liver, diabetes, and an overdose of ultraviolet radiation can cause an exacerbation of psoriasis.

Specialists from the Farmosa Medical Center and Vinnitsa National Medical University. N.I. Pirogova, using previous experience of physiotherapeutic methods for psoriasis, took into account many factors and developed a new model for treating patients with psoriasis in the stationary stage, as a result of which they received a patent for the treatment of psoriasis.

Effective non-drug treatment consists of the combined use of general aerocryotherapy and narrow-spectrum UVB 311 nm phototherapy. The method of treating psoriasis in the stationary stage is carried out in such a way that the patient first undergoes a session of general aerocryotherapy in a cryosauna (lasting up to 180 seconds at a temperature of ⎼170⎼190 °C), and immediately after it a session of narrow-spectrum UVB 311 nm phototherapy. The course of such complex therapy includes, depending on the patient’s clinical data, 10⎼30 outpatient sessions.

AEROCRYOTHERAPY

General aerocryotherapy (ACT) has a beneficial effect on the general condition, exhibiting antidepressant, vasodilating, and immunomodeling effects. The biochemical indicators of metabolic and endocrine processes, the neurovegetative state are improved, and the hormonal levels are stabilized. But the most convincing is the natural and characteristic dynamics of immune system indicators: not only simple quantitative regulation of T- and B-lymphocyte pools occurs, but also modulation of the functions of immunocompetent cells, humoral and cellular immunity, as well as nonspecific protection at the level of markers and cytokines. During treatment, the high level of circulating immune complexes and specific antigens recorded in patients with autoimmune diseases has a natural tendency to decrease to physiological values. Therefore, extreme aerocryotherapy is especially relevant for patients with atopic dermatitis, psoriasis and alopecia areata to obtain stable remission.

The effect of cold in the form of ACT is very important, since this leads to pronounced phase changes in the activity of peripheral vessels, which are manifested by spasm of small arteries and arterioles, slowing down the speed of blood flow - the protective phase of the vascular response to extreme cooling. Then the second protective phase develops - in the form of a pronounced expansion of peripheral arterial vessels, which leads to active arterial hyperemia and sharp redness of the skin, an increase in skin temperature to +35 ° C (normal average skin temperature is +32.5 ° C). Systemic expansion of the integumentary vessels stimulates the functioning of the circulatory system, improves nutrition and oxygenation of all tissues of the body, and reduces the hemodynamic load on the heart muscle. Along with changes in arterial and capillary circulation, ACT provides a moderate improvement in venous outflow.

Schematically, the cryoprocedure looks like this . The duration of exposure sufficient for the development of a therapeutic effect is 60⎼180 seconds. A person is completely placed in a vertical procedural cabin with an air environment, the temperature of which ranges from –120 to –180 °C. The head is located outside the air flow. Only cotton underwear remains on the body, warm socks are put on, and the hands are clamped in the armpits. The patient, actively moving around his axis, prevents local frostbite. During this time, a large volume of surface tissue is cooled to a temperature of –2 to +4 °C.

It is necessary to understand that cryotherapy is effective only if the temperature on the surface of the skin drops below 0 ° C. For the outer layer of the skin, such short-term hypothermia is safe, but cold skin receptors send a signal to the brain of such strength that the above-described cellular reactions are triggered. In order to properly cool the skin, the temperature of the gas should not be higher than –180 °C, and the contact time with it should not be less than two minutes.

To obtain maximum results, there are a number of principles and rules of cryomedicine:

1. Gradual increase in the intensity of activities.
2. Systematicity: strict adherence to the methodology (exposure time, temperature, number of sessions). A course of cryotherapy procedures is more effective than rare sessions.
3. During therapy, it is necessary to take into account the individual characteristics of the body.

Contraindications

It is very important to consider the seriousness of the cryotherapy technique, so it should be carried out by a knowledgeable specialist. The prescription of a course of treatment with general aerocryotherapy is preceded by clinical, laboratory and functional monitoring (history, ECG, blood pressure, blood test, urine test, etc.). A contraindication to cryotherapy is, firstly, complete intolerance to cold (according to statistics, 1–2% of the population suffers from it), as well as some diseases and characteristics of patients.

In particular, the use of general cryotherapy is not recommended in the following cases:

• myocardial infarction, rehabilitation period after a heart attack;
• stage II hypertension;
• heart failure;
• severe diseases of the respiratory organs and nervous system;
• some blood diseases;
• pathologies of arterial vessels (vasculitis, arteritis, etc.);
• fever, high temperature;
• pulmonary tuberculosis;
• acute inflammatory processes associated with the respiratory tract;
• oncological diseases;

PHOTOTHERAPY

UVB 311 nm phototherapy has an immunoregulatory effect, normalizes the balance of inflammatory and anti-inflammatory factors in the affected skin. Narrow-spectrum phototherapy 311 nm has significant advantages over PUVA therapy: firstly, the doses of ultraviolet radiation used are much lower, which reduces the risk of tumors, and secondly, there is no need for photosensitizers, as a result of which the treatment is much easier to tolerate. In this case, as with PUVA treatment, excessive cell division is inhibited. When treating psoriasis, the elements gradually turn pale, become less dense, and peeling disappears. This occurs due to a decrease in the number of cellular elements in the lesions of psoriasis. There is also a pronounced antipruritic effect and an effect on the metabolism of vitamin D. Treatment is carried out using special PL-S 9W 2P lamps manufactured by Phillips.

Contraindications: history of melanoma or skin cancer, early childhood, skin diseases with a risk of developing neoplasms (xeroderma pigmentosum, Bloom's syndrome, familial dysplastic nevus syndrome); diseases the course of which worsens when exposed to ultraviolet radiation (lupus erythematosus, autoimmune thyroiditis); eye diseases (cataracts, lack of lens).

Side effects: phototherapy takes place without taking photosensitizers, so side effects are minimal and are associated only with the action of ultraviolet radiation: itching and dryness of the skin, redness and burns of the skin (with an excessively high dosage of UV rays). To prevent them, it is necessary to correctly determine the skin phototype and select the dosage of ultraviolet radiation.

Long-term side effects, such as symptoms of skin aging, are associated with prolonged exposure to ultraviolet radiation (with ultra-long or frequent use of UVB 311 nm, phototherapy for many years) and neglect of protective measures (glasses, sunscreens, protective regime). Numerous domestic and foreign studies have not proven the development of skin tumors after phototherapy.

CLINICAL CASE STUDY

Patient N., who had been treated on an outpatient and inpatient basis for 8 years, turned to the Farmosa medical center (Vinnitsa), where the diagnosis of “psoriasis in the stationary stage” was confirmed and a clinical examination was carried out and an anamnesis was collected. Combined physiotherapeutic treatment was prescribed from the first day: 28 sessions of general aerocryotherapy and UVB 311 nm phototherapy. Already during the treatment process, a significant therapeutic effect was obtained: the patient’s general condition improved, local manifestations (papules) on the skin decreased significantly, turned pale, then regressed, and itching disappeared. It was possible to study the long-term results over the next two - no relapse of the disease was observed.

As of 2012, 35 patients with psoriasis in the inpatient stage were registered at the Farmosa Medical Center, treated with this complex method. An important point is that after a session of general aerocryotherapy, the vessels dilate significantly due to the influx of blood, so the subsequent use of UVB 311 nm phototherapy becomes even more effective.

The positive effect of using the proposed treatment method is as follows: in patients with psoriasis in the stationary stage (even without the use of drug treatment), with the help of general aerocryotherapy (cryosauna) and narrow-spectrum UVB 311 nm phototherapy, not only local manifestations on the skin disappear, but also significantly the general somatic and psycho-emotional state improves. This is important for achieving long-term remission and preventing complications of psoriasis, and also improves the patient’s performance and quality of life.

First published in Les Nouvelles Esthetiques 2016/№4