AAD发布银屑病外用疗法管理指南

    由美国皮肤病学会（AAD）制定的银屑病外用疗法管理指南近日在《美国皮肤病学会杂志》[J Am Acad Dermatol 2009，60（4）：643]发表，这是继银屑病和银屑病关节炎分类治疗常规推荐后，AAD发布的银屑病管理指南（共六部分）第三部分。同时，第67届AAD年会亦于2009年3月6～10日在旧金山举行。现奉上新指南和大会的部分精华内容，与您共享。解放军总医院第一附属医院皮肤科邹先彪

    基于对银屑病外用药物（包括皮质类固醇、维生素D类似物、钙泊三醇与丙酸倍他米松软膏、他扎罗汀、他克莫司和吡美莫司）最新研究的全面分析， AAD新指南对银屑病外用疗法中的患者期望、使用方法、联合治疗、治疗时间、使用剂量和患者依从性等问题进行了阐述。此外，新指南还囊括了单用外用疗法或联合其他治疗方法治疗较严重银屑病患者的特殊推荐意见和注意事项。

    根据指南意见，外用疗法可安全有效地用于大多数轻中度银屑病患者，而对中重度或难治局灶性银屑病病例则不能仅单用外用疗法。

    患者期望

    恰当的外用疗法选择应同时满足患者期望与临床实际情况。例如，希望银屑病皮损完全、持续消失的患者会对外用疗法失望，因为这需要长期、大剂量使用药物，但却很难实现；另外一些患者则倾向于间歇性治疗，并很少关注疾病情况。

    AAD主席、皮肤病学家汉克（Hanke）教授认为，了解每位患者的目标并制定切实可行的个体化治疗方案，以帮助患者实现期望很重要。

    使用方法

    剂型选择可显著改变药物用法和渗透性，从而改变治疗效果。常用外用剂型包括软膏、乳膏、溶液、凝胶、泡沫、胶带、喷雾剂、洗发水、油剂和洗剂等。指南建议，尽管不同剂型适用于不同部位的病变，但理想的选择是依据患者意愿选用剂型。

    Hanke教授认为，在有毛发的部位（如头皮），可根据患者需要选用溶液、泡沫、洗发水、喷雾剂、油剂、凝胶或其他剂型；一些患者可能比较喜欢不太油腻的制剂，因此可在白天用乳膏，而晚上用效果更好但美观性较差的软膏。

    联合治疗

    对某些患者，可根据药物不同作用机制选取多种药物联用，患者可能需在一天之内不同时间根据医嘱使用不同药物，这要求医师了解不同药物间的相容性。

    治疗时间

    可间歇或长期进行外用治疗。例如，一般推荐先用较强效制剂在短期内消除银屑病皮损、后间歇长期使用，这可减小长期连续治疗发生副作用的风险。对需持续进行外用疗法的患者，应给予可控制临床症状但强度较弱的制剂，或改为长期使用副作用风险最小的制剂。

    Hanke教授认为，尽管患者对外用制剂常有良好的耐受性，且制剂常无显著副作用，但长期或间歇性使用的患者应定期接受检查，不推荐在无监管情况下使用强效制剂。

    使用剂量

    常用"指尖单位"指导外用制剂的使用剂量。一个指尖单位是大约500 mg，推荐的单位数以可覆盖受累区域为标准。例如，3个指尖单位足以覆盖头皮银屑病，而一整条腿和脚则需8个指尖单位。该方法为患者提供了较为精确的外用药物剂量判断方法。

    患者依从性

    患者依从性差是大多数患者外用治疗效果差的主要原因。Hanke教授说，多种因素与患者依从性差相关，包括对药物治疗效果失望、每日用药所致的不便和药物使用方式的选择错误等。他建议医师应努力改善患者的依从性，包括选择足够强效的外用制剂以获得良好的临床效果、与患者一起选择合适的剂型等。

    其他外用治疗

    指南还指出，在某些病例中可联用其他外用治疗方法，如非药物性保湿剂、水杨酸、地蒽酚和各种联合治疗等，以提高外用治疗效果。

    Hanke教授说，确立一种有效的治疗策略不但对银屑病的治疗很重要，对患者的依从性和总体预后的满意度也很重要。制定指南的目的是为了提高外用疗法治疗银屑病患者的成功率，但医师和患者仍要不断探索所有可用的治疗方法，以确保获得最佳的长期治疗选择。

    总之，Hanke教授认为，AAD指南为医师提供了一个决策框架，用以判断单用外用药物或与紫外线光疗、全身性或生物性药物联用是否可有效治疗银屑病；但同时也应根据患者情况，如银屑病的位置、特点及患者意愿等，进行个体化治疗。（张眉 整理）

    一个指尖单位相当于500 mg

The American Academy of Dermatology (Academy) has released new guidelines of care for the management and treatment of psoriasis with topical therapies based on an extensive review of scientific literature on the subject and recommendations of recognized psoriasis experts. This is the Academy’s third of six sections of the guidelines of care for psoriasis, with two previously published sections focusing on general recommendations for the treatment of psoriasis and psoriatic arthritis with an emphasis on the class of treatments known as biologics.

Published online in the Journal of the American Academy of Dermatology, the new psoriasis guidelines present the latest recommendations for treating patients with psoriasis with topical agents. While nearly 7 million Americans are affected by psoriasis, the majority of patients (approximately 80 percent) have limited disease involving less than 5 percent of the body’s surface area. Studies have shown that these patients are good candidates for topical therapies which usually provide high degrees of safety and efficacy.

“The AAD evidence-based guidelines provide physicians with the framework for determining if a topical therapy alone or in conjunction with ultraviolet light, systemic or biologic medications will effectively manage a patient’s condition,” said dermatologist C. William Hanke, MD, FAAD, president of the Academy. “However, treatments should be tailored to meet individual patients’ needs, which vary depending on body location, characteristics of the psoriasis being treated and patient preferences.”

Psoriasis is a chronic skin condition which usually begins before age 35 and is characterized by thick, red, scaly patches that itch and bleed. Although it is a genetic disease, it is not completely understood how it is inherited. However, there are at least eight chromosomes to date that researchers have identified as being linked to the genetic transmission of the disease. In addition, a number of environmental factors play an important role in the development of psoriasis, including drugs, skin trauma, infection and stress. Although psoriasis has been previously thought to be a disease affecting primarily the skin and the joints, a growing body of research suggests that psoriasis patients are at an increased risk of developing serious medical conditions, including cardiovascular disease and diabetes, particularly when their psoriasis is severe. Recent evidence has even suggested an increased overall risk of mortality in patients with severe psoriasis, especially those who have auto immune and cardiovascular diseases.

General Recommendations

Based on a comprehensive analysis of the most current studies on topical therapies for psoriasis ? including corticosteroids, vitamin D analogues, combination calcipotriene/betamethasone propionate ointment, tazarotene, tacrolimus and pimecrolimus ? the Academy’s guidelines address patient expectations, method of application, use of concurrent therapies, length of use, application amount and patient compliance. In addition, specific recommendations for and precautions about these topical therapies used alone or with other widely used therapies in patients with more extensive psoriasis also are outlined.

According to these guidelines, topical therapies can be used safely and effectively in the majority of patients with mild to moderate psoriasis. However, topical therapies should not be used exclusively without other complementary treatments in cases of moderate to severe psoriasis or when the condition is limited but hard to manage.

Patient Expectations

Dermatologists emphasize the importance of matching patient expectations with practical considerations. For example, patients who want continual clearance of psoriasis with no visible lesions inevitably will be disappointed with topical therapy because of the need for a continuous intense topical regimen that can be very difficult to achieve and maintain. Others may prefer only intermittent treatment with little interest in spending considerable time managing their condition.

“It is important to determine each patient’s goals and then develop a strategy to help fulfill his or her expectations, while also being practical and realistic,” said Dr. Hanke.

Method of Application

The choice of the therapy’s vehicle (the form in which the medicine is delivered) can significantly alter the use and penetration of the medication and, as a result, alter its effectiveness. Several vehicle types for topical medications are available: ointments, creams, solutions, gels, foams, tape, sprays, shampoos, oils and lotions. The guidelines advise that while different vehicles are indicated for different body sites, the optimal choice should be based on what vehicle the individual patient is most likely to use on a regular basis.

“Areas with hair such as the scalp can be treated with solutions, foams, shampoos, sprays, oils, gels or other vehicles, with individual patients having different preferences among these options,” said Dr. Hanke. “Some patients may prefer a less greasy preparation, perhaps a cream for daytime use, and may be willing to use an ointment, which is more effective but less cosmetically appealing, at night.”

Use of Concurrent Therapies

In some cases, topical medications can be used concurrently to take advantage of varied mechanisms of action. When this is the case, patients may be instructed to apply the various medications at separate times throughout the day, and physicians also need to be aware of compatibility issues among the prescribed medications.

Length of Use

The use of topical therapies can be both intermittent and long-term. For example, it is generally recommended that more potent agents should be used on a short-term basis to allow for clearing of psoriasis, after which patients should be instructed to use these agents intermittently for long-term management. It was determined that this strategy may pose less risk of side effects than continuous treatment. On the other hand, patients who require continuous topical treatment should be instructed to use the least potent agent that can adequately control the condition or be transitioned to a topical agent that is associated with the lowest long-term risk.

“Although topical agents for psoriasis are usually well tolerated without significant side effects, it is important that patients receive regular examinations by their dermatologists ? whether they use medications over the long term or intermittently ? as unsupervised use of potent topical medications is not recommended,” said Dr. Hanke.

Application Amount

In terms of the amount of topical medication that generally should be applied to affected skin, dermatologists refer to the “fingertip unit” as the recommended guidance. One fingertip unit is approximately 500 mg, and recommendations for the number of units needed to cover affected areas are offered. For example, three fingertip units are required to adequately cover psoriasis on the scalp, whereas eight fingertip units are needed for the entire leg and foot. This method provides a means for patients to more accurately dose their topical medications.

Patient Compliance/Adherence

Lastly, dermatologists agree that poor compliance (or adherence) to topical treatment of psoriasis is a major issue for the majority of patients. “Many factors contribute to the lack of adherence to a topical treatment regimen, including frustration with a medication’s efficacy, the inconvenience of applying medication daily and poor choice of the medication’s vehicle,” said Dr. Hanke. “We strongly encourage physicians to consider measures to improve patient adherence, including choosing topical medications with adequate potency to achieve a favorable clinical response and working with the patient to select the preferred vehicle.”

Other Topical Treatments

The guidelines also outline other topical treatments ? such as non-medicated topical moisturizers, salicylic acid, anthralin, coal tar and various combination therapies ? as adjunctive therapies that could, in some cases, enhance other topical treatments.

“Establishing an effective treatment regimen is crucial in managing not only the psoriasis, but patients’ adherence to their medications and overall satisfaction with their outcomes,” added Dr. Hanke. “These guidelines are intended to further our understanding of how topical therapies can be used to successfully manage and treat psoriasis in most patients, but dermatologists and patients need to continually review all of the available options to ensure the best chance for long-term management of the condition.”