Sodium thiosulfate for psoriasis: reviews, application  

Psoriasis is one of the most common chronic dermatoses. The results of many studies confirm that patients with psoriasis experience serious problems in social and personal spheres. A negative impact of the clinical picture of psoriasis on the quality of life of patients has been established: a feeling of discomfort due to their unattractive appearance in 81% of respondents, depression in 54%, work problems in 60% of patients (absence due to illness of approximately 26 working days a year) [ 1]. The increase in morbidity, the presence of disabling and life-threatening forms, the negative impact on the quality of life - all this makes it highly important to study the pathogenesis and treatment of psoriasis [2].

A special place in the formation of clinical manifestations of this severe multifactorial disease belongs to changes in the microvasculature and hemorheological properties of blood. In the development of nonspecific inflammatory changes in the walls of blood vessels in psoriasis, including in the skin, a significant role belongs to the increased activity of lipid peroxidation (LPO) processes with a decrease in the activity of indicators of the antioxidant system (AOS) [3, 4].

It has been shown that the fastest way to correct hypoxia is to activate succinate oxidase processes by increasing the activity of succinate dehydrogenase and improving the penetration of exogenous and endogenous succinate into mitochondria [5].

Succinic acid (SA) is a universal intracellular metabolite with antihypoxic, antioxidant, detoxifying, radioprotective and other properties [6]. Performing a catalytic function in relation to the Krebs cycle, UC reduces the blood concentration of other cycle products (lactate, pyruvate, citrate) that accumulate in the early stages of hypoxia, and is thereby included in energy metabolism, directing the oxidation process along the most economical path [7, 8 ]. Thus, the entry of UC into cells helps compensate for the energy deficit that develops as a result of the uncoupling of oxidative phosphorylation processes initiated by the hypoxic state.

In connection with the above, studying the effectiveness of drugs containing succinic acid ( Remaxol

,
Reamberin
) in the treatment regimen for patients with psoriasis in a progressive stage is of interest.

The purpose of the study is to study and evaluate the clinical effectiveness of treatment of patients with psoriasis in a progressive stage with Remaxol

and
Reamberin
.

For whom is it intended and for whom is it contraindicated?

The drug is used to suppress the reaction to poisoning:

• cyanide;
• hydrocyanic acid;
• lead;
• cadmium;
• mercury;
• arsenic;
• lithium;
• aluminum, etc.

Sodium thiosulfate is used in the treatment of lupus erythematosus, neuralgia, arthritis, allergies, and scabies.

The only contraindication for medical procedures is individual intolerance to its component composition. During treatment, side effects may occur in the form of allergies or discomfort in the area where the medication was administered.

Description of the drug

Sodium thiosulfate is crystals or transparent, colorless, odorless granules with a salty-bitter taste. Easily dissolves in water (the recommended proportion is 1:1) and is practically insoluble in alcohol. Sold as a solution in ampoules. In medicine, sodium thiosulfate has found use as a desensitizing, antitoxic, and anti-inflammatory agent. These properties determine its use for psoriasis. The antitoxic and cleansing effect is due to its ability to form non-toxic compounds with toxic elements - sulfites with mercury, thallium, arsenic, lead. Sodium thiosulfate also has antidote properties against iodine, aniline, copper, bromine, benzene, sublimate, hydrocyanic acid, and phenols.

Features of sodium thiosulfate therapy

The instructions recommend the following methods and dosages:

1. Topical application is used for scabies mites. A 60% solution is rubbed into the skin of the entire body. After it dries, additional treatment is carried out with a 6% solution of hydrochloric acid.
2. Intravenous administration is used to cleanse the body of poisonous and toxic substances. 30% of the drug is administered intravenously, 5-50 ml. The exact dosage depends on the severity of the disease and the type of toxic compound.
3. Oral – for procedures a 10% composition is used, a single dosage is equal to 2-3 g of medication.

In gynecological practice, the drug is part of complex therapy:

• endocrine infertility;
• ovarian cysts;
• genital tuberculosis.

If necessary, sodium thiosulfate is included in microenemas. This approach is used to detect adhesions in the pelvic area and inflammation of the reproductive tract. A 10% solution is suitable for enemas; 30 to 50 doses of medication are sufficient for one procedure.

Treatment for psoriasis involves taking medication orally. Cleansing the body has a positive effect on the immune system and facilitates the course of many chronic diseases. Therapy for psoriasis continues for 5-12 days; you can take from 10 to 20 ml of the product per day. The exact dosage depends on the weight and tolerance of the component composition.

A measured amount of medicine is diluted in half a glass of water and consumed before going to bed. If the medicine provokes a laxative effect, then the dose is reduced to 10 ml per day.

Sodium thiosulfate can be used to cleanse the circulatory and lymphatic systems. The procedures can improve the condition of nail plates and hair, get rid of allergies, depression, and improve general condition.

Cleansing procedures last 10 days; half an ampoule can be used at one time; the solution is diluted in half a glass of water. The first procedure is designed for the morning - half an hour before breakfast, the second - an hour before dinner.

Effect of the drug

The essence of treating psoriasis with sodium thiosulfate comes down to thorough cleansing, which helps alleviate many other chronic diseases. Getting rid of dirt that has accumulated in the body for years helps it strengthen its own immune defense and cope with diseases.

Reviews from those taking sodium thiosulfate indicate a significant improvement in their condition. Some patients claim that they were able to completely get rid of psoriasis, however, given the chronic nature of the disease, it should be recognized that we are obviously talking about achieving stable remission.

• The drug effectively cleanses blood and lymph. Once in the intestines, it attracts toxins and waste products that penetrate the gastrointestinal tract from lymph, blood, interstitial and intercellular fluid.
• Binds heavy metals and toxins due to the presence of sulfur molecules, which have a pronounced restorative effect.
• Sodium thiosulfate has a laxative effect, enhancing intestinal motility and leading to liquefaction of its contents, which significantly accelerates the elimination of toxins, thereby restoring the normal functioning of organs.
• The drug also slows down the absorption of toxic compounds through the intestinal mucosa and prevents them from entering the blood.

Manufacturer's instructions

The instructions draw attention to the following nuances:

• combination with iodides and bromides leads to their lack of effectiveness;
• combination with drugs that cause rhodanization weakens their effectiveness;
• immediate administration of sodium thiosulfate is necessary in case of cyanide intoxication; delay causes death;
• The powder of the drug has a specific smell, reminiscent of the aroma of sodium acetate - you can check the authenticity of the product with iodine, a chemical reaction will lead to its discoloration.

Therapeutic measures for poisoning require constant supervision by the attending physician. If symptoms of intoxication resume after their initial disappearance, it is necessary to repeat the procedure with half the dose.

Additional effect of taking the drug

In addition to improving the condition of patients diagnosed with psoriasis, based on reviews of patients who took sodium thiosulfate, we can conclude the following effects of the drug, achieved as a result of thorough cleansing of the body:

• improvement of skin condition, its noticeable rejuvenation;
• stopping nail splitting;
• restoration of hair structure;
• relief of osteochondrosis, atherosclerosis, cholecystitis;
• weakening of cravings for alcohol;
• clearing the head.

Analogs

Sodium thiosulfate can cause reactions in the body. The appearance of side effects or signs of intolerance to the medication requires its replacement. The list of popular analogues is presented:

• Algisorb, Amyl nitrite, Braidan;
• Glation, Dipiroxime, Carboxim;
• Lobelin, Naloxone, Sodium nitrite;
• Pelixim, Pentacin, Unithiol;
• Ferrocin, Amber-antitox.

Independent replacement of medication is strictly prohibited. The selection of an analogue is carried out by the attending physician, based on diagnostic data and the reasons that necessitated the need to change the therapeutic course.

Diet is an important factor in all treatment

When a patient is undergoing treatment for psoriasis with sodium thiosulfate, a special, light diet must be followed. It is important to completely avoid foods that are difficult to digest:

• meat;
• cereals;
• potato;
• pasta.

You should also take plenty of vegetables and fruits. Bake them, boil or steam them. The menu should be light and varied. For breakfast it is better to eat porridge with chicken, fish or rabbit. It would be good to eat cucumber or tomato, cabbage, zucchini (boiled).

It is strictly forbidden to use the following:

• coffee;
• sausage or milk;
• baked;
• canned meat;
• chocolate products;
• alcohol;
• smoked.

In order for sodium thiosulfate to be better absorbed by the body, it is important to drink plenty of fluids. It is also better to replace black tea with green tea or brew herbs. Compotes, juices (for example, orange or lemon), mineral water, etc. are good options.

Combination with alcohol

Sodium thiosulfate is actively used in the treatment of alcohol dependence. Treatment involves taking medication and alcohol at the same time to cause certain symptoms:

• attacks of vomiting with nausea;
• hand trembling;
• increased sweating;
• disturbances in heart rate;
• cough, etc.

This approach allows us to develop an aversion to ethanol. Therapeutic procedures take 16-20 days, take place every day, then three times a week and once a month. The drug solution is administered intravenously, the dosage is selected for each patient separately.

conclusions

It has been established that the inclusion of Reamberin

and
Remaxol
in the treatment regimen for psoriasis in the progressive stage with concomitant toxic liver damage of alcoholic origin increased the effectiveness of treatment, which was manifested in a decrease in clinical signs of psoriasis (decrease in PASI and DLQI indices) and pronounced positive dynamics of liver tests.

It was revealed that the most pronounced and statistically significant positive dynamics of clinical and laboratory parameters were observed in patients who received Remaxol

.

Combined treatment of psoriasis with broadband medium-wave phototherapy and methotrexate

Recent reviews report that the prevalence rate of psoriasis is 2% in the global population, with 2/3 of patients suffering from mild skin lesions and 1/3 having more severe skin lesions. Under these circumstances, psoriasis is an important medical and social problem, and the search for new ways to treat this disease is still relevant. I want to share my experience of combined treatment of patients with psoriasis using broadband medium-wave phototherapy and methotrexate. Phototherapy has been used for a long time, and even more so nowadays, in combination with both local and systemic agents. The purpose of such combinations is to overall increase the effectiveness of treatment, as well as to reduce the dose or number of applications of each treatment method. In the case under consideration, a reduction in the cumulative dose of methotrexate and the total dose of UVR. Various types of phototherapy are the first line of treatment for patients with moderate to severe psoriasis. UVB phototherapy is the use of artificial UVB radiation without the additional use of exogenous photosensitizers. UV radiation is absorbed by endogenous chromophores and photochemical reactions involving these absorbed biomolecules mediate a range of biological effects ultimately leading to a therapeutic outcome. The most important chromophore for UVB is nuclear DNA, and absorption of UVB by nucleotides causes the formation of DNA photoproducts, mainly pyrimidine dimers. UVB exposure inhibits DNA synthesis and is thus used to suppress the accelerated DNA synthesis found in psoriatic epidermal cells. UVB also stimulates the expression of the tumor suppressor gene p53, and this can lead to either cell cycle arrest (allowing DNA repair) or keratinocyte apoptosis (“burned cells”) if the DNA damage is too severe to be repaired. UVR causes the secretion of prostaglandins and cytokines. For example, interleukin-1 and interleukin-6 appear to play important roles in the symptoms of UV phototoxicity and immunosuppression, respectively. However, these responses may be equally important for therapeutic efficacy. There is also growing evidence that UV radiation can affect extranuclear targets located in the cytoplasm and cell membrane. These targets include cell surface receptors, kinases, phosphatases, and transcription factors. In psoriasis, both epidermal keratinocytes and skin lymphocytes can be targeted by UVB. Immunosuppression, altered cytokine secretion, and cell cycle arrest may all contribute to the suppression of disease activity in psoriatic plaques. Indications for broadband UVB therapy are moderate to severe psoriasis, with guttate psoriasis and plaques with minimal infiltration responding favorably and quickly to treatment, while chronic plaque psoriasis with severe infiltration is more resistant. I do not use phototherapy for genetic conditions characterized by increased photosensitivity or an increased risk of skin cancer; with skin phototype 1; photosensitive dermatoses and simultaneous use of general or local phototoxic drugs; vitiligo, history of exposure to arsenic, ionizing radiation, or excessive phototherapy; simultaneous use of cyclosporine; with anamnestic information about previous skin cancer, atypical melanocytic nevi; epilepsy and poor adherence to treatment. The immediate side effects of phototherapy are erythema, dry skin with itching, rarely blistering and an increased incidence of recurrent herpes viral infection. Long-term side effects include skin photoaging and carcinogenesis. However, modern studies on large groups of patients treated with UVB phototherapy have not revealed an increased incidence of basal cell carcinoma, squamous cell skin cancer and melanoma. When used on its own, broadband UVB phototherapy is usually used in combination with topical medications - topical steroids or, preferably, calcipotriol or zinc pyrithione, as well as moisturizers, such as Topicrem moisturizing emulsion for face and body. Phototherapy sessions are carried out 3–5 times/week, the course of treatment ranges from 20 to 30 sessions, i.e. the entire treatment cycle lasts from 7 to 10 weeks, the cumulative dose of UVB ranges from 7.0–10.5 to 15.5–16.0 J/cm2. More than 2 courses are not applicable during the year; in the case of frequently relapsing psoriasis, maintenance treatment is used - 2 times a week. 1 month after completion of the main course and 1 time per week. in the 2nd month. The last effective dose of UVB is prescribed. Methotrexate is the first-line drug for systemic treatment of psoriasis due to its effectiveness in severe disease and all clinical variants of psoriasis. The main indications for its use are severe forms of the disease - chronic plaque psoriasis, affecting more than 15-20% of the body surface, or impairment of labor or social function; pustular psoriasis (localized and generalized forms); psoriatic erythroderma; arthropathic psoriasis (moderate and severe); severe nail psoriasis, as well as psoriasis that does not respond to topical treatment, phototherapy and/or retinoids. The mechanism of action of methotrexate is associated with blocking the enzyme tetrahydrofolate reductase, which converts dihydrofolate into tetrahydrofolate, because methotrexate is an analogue of folic acid. Tetrahydrofolate is an essential cofactor for the synthesis of thymidylate and purine nucleotides, which in turn are required for the synthesis of DNA and RNA. Methotrexate competitively inhibits tetrahydrofolate reductase, although this inhibition may be partially attenuated by concomitant administration of folic acid. Methotrexate also partially affects the reversible inhibition of thymidylate synthetase, suppressing cell division in the S phase. Although methotrexate was originally thought to inhibit keratinocyte proliferation, it is more likely that methotrexate inhibits DNA synthesis in immunologically active cells. Methotrexate also reduces inflammation through other mechanisms. By inhibiting aminoimidocarboxyamido-ribonucleotide transformylase, methotrexate increases the local tissue concentration of the strong anti-inflammatory mediator adenosine. By inhibiting methionine synthase, methotrexate reduces the production of the pro-inflammatory mediator S-adenylmethionine. Methotrexate is contraindicated in case of impaired renal function (creatinine clearance less than 60 ml/min.); severe anemia, leukopenia and/or thrombocytopenia; significant liver dysfunction, active or recent hepatitis, severe liver fibrosis or cirrhosis, excessive alcohol consumption; simultaneous use of hepatotoxic drugs or drugs that increase plasma levels of methotrexate; significant weakening of lung function; pregnancy and lactation, planning pregnancy (contraception is required during treatment and for at least 3 months after the end of pregnancy for both men and women); immunodeficiency syndromes; severe and active infections; gastritis and active gastric ulcer; simultaneous radiation therapy; pleural effusion and ascites; hypersensitivity to methotrexate; with insufficient adherence to treatment. Frequent subjective symptoms during treatment with methotrexate are nausea, vomiting, abdominal pain, fatigue, headache, and rarely, decreased libido and decreased memory. On the skin and mucous membranes, oral erosions, alopecia, tenderness and/or plaque necrosis due to overdose, delayed phototoxicity (discussed below) and rarely urticaria, angioedema and vasculitis may be observed. Methotrexate can cause leukopenia, anemia and thrombocytopenia; hepatitis and cirrhosis of the liver; interstitial pneumonitis; congenital developmental defects - absence of fingers and skull defects; treatment with methotrexate is a risk factor for the development of squamous cell skin cancer in patients treated with PUVA therapy, and the risk of lymphoma is increased in patients with rheumatoid arthritis. However, large groups of patients with psoriasis have shown that the risk of developing malignant tumors is not increased. Methotrexate can also cause the development of opportunistic infections (for example, disseminated herpes zoster) or idiosyncrasies - pancytopenia, severe pneumonia and hemorrhage in the gastrointestinal mucosa (when treated with full doses at the very beginning of the course). Unusual reactions to methotrexate include osteopathy, ventricular arrhythmias, and decreased seizure threshold. When treating with methotrexate as monotherapy after a test dose of 5 mg, depending on the effectiveness and tolerability, 7.5 to 15 mg/week is usually prescribed, less often - up to 20–25 mg/week. In the case of psoriatic arthritis, the weekly dose of methotrexate should be at least 10 mg/week. To reduce toxicity, folic acid 1–2 mg/day is used. With methotrexate treatment, improvement usually begins within 1–4 weeks. treatment, the full therapeutic effect is achieved in most patients by 10–12 weeks. treatment, sometimes later. If necessary, treatment with methotrexate to maintain remission can be carried out indefinitely, from time to time reducing the dose of methotrexate to the minimum maintenance dose by 2.5–5.0 mg once every 3–4 weeks. It is important to remember that when a cumulative methotrexate dose of 1500 mg is reached, a liver biopsy or non-invasive diagnostic test, such as the Fibrometer test, is required to assess the toxic effect of methotrexate on the liver and the possibility of developing liver fibrosis or cirrhosis. In clinical practice, the duration of treatment with methotrexate is 7.5 mg/week. for 50 months. will be safe from the point of view of achieving a cumulative dose. For combination therapy of psoriasis using broadband medium-wave phototherapy and methotrexate, taking into account contraindications to both methods of treatment, patients with severe chronic plaque psoriasis affecting more than 15% of the skin surface or affecting cosmetically important areas of the skin, such as the dorsum of the hands or face; patients with moderate psoriasis who have not responded adequately to phototherapy and local treatment and with heavily infiltrated plaques. There are several clinical situations of combining UVB phototherapy and methotrexate. For example, a course of broadband medium-wave phototherapy can be prescribed to a patient already receiving methotrexate, but who has not achieved the required level of improvement at a certain dose of the latter; in this case, the purpose of the combination is to increase the effectiveness of treatment without increasing the dose of methotrexate. The second option occurs when a course of phototherapy does not achieve the required level of improvement or recovery within the expected time frame, in which case methotrexate is prescribed during the course of phototherapy. The third option was the initially planned combination of methotrexate and UVB phototherapy. In this case, the patient takes methotrexate three times and then begins a course of phototherapy. The goal of this combination is to reduce the cumulative doses of both UVR and methotrexate. In this case, the main problem of the combination may be the so-called “anamnestic reaction,” which manifests itself in the form of a generalized phototoxic reaction in a patient receiving UVB therapy and methotrexate. However, such a reaction can also be observed from natural sun exposure, so it can occur in a patient on therapeutic doses of UVR and is most likely to occur in patients who have received sunburn in the past. In any case, this is a rather rare and unpredictable situation, the only possible prevention of which may be to advise the patient to avoid additional natural UVR during the course of treatment. Under my supervision in 2008–2012. Three groups of patients suffering from psoriasis were and continue to be and receive treatment. Broadband UVB phototherapy was carried out in an ultraviolet cabin of the German company Waldmann Meditsintechnik UV 1000 K, tableted methotrexate or an injection solution in ready-made syringes was used. Group 1 consisted of patients with moderate and severe psoriasis receiving broadband UVB phototherapy and local agents (calcipotriol, zinc pyrithioneate, glucocorticoids in combination with emollients). In addition, patients were prescribed traditionally used medications - calcium gluconate, sodium thiosulfate, hemodez, essentiale, vitamins B1, B6, B12, pentoxifylline parenterally in saline solution - all that is now provided for by MES MO 3.30.008.0, in force since October 1, 2009 ., and also in some cases glutoxim, immunofan and ademetionin. In 2008, 33 people were treated in this way, including 20 men and 13 women, the average age was 32 and 34 years, respectively. In 2009, 35 men and 10 women were treated, a total of 45 patients, with an average age of 37 and 27 years, respectively. In 2010, there were 31 male and 12 female patients, for a total of 43 with a mean age of 34 and 28 years, respectively. In 2011, 34 patients received treatment, of which 18 were men and 16 women, with an average age of 36 and 30 years, respectively. In 2012, assistance was provided to 17 men, average age 36.6 years, and 9 women, average age 31.8 years. A total of 181 patients were treated with broadband UVB therapy over a 5-year period. Clinical recovery was achieved in 109 (60%) patients, marked improvement was observed in 51 (28%) patients, and in 21 (11%) patients the response to phototherapy was insufficient. The total UV dose ranged from 9.1 to 18.5 J/cm2. Group 2 consisted of patients with severe chronic plaque psoriasis, incl. with damage to key areas of the skin - face, scalp, hands; psoriatic erythroderma; arthropathic psoriasis. This group of patients received methotrexate as a basic agent, traditional general and local treatment, as well as NSAIDs and magnetic therapy of the affected joints. In addition, patients with psoriatic arthritis with high activity of the joint process additionally received prednisolone 7.5–10 mg/day. for 4–6 weeks. as bridge therapy until the disease-modifying disease-modifying antirheumatic drug methotrexate begins to work. In 2008, 13 patients, 10 men and 3 women, with an average age of 42.8 and 48 years, respectively, received methotrexate. In 2009, 15 patients, 9 men and 6 women, with an average age of 48 and 47 years, respectively, received treatment. In 2010, there were 13 men and 6 women, a total of 19 people, with an average age of 53 and 57 years, respectively. In 2011, 12 patients were treated with methotrexate, the ratio of men to women was 1:1, and the average age of men was 49 years, and women - 60. In 2012, 9 males were treated, the average age was 45 years, and 8 women, the average age is 60.6 years. In total, 76 patients were treated with methotrexate. Clinical recovery was observed in 51 (67%) patients, clinical improvement occurred in 14 (18%) patients, insufficient treatment effect was observed in 11 (15%) people. The course dose of methotrexate ranged from 60 to 120 mg. Group 3 was formed by patients who received combination therapy with methotrexate and broadband UVB phototherapy according to the above selection criteria. The patients also received treatment provided by the MES. In 2008, 2 men received treatment; the average age was 28 years. In 2009, 14 patients were already treated, of which 10 were men and 4 women, with an average age of 44.8 and 41 years, respectively. There were also 14 patients in 2010, 9 men and 5 women, with a mean age of 37 years and 31 years, respectively. In 2011, 15 people received treatment, including 11 males and 4 females with an average age of 38.6 years and 31 years, respectively. In 2012, 7 men and 3 women were treated with an average age of 46 years and 51.6 years, respectively. Over five years, 55 patients received the combination treatment. Clinical recovery was observed in 48 (87%) patients, clinical improvement – ​​in 7 (13%) patients. The total dose of ultraviolet radiation ranged from 10.75 to 15.3 J/cm2, the course dose of methotrexate ranged from 45 to 100 mg. It should be noted that often a number of patients moved from group to group and served as controls for themselves. Conclusions: 1. Various types of phototherapy, and in particular broadband medium-wave phototherapy, from its inception to the present day remain an effective and safe way to treat moderate and severe psoriasis. The only disadvantage of UVB phototherapy is the relative high cost and the need for frequent visits to a medical facility, which is more than compensated for by the more than 70% effectiveness of patient treatment. 2. Metorsat, despite the onset of biological drugs, is a “gold standard” for the treatment of severe psoriasis and is especially effective in the treatment of erythrodermic and pustular forms, psoriatic arthritis. Metotrexate causes remission in most patients and is able to support it for a long period of time. The drug is relatively safe and well tolerated, from the point of view of pharmacoeconomics and side effects, it has undeniable advantages over the second line system drugs - cyclosporine and retinoids. Biological drugs are used only if the patient needs systemic treatment, but has contraindications to all existing methods of treatment or they have led to insufficient improvement, or the patient did not answer adequately to any system treatment method. The number of patients reaching PASI 75% during 2-3-month treatment with modifiers of the immune response is comparable to the number of patients who received methotrexate. 3. Combined treatment of psoriasis with broadband medium -volume phototherapy and methotrexate with a rational selection of patients opens up new opportunities in increasing the overall effectiveness of treatment with psoriasis, as well as reducing cumulative doses of ultraviolet radiation and cumulative dose of metotrectorsat by reducing one -time weekly doses of the latter. A decrease in doses of methotrexate without reducing the overall effectiveness of treatment allows you to reach a cumulative dose of 1500 mg later, which in turn reduces the need for liver biopsy or the use of a fibrometer test. A decrease in the cumulative dose of UFI reduces the risk of photographic artistic and photographic cargenesis. The expected overall effect of combining UFV phototherapy and methotrexate also consists in the fact that more patients will be rendered relatively inexpensive, but effective from the point of view of the health economy, assistance by reducing the need for patients in treatment with expensive biological drugs. 4. Qualified treatment of patients with psoriasis with the help of medium-volume phototherapy, as well as bullet-therapy, adequate use of the first line of the first line of methotrexate therapy in the form of monotherapy or combination with UFV in most cases is possible on an outpatient basis, because Neither phototherapy nor treatment with methotrexate in themselves are round -the -clock methods of treatment, and round -the -clock observation is shown only to patients with erythrodermic and generalized pustulent psoriasis, some forms of psoriatic arthropathy. The transfer of a significant number of patients with medium -sized psoriasis and severe to outpatient treatment is in harmony with a modern tendency in healthcare to develop stationary -substituting technologies, reducing expensive stationary assistance and transferring medical care to an outpatient link, and also fully and fully meets the needs of patients to effective and fully and fully meets the requests of patients and fully. Not related to a significant change in the usual way of life treatment.

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