van de Kerkhof Peter C M, Murphy Gillian M, Austad Joar, Ljungberg Anders, Cambazard Frederique, Duvold Laetitia Bouérat
Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
J Dermatolog Treat. 2007;18(6):351-60. doi: 10.1080/09546630701341949.
Facial and flexural psoriasis may impair the quality of life of psoriatic patients considerably. For the adequate management of psoriasis it is important to pay attention to lesions at these sensitive sites, which require an approach different to that for lesions on other sites in several respects. An extensive literature search was carried out to collect evidence-based data on facial and flexural psoriasis with respect to epidemiology, clinical aspects, pathogenetic factors and various treatments. Subsequently, a panel of experts, the Copenhagen Psoriasis Working Group (CPWG), discussed these aspects and several recommendations were formulated reconciling the evidence-based data. Facial psoriasis occurs in 17-46% of psoriatics and flexural psoriasis is experienced by 6.8-36% of patients with psoriasis. Therefore, psoriasis at these sites cannot be regarded as a rare manifestation. Facial psoriasis is a prognostic marker indicating a poor prognosis of psoriasis. Facial and flexural psoriasis cannot be regarded as distinct disease entities but rather as site variations. The clinical features of facial psoriasis suggest that there are three subtypes: hairline psoriasis, sebo-psoriasis and true facial psoriasis. Otitis externa and ocular manifestations should not be neglected. Evidence that microbiological factors may be relevant to facial and flexural psoriasis is virtually absent. For facial psoriasis the response to UV radiation is variable. At least 5% of psoriatics have photosensitive psoriasis. In these patients photosensitive diseases such as lupus erythematodes and polymorphic light eruption have to be excluded. Based on the literature assessment and working group discussions the CPWG concluded the following. (1) Low-potency topical corticosteroids, vitamin D3 analogues and calcineurin inhibitors are first choice treatments in facial and flexural psoriasis. Evidence for the efficacy of the first two modalities is at level 3 while it is at level 1 for the third one. An individualized approach is indicated; for example, in case of corticosteroid side effects in the past the other two modalities should be selected and in unstable psoriasis prone to irritation, monotherapy with vitamin D3 analogues should be avoided. (2) Antimicrobial treatments are not indicated for facial and flexural psoriasis. (3) Dithranol and tar treatment are not indicated as first-line treatment but only if the first-line options fail. (4) In case topical therapies are not effective, phototherapy and systemic treatments are indicated. (5) For future drug development the combination of vitamin D3 analogues with low strength corticosteroids is recommended.
面部及屈侧银屑病可能会严重影响银屑病患者的生活质量。对于银屑病的恰当管理而言，关注这些敏感部位的皮损非常重要，这些部位在多个方面需要与其他部位的皮损采取不同的治疗方法。我们进行了广泛的文献检索，以收集关于面部及屈侧银屑病在流行病学、临床特征、发病因素及各种治疗方法方面的循证数据。随后，一个专家小组，即哥本哈根银屑病工作组（CPWG），对这些方面进行了讨论，并根据循证数据制定了若干建议。17% - 46%的银屑病患者会出现面部银屑病，6.8% - 36%的银屑病患者会有屈侧银屑病。因此，这些部位的银屑病不能被视为罕见表现。面部银屑病是银屑病预后不良的一个预后指标。面部及屈侧银屑病不能被视为不同的疾病实体，而应看作是部位差异。面部银屑病的临床特征提示有三种亚型：发际线银屑病、脂溢性银屑病和真性面部银屑病。外耳道炎和眼部表现不应被忽视。几乎没有证据表明微生物因素与面部及屈侧银屑病有关。对于面部银屑病，对紫外线辐射的反应存在差异。至少5%的银屑病患者有光敏性银屑病。在这些患者中，必须排除如红斑狼疮和多形性日光疹等光敏性疾病。基于文献评估和工作组讨论，CPWG得出以下结论。（1）低效外用糖皮质激素、维生素D3类似物和钙调神经磷酸酶抑制剂是面部及屈侧银屑病的首选治疗方法。前两种治疗方式的疗效证据为3级，而第三种为1级。应采取个体化方法；例如，如果过去有糖皮质激素副作用，应选择其他两种方式，对于容易出现刺激的不稳定银屑病，应避免单独使用维生素D3类似物。（2）面部及屈侧银屑病不适用抗菌治疗。（3）蒽林和焦油治疗不作为一线治疗方法，仅在一线治疗方案无效时使用。（4）如果局部治疗无效，应采用光疗和全身治疗。（5）对于未来的药物研发，建议将维生素D3类似物与低强度糖皮质激素联合使用。
