作者:Jennifer Cather、Alan Menter
DOI:10.2165/00128071-200203030-00003
日期:——
The T cell-driven immunopathogenesis of psoriasis has been well recognized since cyclosporine first revolutionized the treatment of psoriasis 20 years ago. Almost all investigative and clinical research subsequently, has concentrated on elucidating the specifics of antigen presentation, T cell interaction and the production of specific cytokines. The role of the keratinocyte, previously thought to be the primary target cell in psoriasis pathogenesis, has been relegated to a secondary role and the mechanism of action of systemic methotrexate in psoriasis has been challenged, the primary role of the T lymphocyte is now well known. While psoriasis has traditionally been treated ‘ab initio’ with topical medications (corticosteroids, vitamin D3, and retinoid derivatives), either singly, in combination, or with ultraviolet B (UVB) or psoralens and ultraviolet A (PUVA) therapy, the role of systemic medications has assumed greater prominence. Thus, three systemic medications currently are approved worldwide for the treatment of moderate to severe forms of psoriasis, namely cyclosporine, methotrexate and acitretin. The first two are likely to give significant clearing (greater than 75%) in the majority of cases, whereas acitretin is significantly less effective as monotherapy, but may approach methotrexate and cyclosporine in efficacy, if combined with PUVA or UVB phototherapy. The main limitations of these three drugs remain organ toxicity, especially hepatic toxicity with methotrexate, hypertension and nephrotoxicity with cyclosporine, and teratogenecity and mucocutaneous toxicity with acitretin. Thus, the need for more specific systemic therapy, targeting the T lymphocyte. This has become the major area of clinical research interest over the past 5 years, with the promise of longer-term disease control (improved remissions) and less organ toxicities. Currently, there are over 15 of these ‘biologic’ drugs in various stages of development and clinical trials, either by the subcutaneous, intramuscular or intravenous route. The three main variables are the rapidity of onset, percentages of improvement and remission rates. Without exception, these new systemic agents appear to be remarkably free of systemic organ toxicities (liver, renal, bonemarrow, etc.), with adverse effects being limited to mild flu-like symptoms with the anticipated increase in infections (e.g., herpes simplex) being either equal to placebo or only marginally increased. Not all these agents under evaluation give clinical responses equal to methotrexate or cyclosporine (75% or greater clearing in 75% of cases). In addition, response rates may be slower with some therapies versus others. However, the need for intermittent administration even by the injectable route, longer remissions, lack of systemic organ toxicities and the potential for safer usage in females of child-bearing age, make a compelling argument for widespread acceptance by both patients and the dermatological community. Other modalities under clinical evaluation include vitamin D and retinoid drugs, topically and systemically, with effects on nuclear receptors, as well as more specific wavelengths (308 to 311nm) of UVB phototherapy with application for more localized forms of psoriasis. For the 2 to 3% of the worldwide population of patients with psoriasis the future has never looked brighter.
自从20年前环孢素首次彻底改变了牛皮癣的治疗以来,以T细胞驱动的免疫病理机制已被广泛认知。随后的几乎所有研究和临床试验都集中在阐明抗原呈递、T细胞相互作用和特定细胞因子的产生上。角质形成细胞曾被认为是牛皮癣病理机制中的主要靶细胞,但现在其角色已被降为次要,系统性甲氨蝶呤在牛皮癣中的作用机制也受到挑战,T淋巴细胞的主要角色现在已得到了公认。虽然牛皮癣传统上是通过外用药物(如皮质类固醇、维生素D3和类视黄醇衍生物)进行“初始”治疗,单独使用、联合使用,或与紫外线B(UVB)或光敏剂及紫外线A(PUVA)疗法结合使用,但系统性药物的作用变得越来越重要。目前,全球已批准三种系统性药物用于中重度牛皮癣的治疗,即环孢素、甲氨蝶呤和阿维A。前两者在大多数病例中可能给予显著清除(超过75%),而阿维A作为单药治疗的效果明显较差,但如果与PUVA或UVB光疗结合使用,其疗效可能接近甲氨蝶呤和环孢素。这三种药物的主要限制依然是器官毒性,尤其是甲氨蝶呤的肝毒性,环孢素的高血压和肾毒性,以及阿维A的致畸性和黏膜皮肤毒性。因此,针对T淋巴细胞的更特异性系统治疗的需求显得尤为重要。这已经成为过去五年临床研究的主要关注领域,承诺提供更长期的疾病控制(改善的缓解情况)以及更少的器官毒性。目前,已有超过15种“生物”药物在不同开发和临床试验阶段,通过皮下、肌肉或静脉注射给药。三个主要变量是起效的快速性、改善的百分比和缓解率。这些新的系统性药物在器官毒性(肝、肾、骨髓等)方面显然非常少见,副作用仅限于轻度流感样症状,预期的感染增加(如单纯疱疹)则与安慰剂相等或仅稍有增加,并非所有正在评估的药物在临床反应上都能达到甲氨蝶呤或环孢素的水平(在75%的病例中清除达到75%以上)。此外,某些疗法的反应速度可能较慢。然而,即使是通过注射途径的间歇性给药,较长的缓解期,缺乏系统性器官毒性,以及在育龄女性中潜在的更安全使用,使得这些药物得到了患者和皮肤病学界的广泛认可。其他正在临床评估的方法包括维生素D和类视黄醇药物的外用和系统用药,对核受体的影响,以及针对更局部形式的牛皮癣的特定波长(308到311nm)的UVB光疗。对于全球有2%到3%牛皮癣患者的人群来说,未来从未如此光明。