PATIENT-CENTERED APPROACH IN THE TREATMENT OF PSORIASIS VULGARIS: PRESENTATION OF CLINICAL CASE

:Introduction : Psoriasis is a complex, chronically recurrent, multifactorial disease that affects the somatic health (musculoskeletal, nervous, endocrine, cardiovascu-lar, digestive systems) as well as the psyche and social adaptation. The organism’s individual characteristics and tolerance to the applied therapy impose the need for complex treatment in order to achieve long-term clinical remission and change in the quality of life. Aim: to monitor the effectiveness of the patient-centered approach in the complex treatment of patients with psoriasis vulgaris. Case report: A 40-year-old woman with a 20-year-old history of psoriasis vulgaris visited the University Center for Eastern Medicine (UCEM-MU-Varna) with complaints of extensive, itchy erythemo-squamous plaques covering the body, face, scalp and limbs. The patient’s disease progresses in a chronically recurrent course without long-term remission. We applied combined physical therapy, including laser acupuncture, magnetic therapy and aromatherapy. Results: After a 10-day treatment, we reported a reduction in the number and size of the plaques, subjective complaints and an improved psycho-emotional tone. When monitoring the condition during the 3rd, 6th and 9th month of the treatment, the patient reported no activation of the plaques and no other subjective complaints. The complex treatment, including conventional and unconventional physical factors, ensured a long-term remission of the disease. Conclusion: The patient-centered approach in the treatment of psoriasis vulgaris increases the effectiveness of the applied complex treatment. The selection and combination of conventional and unconventional physical factors selected according to the patient’s tolerance help to slow the progression and ensure long-term remission of the disease.


INTRODUCTION
Psoriasis is a complex, chronically recurrent, multifactorial disease that affects about 1-3% of the world's population [1]. According to data from patient organizations and medical practices, the frequency in Bulgaria is 1-2%. Although, at first glance, low in prevalence, psoriasis has serious consequences for the quality of life, affecting the somatic health (musculoskeletal, nervous, endocrine, cardiovascular, digestive systems) as well as the psyche and social adaptation [2]. The diverse clinical picture of the disease complicates the development of a physiotherapeutic algorithm for the treatment of patients with psoriasis [3].
The role of physical therapy in the treatment of dermatological diseases is recognized by the Bulgarian physiotherapeutic practice. N. Todorov (1982) and E. Iliev (1988) created and applied established methods for the treatment of psoriasis -low-frequency, pulsed magnetic field (local or adrenal) and local low-energy laser therapy (red spectrum) in limited focal points and smaller-sized plaques. Other authors (Y. Dafinova, 1997; M. Ryazkova, 2002) describe the impact of the pulsed magnetic field and laser acupuncture -function regulation of the immune, endocrine and musculoskeletal systems and the gastrointestinal tract; sleep and psycho-emotional improvement. Low-energy laser therapy and laser acupuncture have proven effective in accelerating the process of tissue regeneration in the treatment of psoriasis. Due to its non-invasive nature and rare side effects, laser acupuncture is preferred in cases of acupuncture needle limitations. [4,5,6,7].
Practice shows that the established physiotherapeutic methods concentrate not only on the reduction of somatic complaints but also on achieving remission of the disease. Despite the good results, however, they do not offer therapy personalization according to the patient's psycho-social characteristics. Some researchers believe that this barrier can be overcome by applying a patient-centered approach on the one hand and a combination of conventional and unconventional physical factors on the other [8, 9,10]. The main advantage of patient-centered care is the im-provement in the diagnostic and therapeutic process by building a trustworthy relationship between the patient and the physician [11,12]. Its individual focus makes it possible to select the proper methods and tools that physical medicine can offer (conventional and unconventional) that could help ensure long-term remission for patients with psoriasis.

AIM:
To monitor the effectiveness of the patient-centered approach in the complex treatment of patients with psoriasis vulgaris.

CASE REPORT:
A 40-year-old woman with a 20-year-old history with psoriasis vulgaris visited the University Center for Eastern Medicine (UCEM-MU-Varna) with complaints of extensive, itchy erythemo-squamous plaques covering the body, face, scalp and limbs. She shared that no remission has been achieved so far despite systematic therapy (local and oral) -after the application of acupuncture, in case of stronger pressure or light impact, the patient reports the appearance of new plaques. She rejects oral or parenteral intake of medication and supplements due to recent negative experience after treatment with interleukins.
Multiple extensive erythemo-squamous plaques were objectively found covering the body, limbs, face and scalp. The specific characteristics, as well as the patient's psycho-emotional condition, were taken under account while preparing the therapeutic program. The possibility of acupuncture was excluded due to the risk of increasing the number and size of the plaques after its application. We applied laser acupuncture with technical parameters 650 nm, 5 mW, 60 sec in points GV 20, Yintang, CV 6, CV 17, BL 23, SP 10, SP 6, ST 25, St 36, LI 4, LI 11, LIV 2, LIV 6, R 1, PC 6. We sought the patient's feedback daily, adapted the recipe's formulation and included a pulsed magnetic field treatment (35 mT, rectangular shape, with a pulse duration of 8 ms and pause -15 ms) locally on the elbows, both calves, sacrum and adrenal area. For external use, we appointed an essential oil mixture of Yarrow oil / Achillea millefolium L./, Pomegranate seed oil /Punica granatum L./, Roman chamomile oil /Chamaemelum nobile L./, Peppermint oil /Mentha x piperita L./, Jojoba oil / Simmondsia chinensis L./, Grape seed oil /Vitis vinifera L./, Argan oil /Argania spinosa L./ and Green coffee seed oil / Coffea sp./. The patient rejected the possibility of photo-, helio-and balneotherapy, reporting individual intolerance in the past. Knowing the particular functioning of the gastrointestinal tract, the patient made her choice of diet, according to previous experience, under our mentoring.
On the second day of the treatment, we determined that the squamae had cleared out. At the end of the 10-day physiotherapeutic treatment, we reported a reduction in the number and size of the plaques, subjective complaints and an improved psycho-emotional tone. A number of researchers, including S. Shrotrya, H. Kazeiman, R. Guimarães, A.C.C.M. Castro, Z. Drinic and others, describe the therapeutic effect of essential and base oils -erythema reduction after combined application of both essential and base oils, improvement of skin hydration and trophicity, as well as prevention of the squamae [13, 14, 15, 16, 17, 18, 19]. It has been determined that the combination of essential oils, physical factors, and laser acupuncture accelerates the reduction of psoriatic plaques, but their inclusion in the treatment depends on the individual tolerance and the psycho-emotional condition of the patient [20, 21, 22, 23]. When monitoring the patient during the 3rd, 6th and 9th month of the treatment, she reported no activation of the plaques and no other subjective complaints. The complex treatment, including conventional and unconventional physical factors, ensured a long-term remission of the disease.

CONCLUSION:
The patient-centered approach in the treatment of psoriasis vulgaris increases the effectiveness of the applied complex treatment. Essential and base oils that work as emollients and substances with targeted epigenetic and cell regeneration stimulating effect were successfully included in the treatment. The pulsed magnetic field and laser acupuncture have a powerful and, at the same time, universal biotherapeutic effect on the whole organism. The individualization and everyday adaptation of laser acupuncture in biologically active points further favors not only the reversal of psoriatic plaques but also the achievement of long-term remission and prevention of complications in other organs and systems. The selection and combination of the appropriate methods and means that physical medicine can offer (conventional and unconventional), tailored to the patient's personal perceptions, help slow the progression and ensure long-term remission of the disease.