Psoriasis Revolution

Psoriasis Holistic Treatments

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Psoriasis is a common skin disorder that most often appears as inflamed plaques covered with a thickened, silvery-white scale.

Psoriasis is divided into the following nine categories, although a patient can have more than one type at the same time:

1. Plaque psoriasis accounts for 80% to 90% of patients with psoriasis (Fig. 33-18).

2. Scalp psoriasis causes plaques on the scalp (Fig. 33-19).

3. Guttate psoriasis appears as small, round plaques that resemble water drops (Fig. 33-20).

4. Inverse psoriasis causes inflammation in the intertrigi-nous areas of the axilla, groin, inframammary folds, and intergluteal fold. Inverse psoriasis may not exhibit classic scaly plaques, and the erythema, scaling, or maceration in intertriginous areas is often mistaken for fungal infection (Fig. 33-21).

5. Palmar-plantar psoriasis occurs on the plantar aspects of the hands and feet (palms and soles) (Fig. 33-22).

Seboritic Psoriaza
Figure 33-16 Seborrheic dermatitis. (O Richard P. Usatine.)
Psoriasis Beard
Figure 33-17 Seborrheic dermatitis around beard and mustache. (©Richard P. Usatine.)

6. Erythrodermic psoriasis is widespread erythema and scales.

7. Pustular psoriasis can be localized or generalized. In the generalized form, superficial pustules may appear and coalesce to form lakes of pus that dry and desquamate in sheets (Fig. 33-23).

8. Nail psoriasis causes the nails to develop pits, onycholy-sis, and oil spots and to thicken.

9. Psoriatic arthritis affects the joints of the hands, feet, and knees but can involve other joints as well.

From 1% to 2% of the U.S. population has plaque psoriasis. Genetic factors are involved; when both parents are affected by psoriasis, the rate of psoriasis may be as high as 50%; with one parent affected, the rate is approximately 16%. Psoriasis can appear at any age, but the two peak age ranges are 16 to 22 and 57 to 60. Guttate psoriasis often occurs after strep-tococcal pharyngitis or another upper respiratory infection. Pustular psoriasis may be provoked by the withdrawal of systemic steroids in a patient already diagnosed with psoriasis.

The most common areas involved include the elbows, knees, extremities, trunk, scalp, face, ears, hands, feet, genitalia, intertriginous areas, and the nails. In most cases,

Epithelial Wound Bed Tissue
Figure 33-18 Psoriatic plaques. (e RichardP. Usatine.)
Blue Waffle Virginia
Figure 33-19 Scalp psoriasis. (e RichardP. Usatine.)

diagnosis of psoriasis is based on the clinical appearance. The differential diagnosis list is long, however, and a KOH preparation or skin biopsy may be needed. A biopsy may also be helpful to establish the diagnosis in less common types of psoriasis (pustular, palmar-plantar, inverse). Do not treat psoriasis with oral or systemic steroids; this can precipitate a life-threatening case of generalized pustular psoriasis.

A meta-analysis showed that 68% to 89% of patients treated with clobetasol (ultrahigh-potency steroid) had clear improvement or complete healing (Nast et al., 2007). Comparable efficacy was shown for topical calcipotriene (vitamin D analogue) and tazarotene (retinoid), with a slight increase in adverse effects for tazarotene (Afifi et al., 2005). Combination topical steroids and calcipotriene or tazarotene is the most promising

Herpes Simplex Resolving

Figure 33-20 Guttate psoriasis after streptococcal throat infection in child.

Figure 33-20 Guttate psoriasis after streptococcal throat infection in child.

Psoriasis Breast
Figure 33-21 Inverse psoriasis under breasts. © Richard P. Usatine.)

current topical treatment and seems to have increased efficacy and fewer side effects (Afifi et al., 2005; Nast et al., 2007). Clinical trials suggest that tacrolimus (0.1 %) ointment twice daily produces a good response in a majority of patients with facial and intertriginous (inverse) psoriasis (Brune et al., 2007; Lebwohl et al., 2004; Martin et al., 2006). Methotrexate as a weekly oral dose of 5 to 15 mg can be very effective for widespread psoriasis not responding to topical treatments (Saporito and Menter, 2004). Acitretin (Soriatane) is a potent systemic reti-noid used for psoriasis that is widespread or palmar-plantar and not responding to topical treatments (Pearce et al., 2006) Etanercept (Enbrel) is a subcutaneous biologic agent that is especially valuable in patients with psoriatic arthritis, as well as those with moderate to severe cutaneous psoriasis (Nast et al., 2007). Adalimumab (Humira), a subcutaneous biologic agent, and infliximab (Remicade), an intravenous biologic agent, are effective for patients with psoriatic arthritis as well as those with moderate to severe cutaneous psoriasis (Bansback et al., 2009). Ustekinumab (Stelara), the most recently approved subcutaneous biologic agent, significantly reduced signs and symptoms of psoriatic arthritis and diminished skin lesions compared with placebo (Gottlieb et al., 2009).

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