New Diet for Psoriasis

Psoriasis Revolution

Psoriasis Revolution is a natural program that has been well researched by the experienced medical nutritionist and a psoriasis sufferer Dan Crawford. It is designed to guide users on how they can completely cure psoriasis and eliminate red, silvery scales, patchy itchy skin, haemorrhage and also boost the immune system, essentially a life-time solution. Psoriasis is not only a long-term solution, but also provides instant remedy to psoriasis. For example, the program can lower the burning sensation and itchiness within 24 hours. Although results will vary from one person to another, many users have reported significant results within 1 to 2 months of its use. Dan is a popular medical nutritionists, wellness adviser, research worker and a person who has suffered psoriasis for 27 years. Dan spent more than 12 years, 47,000 hours doing clinical analysis and a lot of money doing trial and error methods to develop a program that can truly cure any type of psoriasis at any level of severity. Read more here...

Psoriasis Revolution Summary

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Local therapies of nail psoriasis only rarely induce complete remission of the disease

A nail lacquer containing 8 clobetasol propionate, formulated to optimize penetration of the drug through the nail plate, has been developed for use in this condition. This topical treatment, which is effective and well tolerated, produces improvement in most cases of nail psoriasis, with effects directly related to the duration of treatment. Topical calcipotriol is effective when onycholysis and subungual hyperkeratosis are prominent symptoms. Topical tazarotene 0.1 gel has also been used with good results and tolerability in psoriasis. The latter drug is especially effective in reducing onycholysis (in occluded and non-occluded nails) and pitting (in occluded nails). thickened. However, this treatment may be useful in pustular psoriasis when recurrent pustular lesions have destroyed the nail plate. Intralesional injections of triamcinolone acetonide 10 mg ml, at a dose of 0.2-0.5 ml per nail, have proved effective in some cases of nail matrix psoriasis. In patients with nail-plate...

Acropustulosis and pustular psoriasis

Tumore Della Pelle

In pustular psoriasis and acrodermatitis continua (Hallopeau's disease), involvement of a single digit is common. It is often misdiagnosed when the pustule appears beneath the nail plate with necrosis of tissue resulting in desiccation and crust formation. New pustule formation may develop at the periphery or within the lesions. The nail is lifted off by the crust and lakes of pus and new pustules may form on the denuded nail bed (Figures 5.425.44). Permanent loss is possible. Acral pustular psoriasis has been reported with resorptive osteolysis ('deep Koebner phenomenon') and pronounced skin and subcutaneous tissue atrophy. There may be progressive loss of entire digits in the feet and loss of finger tips and finger nails. 'Tuft' osteolysis may occur independently of acropustuloses and arthritis. Histopathology reveals Munro-Sabouraud 'micro-abscesses' or the spongiform pustule of Kogoj. Localized psoralens with ultraviolet irradication (PUVA) therapy can be of benefit. Oral retinoid...

Clinical Presentation and Diagnosis of Other Types of Psoriasis

Inverse psoriasis spares the areas commonly involved in plaque psoriasis and instead appears in intertriginous areas, where scaling is minimal. Guttate psoriasis presents as a sudden eruption of small, disseminated erythem-atosquamous papules and plaques, and is often preceded by a streptococcal infection 2 to 3 weeks prior. Pustular psoriasis may be localized or generalized and may be an acute emergency requiring systemic therapy. Generalizedpustular psoriasis is characterized by disseminated deep-red erythematous areas and pustules, which may merge to become lakes of pus. Psoriatic diaper rash is the most common type of psoriasis in children under 2 years old. This usually affects inguinal folds and greater than 90 of psoriatic diaper rash cases may have involvement outside the diaper area.

All the nail signs in Reithers syndrome may be present in severe psoriasis

Involvement suggesting inflammation of the proximal nail fold. Onycholysis, ridging, splitting, greenish-yellow or sometimes brownish-red discoloration and subungual hyperkeratosis may be present. Small yellow pustules may develop and slowly enlarge beneath the nail, often near the lunula. Their contents become dry and brown. The nails may be shed. Nail pitting may be seen in Reiter's syndrome, individual pits being deep and punched out. This nail pitting may reflect a predisposition to the development of psoriasis or psoriasiform lesions dependent on the HLA-A2 and B27 antigens, as suggested by previously reported HLA typing studies. Both HLA-A2 and B27 were present in a 6-year-old boy who had only the nail changes which were compatible with Reiter's syndrome the same antigens were also present in his father, who had uveitis, arthritis and amyloidosis.

Psoriasis

Nail psoriasis is most commonly characterized by pits, 'salmon' or oil patches, onycholysis and nail dystrophy. Pits develop from tiny psoriatic lesions located in the most proximal matrix region. These produce parakeratotic mounds which remain on the nail plate surface as long as the growing nail is covered by the proximal nail fold they then break off and leave a small depression in the nail surface. The depth of the pits reflects the severity of the lesion, their longitudinal diameter their duration. Salmon spots are psoriatic lesions in the distal matrix or nail bed. There is an inflammatory, mainly lymphocytic infiltrate in the upper dermis with wide capillaries, mild to moderate spongiosis with lymphocytic exocytosis and parakeratosis that may contain single neutrophils or small neutrophilic abscesses. Serum imbibition of the parakeratosis is probably the cause of their yellowish colour. When such a lesion reaches the hyponychium air penetrates under the nail plate and...

PsoralenUVA Photochemotherapy

Patients with psoriasis undergoing treatment with Psoralen-UV-A photochemotherapy are at an increased risk of penile cancer although there are limited studies which have reported this.29 In a cohort of 892 men who were treated with oral methoxsalen (8-methoxypsoralen) and ultraviolet A photochemotherapy (PUVA), a total of 14 patients (1.6 ) with 30 genital neoplasms were identified. In patients exposed to high levels of PUVA, the incidence of invasive squamous-cell carcinoma was 286 times that of the general population and 16.3 times that in patients exposed to low levels of PUVA indicating a dose-dependent risk. Patients treated for psoriasis using immunosuppressive drugs also appear to have an increased risk of developing penile cancer and therefore a genital examination is mandatory in these patients.

Table 42 Causes and associations of nail shedding

Ideally, the term 'hypertrophy of the nail plate' should be restricted to conditions causing nail enlargement and thickening by their effects on the nail matrix (excluding nail bed and hyponychium). The term 'subungual hyperkeratosis' should relate to those entities leading to thickening beneath the preformed nail plate that is, thickening of the nail bed or hyponychium (Figure 4.13). In practice, this differentiation is difficult to define and mixed cases are commonly seen, for example in psoriasis (Figures 4.14, 4.15). disease states such as congenital ichthyoses, Darier's disease, psoriasis and repeated trauma. The latter particularly relates to toe nails where microtrauma and footwear are constantly affecting the nails. Subungual hyperkeratosis due to psoriasis. Subungual hyperkeratosis due to psoriasis. Distal subungual hyperkeratosis in psoriasis note proximal inflammatory brown margin. Distal subungual hyperkeratosis in psoriasis note proximal inflammatory brown margin....

Topical drug delivery

Topical drug delivery is the term used for localized treatment of dermato-logical condition where the medication is not targeted for systemic delivery (Osborne, 2008) examples include treatment of dermatological conditions like eczema or psoriasis by topical application. Examples of drugs delivered topically include corticosteroids, antifungals, antivirals, antibiotics, antiseptics, local anesthetics, and antineoplastics. Topical agents that act by physical action would include protectives, adsorbents, emollients, and cleansing agents, whereas the astringents, irritants, rubefacients, and kera-tolytic agents are the ones which act by chemical means.

Decreased innate immune response

Using electron microscopy, Morishita et al18 found colonies of S. aureus distributed on the surface of the epidermis as well as growing between layers of ker-atinocytes. This study suggests that an exponential increase in S. aureus could result from failure of the innate immune response to restrict the growth of microorganisms. Indeed, a direct comparison of AD and psoriasis showed that about 30 of AD patients suffered from infections whereas only 6.7 of psoriasis patients had this complication,19 despite the fact that both skin diseases have defective skin barrier function.20 It has been speculated that the reduced prevalence of infections in psoriasis may be associated with the increased production of antimicrobial peptides.21 Recently, we compared the expression of antimicrobial peptides in these two skin diseases to determine if the increased susceptibility to infection in AD is due to a deficiency in antimicrobial peptides.30 In this study, we compared the expression of HBD-2 and...

Patient Encounter Part 5

There are several natural health products which are considered possibly effective for psoriasis. The most promising is Mahonia aquifolium (Oregon grape). This is not a grape, but a plant with blue-violet berries which is native to southern British Columbia, western Oregon and northern Idaho, and is the state flower of Oregon. An extract from the medicinal part of the plant, the rhisome and root, has been formulated into a 10 topical cream lotion (Relieva, Apollo Pharmaceuticals) and is marketed in Canada for the treatment of psoriasis. This product has been shown in several recent clinical trials to modestly decrease the severity of psoriasis and improve the quality of life for patients with mild to moderate psoriasis.4 Preliminary research suggests that it is as effective as calcipotriene cream for some patients.49 Adverse effects include a burning sensation, irritation, redness and itching, and possible allergic reactions. Other natural health products which are possibly effective...

Oncology and Photosensitizers

Investigations on the photosensitized reactions in medicine, particularly in photodynamic therapy, havebeen of considerable interest in recent years. Intensive research efforts are being made currently to the study of photosensitized reactions in medicine, particularly in photodynamic therapy of tumors. Photodynamic therapy is a common treatment for cancer and various pathologies such as psoriasis. These treatments rely on the administration of pho-tosensitizer and the irradiation of the zone treated. In the photosensitized reactions, the photosensitizer is excited by absorbed light and undergoes intersystem crossing to triplet state from which it either reacts with the nearby molecules or produces cytotoxic oxygen derivatives, such as singlet oxygen or superoxide anion. The drugs used for photosensitization processes must show very low fluorescent quantum yield and nonradiative decays with very high efficiency. In this sense, PAS is an excellent tool for studying the photophysical...

Topical Corticosteroids

The duration of therapy is usually the time required for resolution of symptoms or lesions. To avoid adverse effects, the highest-potency steroids should not be used for longer than 2 to 4 weeks continuously. However, these can be used intermittently for chronic conditions such as psoriasis in a pulse-therapy mode (e.g., apply every weekend, with steroid-sparing medication on weekdays). For conditions with dry skin, liberal use of emollients between steroid applications can minimize steroid exposure while maximizing the benefits of therapy.

Phase I And Phase Ii Studies

The ordered development of treatment modalities according to well-identifiable phases29 is the exception rather than the rule in dermatology. There are several reasons for this situation. Many treatments are non-pharmacological interventions (e.g., ultraviolet phototherapy) which do not need to comply with the regulatory requirements for drug development, and there are no strict guidelines on how to assess them at an early clinical phase. Secondly, in spite of being so common, the resources allocated to the study of skin disorders are limited as compared with other clinical areas. As a consequence, our understanding of pathomechanisms is limited, as it is the development of disease-specific therapy. Until the causation of the main skin disorders is unravelled, disparate therapies with imprecisely defined biological activities will continue to be available and many treatments will enter the therapeutic arena serendipitously. It was the case of a renal-transplant recipient with...

Intimal Capillaries Potential Routes For Inflammatory Cell Entry Into Lesions

Decades of research have led to the recognition of atherosclerosis as an inflammatory disease (Ross 1999). Angiogenesis and inflammation are independent processes but are closely related in biologic processes such as wound healing and response to injury. Pathologic neovascularization accompanies chronic inflammation in psoriasis, synovial pannus formation in rheumatoid arthritis, and chronic granulomatous diseases (Folkman 1995). In acute inflammation, microvessels dilate and increase their permeability. In chronic inflammation, neo-vascularization is the prominent vascular response and may function to sustain it (Folkman and Brem 1992). Chronic inflammation of large blood vessels affected by vasculitis or atherosclerosis show intimal neovasculariza-tion in regions that are rich with inflammatory cells (O'Brien et al. 1996 Kaiser et al. 1999). Several types of leukocytes, including macrophages, T cells, and mast cells, have been shown to activate angiogenesis (Polverini et al. 1977...

Ankylosing Spondylitis

Ankylosing spondylitis (AS) is one of the group of seronegative forms of arthritis, which also includes Reiter's syndrome and psoriatic arthritis. There is a close association with the HLA-B27 type, and the disease is more than three times more common in men than in women. In many patients, the disease seems to progress slowly for years, primarily with back pain, and then stabilizes without much disability. In some cases the disease progresses to total spinal fusion, producing a typical bamboo spine on x-ray criteria. In all patients, the presence of sacroiliac joint disease on radiographs is required to make the diagnosis. There are two major neurological complications of AS a cauda equina syndrome of unclear etiology, and several types of cervical spinal cord compression due to dislocation or deformity.

Autonomic Dysfunction Secondary to Focal Central Nervous System Disease

Vasomotor disorders in the limbs include Raynaud's phenomenon, acrocyanosis, livedo reticularis, vasomotor paralysis, and erythromelalgia. Raynaud's phenomenon is the episodic, bilateral, symmetrical change in skin color (pallor, followed by cyanosis and terminating in rubor after rewarming) that is provoked by cold or emotional stimuli. This response is due to episodic closure of the digital arteries. There is, however, no consistent evidence of exaggerated sympathetic outflow to the skin. Raynaud's phenomenon may be associated with connective tissue disease (e.g., scleroderma, rheumatoid arthritis, psoriasis), occupational trauma (such as the use of pneumatic hammers, chain saws producing vibration), the thoracic outlet syndrome, the carpal tunnel syndrome, or certain drugs (e.g., beta blockers, ergot alkaloids, methysergide, vinblastine, bleomycin, amphetamines, bromocriptine, and cyclosporine). y

Table 43 Causes and associations of onychogryphosis Dermatological

What Causes Pincer Nails

Ichthyosis Psoriasis Onychomycosis Syphilis, pemphigus, variola Local causes positive, homogeneous, rounded or oval, amorphous masses surrounded by normal squamous cells which are usually separated from each other by empty spaces caused by the fixation process. These clumps, which coalesce and enlarge, have been described in psoriasis of the nail, onychomycosis, eczema and alopecia areata, and also in some hyperkeratotic processes such as subungual warts and pincer nails. The horny excrescences of the nail bed are not very obvious, but the ridged structure may become apparent if the nail plate is cut and shortened.

Parakeratosis pustulosa Hjorth Sabouraud syndrome

Parakeratosis Pustulosa

Histological findings are of some value, including hyperkeratosis and parakeratosis, pustulation and crusts, acanthosis and mild exocytosis, papillomatosis and heavy cellular infiltrates composed mainly of lymphocytes and fibroblasts around dilated capillary loops. This histological picture presents many of the features common to psoriasis and eczema. Pustules are rare and are only seen in the initial stage, unlike pustular psoriasis or acropustulosis. Patients with psoriasis develop a coarse sheet of scales and not the fine type of scaling typically seen in parakeratosis pustulosa.

Nummular Dermatitis Nummular Eczema

Nummular Eczema

Nummular dermatitis consists of well-demarcated, coin-shaped lesions of eczema, typically on the extremities and less often the trunk (Fig. 33-33). Nummular dermatitis tends to worsen in dry, cold weather. Lesions may be mildly to severely pruritic and as a result become excoriated or even lichenified with scratching. Nummular dermatitis can be confused with plaques of psoriasis or tinea corporis but skin scrapings will not reveal hyphae on KOH preparation. Also, lesions lack the typical central sparing of tinea corporis. If necessary, a biopsy can help differentiate nummular eczema from psoriasis.

Chronic Inflammatory Demyelinating Polyradiculoneuropathy

There is no conclusive evidence that CIDP patients have a higher incidence of other medical conditions, including autoimmune disorders. However, associated disorders, including systemic lupus erythematosus, Hashimoto's thyroiditis, thyrotoxicosis, chronic active hepatitis, inflammatory bowel disease, urticaria, eczema, and psoriasis do occur in some CIDP patients.y A CIDP-like disorder may occur in the setting of monoclonal gammopathies of uncertain significance (MGUS), as well as with multiple myeloma, osteosclerotic myeloma and other lymphoproliferative disorders. These disorders are discussed as distinct entities in the following sections.

Epidemiology and etiology

Psoriasis is a common inflammatory, skin disorder which is estimated to affect 1.5 to 3 of the Caucasian population. ,2 It may present at any age.3,4 Ethnic factors influence disease prevalence. In the United States, prevalence among blacks (0.45 to 0.7 ) is lower than in the remainder of the U.S. population (1.4 to 4.6 ).1 Between 10 and 30 of patients with psoriasis will also have psoriatic arthritis.5 In 10 to 15 of psoriatic patients with arthritis, joint symptoms actually appear prior to skin involvement.3 Our understanding about comorbidities associated with psoriasis is growing. Associated conditions include well known psychiatric psychological comorbidities such as depression, anxiety and poor self-esteem as well as more recently found medical comorbidities, such as inflammatory bowel disease, diabetes, cardiovascular disease, and lymphoma.6 In 2008 the National Psoriasis Foundation published a clinical consensus on psoriasis comorbidities and recommendations for screening,...

Disorders of the External Ear Otitis Externa

Other conditions that affect the external auditory canal include impacted cerumen, seborrheic dermatitis, psoriasis, contact dermatitis, and staphylococcal furunculosis. Symptoms and signs include pruritus, edema, scaling, crusting, oozing, and fissuring of the external auditory canal. Treatment of the underlying disease is the primary goal. Cortico-steroid preparations are indicated for seborrheic dermatitis, psoriasis, and contact dermatitis. Oral antibiotics and sometimes incision and drainage are required for staphylococcal furunculosis.

Psychosomatic aspects of atopic dermatitis

Significance Neurosecratory

Chronic skin diseases lead to severe psychosocial burdens that are quite frequently underestimated, since as a rule these diseases are not life-threatening.44 Specific dermatologic burdens are itching, and a visible impairment in the case of atopic eczema. The itching may be extensive, so that a reflexive scratching may be the case which then leads to a circulus vitiosus of tissue damage and subsequent itching. This itching-scratching circle is perceived as a loss of control and is often accompanied by extensive feelings of guilt. The visible skin alterations may be experienced as a stigma, which may contribute to a negative self-concept and to avoidance and social withdrawal to reduce the anxiety of being stigmatized by the social environment.45 The feeling of being stigmatized correlates with the extent of brooding, i.e. a strong inner preoccupation with the dermatosis.46 Women are more influenced by skin diseases than men patients with an atopic eczema or psoriasis had a more...

Patient Encounter Part 4

The patient's psoriatic condition remains well controlled with topical treatments for about 10 years, then flare-ups become a frequent occurrence. Phototherapy with NB-UVB was initiated. The patient did not respond well to NB-UVB therapy used alone. He is currently presenting with fairly extensive plaque psoriasis, affecting about two-thirds of his body surface area. There are signs of excoriation as well. Systemic Therapy for Psoriasis Systemic therapies are seldom used for mild to moderate psoriasis, and are generally reserved for patients with moderate to severe psoriasis. 15,26 Oral agents include sulfasalazine, acitretin, methotrexate, cyclo-spor-ine, mycophenolate mofetil, azathioprine, tacrolimus, and hydroxyurea. Parenteral agents include the BRMs alefacept, etanercept, infliximab, and many others, currently at various stages of research or approval for psoriasis. Rotational therapy (i.e., rotating systemic drug interventions in a sequential manner) is a means to minimize...

Generalized Exfoliative Dermatitis

Exfoliative Dermatitis

Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder defined as erythema and scale covering over 90 of the body surface area (Fig. 33-34). The four most common causes of erythroderma are psoriasis, AD, cutaneous T-cell lymphoma (CTCL), and drug reactions. More than 60 drugs have been implicated in cases of exfoliative dermatitis more often allopurinol, beta-lactam antibiotics, antiseizure medications, and sulfa drugs. More than half of patients will have a known underlying skin disease, but in up to 25 an etiology may never be determined and is termed idiopathic erythroderma. The majority of patients are adults over age 40. Figure 33-34 Erythroderma secondary to pustular psoriasis. Richard P. Usatine.)

Skin Disorders And Clinical Trial Methods Adapting Study Design To Setting And Disease

For quite different reasons, there are also common skin conditions where randomised clinical trials have been rarely performed. These conditions include several varieties of eczematous dermatitis (e.g., nummular eczema), psoriasis (e.g., guttate psoriasis) and urticaria (e.g., pressure urticaria), a number of exanthematic reactions (e.g., pytiriasis rosea), rosacea, and common Randomised clinical trials are usually designed in dermatology with an expected large effect from the test treatment and most trials do not recruit more than a few dozen patients. In small trials there may be substantial differences in group sizes that will reduce the precision of the estimated differences in treatment effect and hence the efficiency of the study. As a consequence, block randomisation may be preferable. On the other hand, a substantial imbalance may persist in prognostic characteristics, and minimisation can be used to make small groups more similar with respect to major prognostic variables.17...

BRM other agents Can also consider BRM earlier even as first line bul costly

Treatment algorithm for moderate to severe psoriasis. Pharmacologic Treatment Pharmacologic alternatives for psoriasis include topical agents, phototherapy, and systemic agents including the use ofBRMs. See Figures 64-1 and 64-2 for treatment algorithms. Topical Therapy for Psoriasis Topical therapy is the initial drug treatment strategy for patients with mild to moderate psoriasis. It is estimated that approximately 70 to 80 of all patients with psoriasis can be treated adequately with use of topical therapy.1 Topical therapies include corticos-teroids, coal tar products, anthral- Topical agents may be incorporated into various vehicles including ointments, creams, gels, lotions, foams, pastes, and shampoos. Ointments provide occlusion, which may increase drug penetration and enhance efficacy. Creams and lotions are easier to spread, especially in hairy areas. Gels may have drying and cooling effects in addition to easy spreadability. Foams may have enhanced delivery and...

Acrokeratosis paraneoplastica of Bazex and Dupre

Acrokeratosis Nails

Psoriasis-like Acrokeratosis paraneoplastica. Psoriasis-like Acrokeratosis paraneoplastica. The two extremes of the disease may coexist. In these cases, the proximal third of the nail is atrophic and the distal two-thirds exhibits hypertrophic changes. The histopathological changes are non-specific, although they do enable the exclusion of a diagnosis of psoriasis, lupus erythematosus or other similar eruptions.

Nail plate and soft tissue abnormalities

Soft Tissure Nail

In psoriasis (Figures 4.2-4.4) there is usually a yellow-red margin visible between the pink normal nail and the white separated area. In the 'oil spot' or 'salmon patch' variety, the separation between nail plate and nail bed may start in the middle of the nail this is sometimes surrounded by a yellow margin, inflammatory and eczematous diseases affecting the nail bed. Oil patches have been reported in systemic lupus erythematosus they may be extensive in lectitis purulenta et granulomatosa. especially in psoriasis. The accumulation of large amounts of serum-like exudate containing glycoprotein, in and under the affected nails, explains the colour change in this condition. Glycoprotein is also commonly found in Onycholysis due to psoriasis.

Core Elements of Integrative Medicine

Docosahexaenoic acid (DHA) and are mostly found in fatty fish, such as herring and salmon. Because inflammation plays a role in several common conditions, such as cardiovascular disease, asthma, arthritis, psoriasis, and inflammatory bowel disease, research has explored the role of omega-3 fatty acids in reducing symptoms and improving outcomes. Practical applications for recommending fish oil in the primary care setting included the following (Oh, 2005)

Parrot Beak Nails Raynauds

Plicatured Nail

Renal dialysis transplant thyroid disease Dermatoses alopecia areata Darier's disease lichen planus psoriasis 4 Some dermatological disorders, especially psoriasis, may also cause transverse overcurvature of the nails. Onychatrophy pustular psoriasis. Onychatrophy pustular psoriasis.

Evaluation of Joint and Other Musculoskeletal Symptoms

Musculoskeletal Scleroderma

The number of involved joints and presence or absence of symmetry are criteria for further diagnosis of articular pain (Figs. 32-1 and 32-2). Monoarticular (one joint) or oligoarticular (several joints) arthritides can be caused by conditions such as osteoarthritis (OA), gout, pseudogout, or septic arthritis. Asymmetric polyarthritis occurs in ankylosing spondylitis, psoriatic arthritis, Reiter's disease, and spondyloarthropathies. Symmetric arthritis, meaning that the same joint is affected on the contralateral side but not necessarily to the same degree, is characteristic of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjogren's syndrome, polymyositis, and scleroderma. Fibromyalgia, reflex sympathetic dystrophy, and predominantly psychological

Define ankylosing spondylitis

Ankylosing Spondylitis Ray

B, Lateral radiograph of the thoracic spine in the same patient reveals the bamboo spine appearance owing to ossification of the outer fibers of the annulus fibrosus and resultant fusion of the thoracic spine. C, Grade 4 sacroiliitis (using the modified New York criteria) in a patient with ankylosing spondylitis. The radiograph readily demonstrates bilateral ankylosis of the sacroiliac joints. (From Bennett DL, Ohashi K, El-Khoury GY. Spondyloarthropathies Ankylosing spondylitis and psoriatic arthritis. Radiol Clin North Am 2004 42(1).)

Emergency Department Treatment and Disposition

Generalized Pustular Psoriasis Criteria

Emergency department treatment should ensure no other infectious etiology or systemic symptoms. Pustular forms may need admission to exclude an infectious etiology. Guttate psoriasis responds to amoxicillin, clindamycin, or macrolide antibiotics. Obtain emergent consultation with a dermatologist for patients with generalized presentations and referrals for localized disease. Psoriasis. Note the erythematous plaques with diffuse fissuring in this case of palmar psoriasis. (Photo contributor J. Matthew Hardin, MD.) Psoriasis. Well-defined lesions of chronic plaque psoriasis. (Photo contributor R. Jason Thurman, MD.)

Pathogenesis of eczema herpeticum

A patient's ability to defend himself against HSV infection may critically depend on the production of antiviral type-I interferons. Plasmocytoid dendritic cells (PDC) are a novel dendritic cell subset that circulate in the blood and make up 0.1 of peripheral blood mononuclear cells.31 As PDCs produce a large amounts of antiviral type I interferon (IFN)-a and IFN-P upon viral infection and are capable of inducing both Th1 and Th2 responses, their presence seems most important for the susceptibility of patients to viral skin infections. We demonstrated recently that AD patients have an impaired recruitment of PDC into their skin lesions as compared with other inflammatory skin diseases such as psoriasis or contact dermatitis, which provides a rationale why patients with AD show a predisposition to viral skin infections.32

Seals of Excavated Tombs

In places where there is too much light (chhing, clear) water, disease of the scalp (thu alopecia, ringworm, psoriasis, etc.) and goitre (ying) are commonly found. In places where there is too much heavy (chung, turbid) water, people suffering from swellings and oedematous ulcers of the lower leg (thung1) are commonly found and there are many seriously affected who are unable to walk at all (pi). Where sweet (kan) water abounds, men and women will be health y and handsome. Where acrid (hsin) water abounds there will be many skin lesions, such as abscesses (chii) and smaller boils (iso) where bitter (khu) water abounds there will be many people with bent bones (wang yii).

Large Number Of Different Skin Diseases

Have an impact in terms of physical disability or even mortality, are rare or very rare. They include, among others, autoimmune bullous diseases, such as pemphigus, severe pustular and erythrodermic psoriasis, generalised eczematous reactions, and such malignant tumours as malignant melanoma and lymphoma. The disease frequency may show variations according to age, sex and geographic area. Eczema is common at any age while acne is decidedly more frequent among male adolescents. Skin tumours are particularly frequent in aged white populations. Infestations and infections such as scabies, pyoderma and dermato-phytosis predominate in developing countries and some urban pockets of developed countries. In many cases, skin diseases are minor health problems, which may be trivialised in comparison with other more serious medical conditions. However, as mentioned above, skin manifestations are visible and may cause more distress to the public than more serious medical problems. The issue is...

LeCouter R Lin and N Ferrara

The cardiovascular system is the first organ system to develop and reach a functional state in an embryo (Hamilton et al. 1962). The initial steps in blood vessel development consist of vasculogenesis, the differentiation of endothelial cell precursors, the angioblasts, from the hemangioblasts (Risau and Flamme 1995). The juvenile vascular system evolves from the primary capillary plexus by subsequent pruning and reorganization of endothelial cells in a process called angiogenesis (Risau 1997). More recent evidence suggests that incorporation of bone-marrow-derived endothelial precursor cells contributes to the growing vessels, complementing the sprouting of resident endothelial cells (Asahara et al. 1997 Rafii et al. 2002). The development of a vascular supply is also essential in the adult for wound healing and reproductive functions (Folkman 1995). In addition, angiogenesis is implicated in the pathogenesis of a variety of proliferative disorders age-related macular degeneration,...

Pharmacologic Interventions

Targeted pharmacologic therapy against specific mechanisms of toxicity is currently being piloted. For instance, radiation therapy may induce release of inflammatory cytokines that cause more widespread brain injury. Cytokine antagonists such as the recombinant soluble human TNF receptor (p75)-Fc fusion protein (etanercept) have been used successfully to treat TNF-a-mediated diseases, including rheumatoid arthritis, Crohn's disease, and psoriasis. One study found a significant improvement in symptoms related to myelofibrosis with myeloid metaplasia (MMM), another TNF-a-mediated disease that causes night sweats, severe fatigue, fever, and weight loss. Although objective responses (e.g., increased hemoglobin, transfusion independence) occurred in only 20 of patients treated with etanercept, 60 percent of the patients had improved constitutional symptoms, including cessation of night sweats, weight gain, and improved energy.16

Treatment of the Underlying Cause of Sperm Oxidative Stress

While as yet untested by clinical trials, the effective treatment of systemic diseases linked with oxidative stress (diabetes, Hepatitis B C, HIV, malaria, haemo-chromatosis, haemoglobinopathies, inflammatory bowel disease, psoriasis, rheumatoid arthritis, depression) is likely to reduce overall oxidative stress in the body and benefit sperm function. It is therefore ideal that patients delay conception until after these systemic diseases are under effective control, unless the medications used to achieve control have a detrimental effect on sperm function (e.g. meth-otrexate treatment of inflammatory conditions).

Upon completion of this chapter the reader will be able to

Discuss the etiology of psoriasis including genetic and immune changes. 2. Describe the pathophysiology of psoriasis including the types of psoriasis and clinical presentations. 3. Describe the comorbidities and risks in patients with psoriasis. 4. Compare and contrast the treatment modalities for psoriasis, that is, topical therapies, systemic therapies including biologics, and phototherapies. 5. Recommend an appropriate treatment plan for a patient with psoriasis. 6. Recommend appropriate monitoring parameters for a patient with psoriasis. 7. Provide appropriate counseling information to a patient with psoriasis.

Treatment Desired Outcomes and Goals

Since psoriasis is a chronic illness with no known cure, the goals of treatment focus on controlling the signs and symptoms of disease, including Minimizing or eliminating the signs of psoriasis such as plaques and scales. Ensuring appropriate treatment of associated conditions such as psoriatic arthritis, clinical depression, or itching.

History and Geography

In contrast to ancient Chinese texts of approximately the same period, in which leprosy destroying the center of the face is well described, the clinical evidence for leprosy in the ancient Mediterranean is meager. Nowhere in the Biblical tradition is there more than a general description of the disease that created such a severe response. Hippocratic texts provide no evidence that true leprosy existed in ancient Greece, but the Hippocratic, Greek word lepra, probably describing psoriasis, gave origin to the disease's name. Thus a coherent and powerful tradition in the West stigmatizing the leper was begun in what appears to have been the absence of any organized and reasonably accurate medical description of how these sufferers could be identified. Indeed, the earliest clinical description of leprosy in the West appears neither in the Hippocratic corpus (written in Greek between 400 and 100 B.C.) nor in the 20 surviving volumes of the works of the great second-century Greek...

Clinical Manifestations and Pathology

There is no chancre, and the condition begins as an extragenital papule, usually situated in the lower extremity (and perhaps associated with damage to the skin surface). Within 3 weeks, the papule has expanded into a reactive patch of circinate form, termed a pintid. In the next few months, a more general rash occurs on the face and limbs, which can be similar in appearance to such diseases as psoriasis, ringworm, and eczema.

Roseola Infantum Exanthem Subitum Clinical Summary

This is followed by defervescence and the appearance of the typical exanthem which is composed of erythematous macules and papules on the trunk, neck, proximal extremities, and occasionally the face. The rash fades in a few days. The causative agent in most cases is human herpesvirus 6 (HHV-6). The differential diagnosis includes common viruses such as measles, rubella, parvovirus B19, or infectious mononucleosis. Bacterial infections (eg, scarlet fever), drug reactions, and other skin conditions such as guttate psoriasis, papular urticaria, and erythema multiforme are also included in the differential.

Naturopathic Funcitioanl Testing For Atopic Eczema References

Nomura I, Goleva E, Howell MD, Hamid QA et al. Cytokine mileu of atopic dermatitis, as compared to psoriasis, skin prevents induction of innate immune response genes. J Immunol 2003 171(6) 3262-9. 31. Giustizieri ML, Mascia F, Frezzolini A et al. Keratinocytes from patients with atopic dermatitis and psoriasis show a distinct chemokine production profile in response to T-cell derived cytokines. J Allergy Clin Immunol 2001 107 871-7.

Extracellular Membrane Protein TenascinC

Tenascin-C (TN-C) is a large, extracellular matrix glycoprotein that is overex-pressed during tissue remodeling such as wound healing, atherosclerosis, psoriasis, and tumor growth (Erickson and Bourdon, 1989 Jahkola et al., 1998). Furthermore, TN-C levels predict local tumor recurrence and correlate with invasiveness and metastasis (Jahkola et al., 1998). In order to isolate oligonucleotide that can target anticancer drug delivery, a 2'-fluoropyrimidine-modified RNA selection isolated ligands that bound to recombinant TN-C (Hicke et al., 2001). Eight rounds of selection improved the affinity of the pool to Kd of 3 nmol L, 1000-fold greater than the starting library. TTA1 is a truncated version of an aptamer with a Kd of 5 nmol L, which was a modest 5 -fold decrease in affinity compared with the full-length ligand (Hicke et al., 2001). The TN-C aptamer is currently being developed for tumor imaging applications (Hicke and Stephens, 2000).

Coloured lines

Multiple Normal increase with age after early adulthood (Figures 3.1, 3.3, 3.4) With all causes of thin nail plates Lichen planus (Figure 3.5) Rheumatoid arthritis Graft-versus-host disease Psoriasis Darier's disease Poor circulation Collagen vascular diseases Radiation Frostbite Alopecia areata Nail-patella syndrome _Systemic amyloidosis_

Figure 328

It has been shown that regular pitting may convert to rippling or ridging, and these two conditions appear, at times, to be variants of uniform pitting (Figures 3.26-3.28). Nails showing diffuse pitting grow faster than the apparently normal nails in psoriasis. Occasional pits occur on normal nails. Deep pits can be attributed to psoriasis, and profuse pitting is most often due to this condition (Figures 3.29, 3.30). In alopecia areata (Figure 3.31) shallow pits are usually seen and they are often numerous, leading to trachyonychia (rough nail) and twenty-nail dystrophy however, curiously, one nail often remains unaffected for a long time, Pits may also occur in eczema or occupational trauma. In some cases a genetic basis is thought likely. In secondary syphilis and pityriasis rosea pitting occurs rarely. One case of the latter has been observed with the pits distributed on all the finger nails at corresponding levels, analogous to Beau's lines.

Superantigens

The majority of AD patients have S. aureus cultured from their skin that secrete superantigens such as enterotoxins A, B, and toxic shock syndrome toxin-1 (TSST-1).31'34'35 An analysis of the peripheral blood skin homing T cells expressing cutaneous lymphoid antigen (CLA) from these patients as well as their skin lesions reveals that they have undergone a T cell receptor V-beta expansion within both their CD4+ T cells and their CD8+ T cells indicative of superantigen stimulation.36,37 TCR V-beta skewing was not present within the CLA T cell subsets of patients with plaque psoriasis or normal controls. TCR BV genes from the presumptively super-antigen-expanded populations of skin homing T cells were cloned and sequenced from AD subjects, and consistent with a superantigen-driven effect, were found to be polyclonal.

Clinical Summary

Erythema infectiosum is a viral infection caused by parvovirus B19 presenting most commonly between 4 and 10 years of age. It is characterized initially by bright red macular erythema of the cheeks with sparing of the nasal ridge and perioral areas followed by an erythematous maculopapular eruption on the extensor surfaces of extremities that evolves with central clearing into a reticulated, lacy pattern. It may present with low-grade fever, malaise, sore throat, arthritis, or arthralgias. The differential diagnosis includes morbilliform eruptions caused by viruses such as measles, rubella, roseola, and infectious mononucleosis. Bacterial infections (eg, scarlet fever), drug reactions, and other skin conditions such as guttate psoriasis, papular urticaria, atopic dermatitis, and erythema multiforme are also included in the differential.

Arsenic

Historically, arsenic compounds were commonly used as medications for various disorders such as syphilis, acne, malaria, and anaemia. In addition, arsenic has been used as a poison since the 15th century and was considered the 'perfect poison' because it is odourless, tasteless, and resembles sugar. Fowler's solution of 1 potassium arsenite was used for over 150 years for the treatment of various ailments, including psoriasis, rheumatism, asthma, cholera, and syphilis. Arsenicals are still used in the treatment of African trypanosomiasis (sleeping sickness) and in the treatment of rare forms of leukaemia. Some arsenic compounds may also be found in Chinese and Indian traditional medicines and rarely in some herbal preparations.

What Is Dermatology

Event occurring with conditions such as extensive bullous disorders or exfoliative dermatitis. The most usual health consequence of skin disorders is connected with the discomfort of symptoms, such as itching and burning or pain, which frequently accompany skin lesions and interfere with everyday life and sleeping. Moreover, visible lesions may result in a loss of confidence and disrupt social relations. Feelings of stigmatisation and major changes in lifestyle caused by a chronic skin disorder such as psoriasis have been repeatedly documented in population surveys.1 Additional problems may arise under diverse circumstances the exudation or loss of substances that interfere locally with the barrier function (and dressing) the shedding of scales whenever excessive desquamation occurs the need to prevent contact dissemination in the case of transmissible diseases.

Tinea Cruris

In addition to topical antifungals, treatment can include a low-dose corticosteroid for the first few days to reduce the inflammation of the involved skin. Oral antifungal therapy is needed if the tinea cruris has spread beyond the groin (Fig. 33-47). Inverse psoriasis may be mistaken for tinea cruris and will not respond to antifungal treatment (Fig. 33-48). The fungicidal allylamines naftifine and terbinafine and the allyl-amine derivative butenafine are more costly topical tinea treatments but allow for a shorter duration of treatment compared with fungistatic azoles (clotrimazole, econazole, ketoconazole, oxiconazole, miconazole, sulconazole) (Nadalo et al., 2006).

Phase Iii Trials

It has already been mentioned that one of the main concerns of patients suffering from a skin disorder is the visibility of lesions and, much more than in other areas, the patient self-monitors his her disease. Patients' motivations and previous experience are obvious crucial points when entering a trial. Motivations and expectations are likely to influence clinical outcome of all treatments, but they may have a more crucial role in situations where 'soft end points' are of concern as in dermatology. Commonly, more than 20 of the patients entering randomised clinical trials of psoriasis experience improvement on placebo independently of the initial disease extension. Motivations are equally important in pragmatic trials where different packages of management are evaluated, such as in the comparison of a self-administered topical product for psoriasis with hospital-based therapy like phototherapy. Traditionally, motivation is seen as a characteristic of the patient that is assumed not...

Other Issues

The most precise definition of the profile of an intervention requires a perspective on the risks and benefits, which is wider than the one usually provided by any single RCT. For many chronic skin diseases, efficacy data are derived from short-term RCTs, whereas patients tend to be treated over years. The main issues of safety and long-term effectiveness are usually addressed in the context of observational studies, i.e., phase IV studies. One of the best examples of such a study is the PUVA follow-up study, a cohort study of more than 1400 patients who had received a first course of PUVA-treatment in 1977. These patients are still being followed up and provide information on disease associations and prognostic factors. The study pointed to a dose-related increased risk of non-melanoma skin cancer in PUVA-treated patients. We lack similar studies for many other systemic treatments of psoriasis, including methotrexate, retinoids and cyclosporine. The safety profiles of most systemic...

Light Therapy

However, many claims are made for light therapy as an alternative healing method for conditions other than seasonal affective disorder (SAD). In alternative light therapy, various types of light from different sources are prescribed inappropriately to treat many diagnoses. Types of light include full-spectrum or natural sunlight, bright-light therapy, UV light, colored-light therapy, and various laser therapies. Advocates claim they can treat many maladies, including bulimia, psoriasis, symptoms of AIDS, and even breast, rectal and colon cancers. These claims are false they do not even appear to be logical. Light therapy should never be used instead of mainstream treatment for these or any other medical illness. Examples of these therapies and their false claims are described below.

Chelation Therapy

Some practitioners, however, claim that chelation can treat illnesses and problems other than metal toxicity. Coronary artery disease is primary among these illnesses. Based on the idea that chelation chemicals may remove harmful plaque from the arteries, it is promoted as an alternative to coronary bypass surgery and angioplasty. Chelation is advertised also as a treatment for thyroid disorders, multiple sclerosis, muscular dystrophy, high cholesterol, psoriasis, hypercalcemia, hardening of the arteries, cancer, Alzheimer's disease, and many other disorders.

Nail abrasion

Thick nails caused by diseases such as psoriasis, pityriasis rubra pilaris and pachyonychia congenita can be abraded. Hyperkeratosis is prone to be associated with onychomycosis of the toes. Nail abrasion helps to expose the nail bed to antifungal chemicals, especially in elderly people in whom systemic treatment is not advisable. Abrasion is a good way to improve the contour of an abnormal nail, for example in onychogryphosis. In selected cases of ingrowing toe nail, repeated thinning of the nail plate may be a useful conservative method in association with appropriate definitive treatment.

Lichen Planus

10mg ml represent a possible, but painful, alternative when the disease is limited to a few finger nails. Mild relapses are frequently observed, but recurrences are usually responsive to therapy. Steroid treatment is not useful in pterygium, since the nail matrix cannot be regenerated. Systemic retinoids at dosages suitable for psoriasis are a good alternative.

Combination Products

Male genital herpes (A) Psoriasis (A) Radiation dermatitis Seborrheic dermatitis (A) Atopic dermatitis (A) Cyclic mastalgia Diabetic neuropathy Menopause PMS Psoriasis Schizophrenia Psoriasis (topicals) (A) Testosterone level increase (-) Psoriasis (boric acid ointment) (-Vaginitis (boric acid)

Onychomycosis

Fungal infections of the nail organ are the most common nail disorders. Even though they are usually easily diagnosable they may be indistinguishable from nail psoriasis and the conditions may in fact occur together. To diagnose distal and distal lateral subungual onychomycosis, either nail clippings with adherent subungual hyperkeratosis or a nail biopsy are necessary. Clipped material shows variable amounts of irregular masses of hyphae and often also thick-walled arthrospores. In addition, the subungual keratotic material may contain small, dried neutrophilic abscesses and serum globules that are also PAS positive and may be mistaken for fungal elements if very small. Nail biopsies reveal important pathological alterations of the nail bed and matrix with subepithelial lymphocytic infiltrates, spongiosis, lymphocytic exocytosis and intraepithelial neutrophils, which often form Munro's micro-abscesses in the keratin just beneath the nail plate. If there are only few fungi the wrong...

Initial Evaluation

Trichophyton Mouth

Determine which parts of the skin are affected and which are spared. Be sure to look at the remainder of the skin, nails, hair, and mucous membranes. Patients often show only one small area and appear reluctant to expose the rest of their skin, especially their feet. With many skin conditions, it is essential to look beyond the most affected area because other areas may provide important clues (e.g., nail pitting when considering psoriasis). Patients may have lesions on their back or feet that they have not observed. For example, a patient may have a papular eruption on the hands or arms that represents an autosensitization reaction (id reaction) to a fungal infection on the feet not looking for the fungus on the feet will lead to a missed diagnosis (Figs. 33-1 and 33-2). Some skin diseases have manifestations in the Family history acne, atopic dermatitis, psoriasis, skin cancers, dysplastic nevi

Arthritis

A second general category of arthritis is that of the inflammatory erosive joint diseases. This category includes such syndromes as Reither's syndrome, psoriatic arthritis, and three that are examined in this paper rheumatoid arthritis, ankylosing spondylitis, and gout. Some syndromes of inflammatory erosive joint disease have a known association with bacterial infection of the bowel or genitourinary track. Lyme disease, for example, is initiated by a tick bite that introduces a bacteria (spirochete) into the host. If untreated, the disease produces severe erosive joint destruction in some patients. The prevailing theory is that other erosive arthropathies are probably initiated by infectious agents as well. Inflammatory erosive joint disease occurs in some people when an infectious triggering agent operates in combination with an individual's defective immune response. The major problem in inflammatory erosive joint disease is that the immune response to the infectious agent is not...

Cutaneous diseases

Nail Diseases And Disorders Chart

Psoriasis, Reiter's disease, vesicular or bullous disease, lichen planus, alopecia areata, multicentric reticulohistiocytosis Table 4.1 lists many potential causes of onycholysis. The most common types presenting to dermatologists are due to psoriasis, onychomycosis and the cosmetic 'sculptured' varieties of adult women. Onychomadesis due to psoriasis. Onychomadesis due to psoriasis. Nail shedding due to pustular psoriasis.

Common

Angina Objawy Dziecka

Psoriasis (Figures 3.26, 3.27, 3.29, 3.30) Alopecia areata (Figure 3.31) Eczema Large, deep and irregular pits are common in psoriasis and eczema Multiple nail pits due to psoriasis. Diffuse pitting of the whole nail in psoriasis. The frequency of idiopathic trachyonychia is unknown, although it is certainly rare, more commonly but not exclusively seen in children. Idiopathic trachyonychia may be a clinical manifestation of several nail diseases including lichen planus, psoriasis, eczema and pemphigus vulgaris. It may also represent a clinical variety of alopecia areata limited to the nails. Two clinical varieties of trachyonychia have been described opaque trachyonychia (Figure 3.35) and shiny trachyonychia (Figure 3.33). Both these varieties may occur in association with alopecia areata or may be idiopathic. Opaque trachyonychia is more common than the shiny type. Although trachyonychia is better known as twenty-nail dystrophy, the nail changes do not necessarily involve all nails...

Pruritus

Pruritus, or itching, is a common symptom. Generalized itching may be a symptom of a diffuse skin disorder* or a manifestation of chronic renal or hepatic disease. Intense pruritus may be associated with lymphoma or Hodgkin's disease, as well as with malignancies of the gastrointestinal tract. In older individuals, pruritus may also be caused by dry skin alone. Pruritus ani is localized itching of the anal skin. It has many causes, including fistulas, fissures, psoriasis, parasites, poor hygiene, and diabetes.

Genital Rashes

Rash Skin Penis

Figure 18-8 Psoriasis. The most common inflammatory reaction affecting the male genitalia is psoriasis. The patient develops bright red, well-defined, scaling plaques. Often the entire scrotum, inguinal folds, and penis are involved. Figure 18-8 shows psoriasis of the penis.

Natural History

In general, osteoarthritis is a progressive disease. Whereas disease modifying agents are currently employed in the treatment of gout, rheumatoid arthritis, and psoriatic arthritis, the treatment of osteoarthritis is primarily symptomatic. This treatment may be beneficial to most, but some patients still develop enough spinal degeneration to result in significant morbidity and disability. Decreased mobility coupled with deconditioning portends significant physical decline. Thus, while most patients will stabilize with current therapy, some patients will progress to developing significant pain, neurological deficit, and disability. These patients are the most likely to present to a spine surgeon for evaluation and treatment.

Topical

Although the topical delivery of aptamers has not been reported, there are several examples from the antisense field. Mehta and co-workers (2000) have investigated the local topical delivery of a 20-mer antisense phosphorothioate oligonucleotide that targets the transcript for ICAM-1. This oligonucleotide is being investigated as a potential treatment for psoriasis. In this study the oligonucleotide was formulated into a cream in which the oligonucleotide comprised 2 by mass and this was applied to human cadaver skin and compared with systemic intravenous dosing to SCID mice with human cadaver skin transplants. Additional experiments were performed with hairless mice without transplants. Histological and scintillation-counting approaches demonstrated that concentrations of oligonucleotide in the dermis were 3 mmol L and in the epidermis 230 mmol L after 24h when topically dosed at 0.5 mg cm2 in a 2mg mL (300 mmol L) cream. These concentrations were 4300- and 160-fold less than were...

Natural Treatments For Psoriasis

Natural Treatments For Psoriasis

Do You Suffer From the Itching and Scaling of Psoriasis? Or the Chronic Agony of Psoriatic Arthritis? If so you are not ALONE! A whopping three percent of the world’s populations suffer from either condition! An incredible 56 million working hours are lost every year by psoriasis sufferers according to the National Psoriasis Foundation.

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