Psoriasis Holistic Treatment

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...

Psoriasis Revolution Summary


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Joint disease in psoriasis

Patients with seronegative arthropathy of the non-rheumatoid type show double the normal (2 ) incidence of psoriasis. Psoriatic arthropathy commonly affects the distal interphalangeal joints, sparing the metacarpophalangeal joints, and is usually asymmetrical. Radiological changes include a destructive arthropathy with deformity. Rheumatoid nodules are absent. The sex ratio is equal but a few patients develop a rheumatoid-like arthropathy, which is more common in women than in men. A third rare group have arthritic changes in the larger joints, where there is considerable resorption of bone. Other members of the families of those with psoriatic arthropathy are affected in 40 of cases. There may be pustular psoriasis of the fingers and toes associated with arthropathy which can be sufficiently severe to immobilise the patient.

Treatment of psoriasis

To ignore the impact of the condition on the patient's life is to fail in treating psoriasis. Like the Cheshire cat that Alice met, it tends to clear slowly and the last remaining patches are often the hardest to clear. This is frustrating enough, but there is also the knowledge that it will probably recur and need further tedious courses of treatment, so encouragement and support are an essential part of treatment. In an attempt to quantify the impact of psoriasis on the life of the individual patient the Psoriasis Disability Index (PDI) has been developed. This takes the form of a questionnaire and covers all aspects of the patient's work, personal relationships, domestic situation, and recreational activities. It can be helpful in assessing the effectiveness of treatment as perceived by the patient. Patients understandably ask whether psoriasis can be cured and often want to know the cause. The cause is unknown and the best answer is that the tendency to develop psoriasis is part...


Since treatment of nail psoriasis is always disappointing, before treatment is started the individual problems of every patient should be carefully considered, and in particular the degree of discomfort that results from the nail lesions. Reassuring the patient is probably the best approach for isolated nail pitting, oily patches, mild onycholysis and splinter haemorrhages. However, diffuse onycholysis, subungual hyperkeratosis and severe nail plate surface abnormalities may require a positive therapeutic approach.

Causes of psoriasis

Mechanism Psoriasis

The cause is unknown but there is an inherited predisposition. The strong genetic influence may result from a single dominant gene with poor penetrance or a number of genetic influences. Other factors such as local trauma, general illness and stress are also involved, so the cause of psoriasis is best regarded as being multifactorial. HLA-Cw6 is the phenotype most strongly associated with psoriasis, particularly the early onset variety in which hereditary factors seem to play the greatest part. There is an increase in HLA expression in psoriatic arthropathy. Local trauma, acute illness, and stress may be factors in causing the appearance of clinical lesions. p Haemolytic streptococcal throat infection is a common precipitating factor in guttate psoriasis. Antimalarial drugs, lithium, and p blockers can make psoriasis worse. There is evidence that psoriasis occurs more readily and is more intractable in patients with a high intake of alcohol. Smoking is associated with palmo-plantar...

Assessment of the patient

As well as assessing the clinical changes, the effect of a skin condition on the patient's life and their attitude to it must always be taken into account. For example, severe pustular psoriasis of the hands can be devastating for a self employed electrician and total hair loss from the scalp very distressing for a 16 year old girl. Patients understandably ask whether psoriasis can be cured and often want to know the cause. The cause is unknown and the best answer is that the tendency to develop psoriasis is part of a person's constitution and some factor triggers the development of the clinical lesions. Known factors include physical or emotional stress, local trauma to the skin (Koebner's phenomenon), infection (in guttate psoriasis), drugs (P blockers, lithium, and antimalarial drugs). To illustrate the use of these basic concepts in the diagnosis of lesions in practice two common skin diseases are considered psoriasis, which affects 1-2 of the population, and eczema,, an even more...

Ultraviolet treatment phototherapy

Ultraviolet B is short wavelength ultraviolet light and is used for widespread thin lesions or guttate psoriasis. The dose has to be accurately controlled to give enough radiation to clear the skin without burning. Recently, narrow waveband ultraviolet B treatment has been developed, which increases the therapeutic effect and diminishes burning. It can be used instead of psoralen with ultraviolet A in many cases. After medical assessment treatment is given two or three times a week, with gradually increasing doses of ultraviolet A. Once the psoriasis has cleared maintenance treatments can be continued once every two or three weeks. Protective goggles are worn during treatment with ultraviolet A and dark glasses for 24 hours after each treatment. The glasses are tested for their effectiveness in screening ultraviolet A light. Guttate psoriasis suitable for ultraviolet B treatment Guttate psoriasis suitable for ultraviolet B treatment

Nail plate and soft tissue abnormalities

Lunula Dyschromias

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.

Physical signs in the nails

The changes in the nail may be due to a local disease process, a manifestation of a skin disease, or a systemic disorder. Hereditary disorders may also affect the nails. It is therefore important to take both a general history and specifically enquire about skin diseases. It sometimes happens that the nail changes are the only sign of a dermatological disease, although the patient may have a previous history of lichen planus or psoriasis, for example. Localised infection or trauma will affect one or two nails. Skin disease, such as psoriasis, affects many or all nails, usually symmetrically, whereas systemic illness or drugs will affect all the nails.

Late stage HIV disease

The skin changes are many and variable. Common inflammatory skin diseases such as psoriasis and seborrhoeic dermatitis will be much more florid. Cutaneous infections are more severe due to the impaired immune response and opportunistic infections also develop. In addition, Kaposi's sarcoma occurs in 34 of homosexual men and in 5 of other cases.

Differential Diagnosis

The clinical diagnosis of SCLE is not always obvious. Annular lesions can be confused with erythema annulare centrifugum, granuloma annulare, erythema gyratum repens, autoinvolutive photoexacerbated tinea corporis (Dauden et al. 2001), or EM. Papulosquamous lesions may be confused with photosensitive psoriasis, lichen planus, eczema, pitiryiasis rubra pilaris, disseminated superficial actinic porokeratosis, contact dermatitis, tinea faciei (Meymandi et al. 2003) and dermatomyositis. Lesional photodistribution, characteristic histopathology and Ro SS-A autoantibodies are useful in distinguishing SCLE from its differential diagnosis.

Skin diseases affecting the nails

Since the nail plate consists of specialised keratin produced by basal cells, it is not surprising that it is affected by skin diseases. Some conditions, such as psoriasis, may produce characteristic changes whereas in other conditions, such as eczema, the changes are much less specific. Psoriasis causes an accumulation of keratin, as in lesions of the skin. This may result in the nail being both thickened and raised from the nail bed (onycholysis). There may be the changes of pustular psoriasis in the surrounding tissues, indistinguishable from acrodermatitis pustulosa. Loss of minute plugs of abnormal keratin results in pitting .

Genetically complex disorders

It clusters in some families but does not follow a classical Mendelian pattern of inheritance. Environmental triggers are important, as well as genetic factors. Over the last few years, several wide scans of the genome have been undertaken with the aim of identifying the location of the genes that determine susceptibility to psoriasis. Five have been confirmed, all on different chromosomes, and now designated as Psorsl to Psors5. A further six loci may have similar effects, but the evidence for them is less strong. Psorsl, on chromosome 6p21.3, is an especially important gene for psoriasis susceptibility in many populations and lies within the area of the major histocompatibility complex (MHC). However it is not itself an HLA class 1 gene, and may belong to the newly described MHC class 1 chain-related (MIC) gene family. The possession of one allele (A5.1) of this gene seems to lead to a type of psoriasis that starts especially early, and is more common in...

Secondary Bacterial Infections Complication Skin Lesions

Diabetic foot infections are divided into non-limb-threatening and limb-threatening. Non-limb-threatening infections are superficial, lack systemic toxicity, have minimal cellulitis that extends 2 cm from port of entry, and if ulceration is present it does not extend through the skin, and does not show signs of ischemia. Limb-threatening infections are associated with ischemia, have more extensive cellulitis, lymphangitis is present, and the ulcers penetrate through the skin into the subcutaneous tissue. Epidermal cysts in the chest, trunk, extremities, and vulvovaginal and scrotal areas can also become severely infected (11). Other skin lesions that can be secondarily infected with bacteria are the following scabies (12), eczema herpeticum (13), psoriasis (14), poision ivy (15), diaper dermatitis (16), kerion (17), and atopic dermatitis (18).

Skin Anomalies Pathological Noninfective

PSORIASIS Psoriasis often affects the genital area and typically presents as a well-demarcated pink plaque. The glans penis is a common site, and psoriasis of the vulva can present as discomfort. Other mucosal sites are rarely affected. Because of the moist nature of the genitalia the scaly nature of psoriasis is not readily obvious in psoriasis of the genitalia compared with that of other parts of the body.

The management of skin conditions in general practice

One great advantage of general practice is that there is continuity of care and the family doctor has a much more complete overall picture of the patient, their family and social circumstances than can be acquired in a hospital consultation. Increasingly dressings and other treatments are being used by practice nurses in conjunction with the dermatology liaison nurse when necessary. This applies to inflammatory skin conditions such as psoriasis and eczema as well as leg ulcers, but also to conditions such as Darier's disease, dermatitis herpetiformis, and lupus erythematosus where regular supervision and blood tests may be required. There is no reason why continuing treatment with drugs such as ciclosporin and methotrexate cannot be carried out in general practice once the diagnosis and treatment regime have been established. Regular blood tests are mandatory when these drugs are being used.

Treatment of nail conditions

It is clearly not possible to treat congenital abnormalities of the nail, but avoiding exposure to trauma may help. Nail changes associated with dermatological conditions may improve as the skin elsewhere is treated. Systemic treatment of associated dermatoses will of course tend to improve the nail as well, for example methotrexate or retinoids for psoriasis.

Diabetic and Other Chronic Superficial Skin Ulcers and Subcutaneous Abscesses

Decubitus ulcers can be colonized and infected by a variety of aerobic and anaerobic bacteria. The distribution of organisms depends on the location of the ulcer. While GABHS and S. aureus can be isolated in all body sites, organisms of oral flora origin (Fusobacterium spp., pigmented Prevotella and Porphyromonas, and Peptostreptococcus spp.) can be isolated in ulcers and wounds proximal to that site, while organisms of colonic or vaginal flora origin (B. fragilis group, Clostridium spp., Peptostreptococcus spp., and Enterobacteriaceae) can be recovered from lesions proximal to the perianal area (28). This principle applies to recovery of organisms in other skin and soft tissue wounds and abscesses (28,29) secondarily infected wounds and skin lesions caused by scabies (12) superficial thrombophlebitis (30) decubitus ulcers (31) diaper dermatitis (16) atopic dermatitis (18) kerion lesions (17) secondarily infected eczema herpeticum (13), psoriasis lesions (14), and poison ivy (15)....

Mechanism Of Retinoid Action

Retinoids are a class of chemical compounds that include active metabolites of vitamin A (retinol) as well as a diverse array of synthetic derivatives. Vitamin A is required for normal embryonic development, epithelial homeostasis, maintainance of reproductive capacity, and functioning of the visual cycle (1). Additionally, retinoids have been shown to modulate a wide variety of cellular processes, including proliferation, differentiation, homeostasis, and malignant transformation (for reviews see refs. 2-5). Retinoids also act pharmacologically to restore regulation of differentiation and growth in certain prema-lignant and malignant cells in vitro and in vivo (6,7). Consequently, retinoids are under study as therapeutic and chemopreventive agents for a variety of cancers (see refs. 8-10 for reviews). Retinoids are also potent drugs for the treatment of severe cystic acne, psoriasis, and several other dermatologic disorders (11).

Expression Of Angiogenesis

An example of host factors regulating angiogenesis can be seen in psoriasis, a common inherited skin disease characterized by hyperproliferation of keratinocytes and excessive dermal angiogenesis. Keratinocyte conditioned media from symptomatic and psoriatic plaques induced a vigorous angiogenic response, but media conditioned from normal keratinocytes did not (61). Furthermore, keratinocytes from psoriatic skin expressed a 10- to 20-fold increased level of IL-8 and a sevenfold reduction of TSP-1. These data suggest that aberrant angiogenesis in psoriatic skin might be caused by the overproduction of the positive angiogenic molecule IL-8, and by the concomitant deficiency in the negative angiogenic molecule, TSP-1.

Changes In M0 Tsp1 Expression Levels Influence Tumor Neovascularization

Another piece of evidence linking a defect in the acquisition of the angioinhibitory activity by M0 to pathological angiogenesis in the skin disease psoriasis. Psoriasis is a chronic skin disease linked to both genetic and environmental triggering factors (72). It is characterized pathologically by excessive growth of epidermal keratinocytes, inflammation, and microvascular proliferation, which is believed to result from a disruption in the complex and reciprocal molecular crosstalk between activated keratinocytes and dermal cells (73). Several lines of evidence have implicated psoriatic keratinocytes, inflammatory M0, and dermal dendritic cells in the persistent vascular proliferation that accompanies this disease. Using fresh human psoriatic lesional tissue that was separated into epidermal and dermal components, the angiogenic potential of the lesion was found by two different groups to reside in both the dermal and the epidermal compartment (74-76). Psoriatic keratinocytes are...

Table 42 Causes and associations of nail shedding

Subungual Hyperkeratosis

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....

Table 43 Causes and associations of onychogryphosis Dermatological

Pityriasis Rubra Pilaris 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. Psoriasis Reiter's syndrome (Figures 4.14, 4.15) Onychomycosis (Figure 4.19) Pityriasis rubra pilaris (Figure 4.20) Pachyonychia congenita (Figures 4.21-4.23) Contact eczema Mineral oils Cement

Acrokeratosis paraneoplastica of Bazex and Dupre

Paraneoplasia Bazex

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.

Development duration and distribution

Several diseases may present with blisters or pustules. There is no common condition that can be used as a reference point with which less usual lesions can be compared in the same way as rashes can be compared with psoriasis. A different approach is needed for the assessment of blistering or pustular lesions, based on the history and appearance, and is summarised as the three Ds development, duration, and distribution.

Skin Disorders of the External Meatus

The three major dermatoses of the external ear are seborrheic dermatitis, eczema, and psoriasis. They have some overlapping characteristics and often affect the same areas, namely, the external canal, its meatus, and the concha. Sometimes adjacent regions, such as the lobule and postauricular areas, are affected. They seldom extend deeper than the outer one-third of the canal. Dermatologists refer to all three as the papulosquamous disorders. Patients afflicted with these disorders complain of itching and weeping of the external canal. Occasionally, there is pain if inflammation or superinfection is present.

Modalities That Escape Classification As Antipruritic Interventions

Propofol is an anesthetic with some anti-opiate activity. At subhypnotic doses, propofol was reported to ameliorate the pruritus of cholestasis in an open label study and in a double-blind cross-over placebo-controlled trial that included 10 patients. S-adenosylmethionine (SAMe) was reported to ameliorate the pruritus of cholestasis in a group of patients. It has antidepressant properties. If the antipruritic effect of SAMe is real, a central mood-enhancing effect of the drug, which may have an impact on how pruritus is experienced or may change the central component of pruritus, may play a role in the reported antipruritic actions. Phototherapy to the skin with ultraviolet (UV) light B is used by some clinicians. UV B treatment in erythemogenic doses is one of the treatments of psoriasis. There is no apparent rationale to use this intervention in the treatment of the pruritus of cholestasis. The effect of UV B treatment on this type of pruritus is highly questionable. It is not...

From Leprosy To Hansens Disease

Early Signs Leprosy

Medieval attitudes towards the leper were based on biblical passages pertaining to ''leprosy,'' a vague term applied to various chronic, progressive skin afflictions, from leprosy and vitiligo to psoriasis and skin cancer. The leper, according to medieval interpretations of the Bible, was ''unclean'' and, therefore, a dangerous source of physical and moral pollution. Biblical rules governing leprosy demanded that persons and things with suspicious signs of leprosy must be brought to the priests for examination. Leprosy was said to dwell not only in human beings, but also in garments of wool or linen, objects made of skins, and even in houses. Diagnostic signs included a scaly eruption, boil, scab, or bright spot. When the signs were ambiguous, the priest shut the suspect away for as long as two weeks for further observations. When a final judgment had been reached, the leper was instructed to dwell in isolation and call out as a warning to those who might approach him, ''unclean,...

Skin disease involving the scalp

Tinea Barbae Characteristics

The scalp can be involved in any skin disease, but most commonly in psoriasis and seborrhoeic eczema. A mild degree of scaling from accumulation in skin scales is so common as to be normal (dandruff). Increased accumulation of scales is seen in seborrhoeic dermatitis in which pityrosporum organisms may play a part. Sometimes masses of thick adherent scales develop in pityriasis amiantacea, usually due to psoriasis. Eczema and contact dermatitis can also involve the scalp. Folliculitis decalvans Tinea capitis

Role of Lselectin in disease

In addition to cell-surface adhesion molecules, the soluble forms of these molecules have been receiving an increasing amount of attention. While soluble adhesion molecules have been used successfully as markers of inflammation or disease activity, their role in physiological processes must also be considered (reviewed in 252 ). Specifically, significantly increased levels of sL-selectin have been reported to be associated with a number of different disease conditions including chronic myeloid and lymphocytic leukemia 253-255 , sepsis 19, 256 , HIV infection 19 , atopic dermatitis 257 , psoriasis 258 , and lupus 259 . As discussed above, since sL-selectin retains functional activity, these increased levels may have important physiological effects on leukocyte migration in these patients. In fact, higher levels of sL-selectin in acute myeloid leukemia patients at the time of diagnosis correlated with decreased probability of achieving complete remission, shorter event-free survival,...

Localised lesions with epidermal changes

Psoriasis, seborrhoeic dermatitis, atopic eczema, and contact dermatitis can all present with localised lesions. Psoriasis may affect only the flexures, occur as a genital lesion, or affect only the palms. The lack of itching and epidermal changes with a sharp edge help in differentiation from infective or infiltrative lesions. Apart from athlete's foot, toenail infections, and tinea cruris (most commonly in men), ringworm is in fact not as common as is supposed. The damp, soggy, itching skin of athlete's foot is well known. An itching, red diffuse rash in the groin differentiates tinea cruris from psoriasis. However, erythrasma, a bacterial infection, may be confused with seborrhoeic dermatitis and psoriasis skin scrapings can be taken for culture of Corynebacterium minutissimum or, more simply, coral pink fluorescence shown with Wood's light. The scaling macules from dog and cat ringworm (Microsporum canis) itch greatly, whereas the indurated pustular, boggy lesion (kerion) of...

Mechanisms of Peripheral Tolerance

The most important counterpart of 'type 1' immune responses are 'type 2' responses. They are induced by CD4+ T cells capable of producing IL-4 and IL-13. These two cytokines seem to suppress multiple pro-inflammatory effector functions by macrophages, such as production of tumor necrosis factor (TNF). Th2 cells are primarily known by their capacity to switch the immunoglobu-lin isotype of human B cells towards IgE and probably also IgG4 (Mosmann and Coffman 1989). Thus, Th2 cells do not generally extinct immune responses. They may even induce autoimmune responses and probably also autoimmune disease, such as pemphigus vulgaris, which is associated with autoantibodies of the IgG4 isotype and little local inflammation (Goldman et al. 1991 Hertl et al. 1998). However, when directed against epitopes that are associated with type 1-mediated inflammatory autoimmune disease, type 2 immune responses may exert anti-inflammatory, protective effects. Treating Th1 mediated diseases with Th2 cells...

Breaking T and B Cell Tolerance

These data suggest that immunization against antigens that are structurally related to self-antigens are essential for the induction of autoimmunity. This concept is further supported by functional and structural analysis of T cell epitopes of infectious agents and potential self-antigens. Chlamydia peptides can share functional similarities with peptides expressed by mammalian heart muscle, while other infectious agents share important peptide sequences with potential self-antigens such as myelin basic protein. This aspect is especially significant since molecular mimicry does not require molecular identity. Studies with altered peptide ligands have shown that induction of cytokine production or T cell proliferation requires only poor structural relation as long as important anchor positions are conserved (Gautam et al. 1994 Wucherpfennig and Strominger 1995). Various examples suggest that this may be of relevance for autoimmune diseases of the skin. Thus, the first eruption of the...

Clinical presentation

Erysipelas is the local manifestation of a Group A streptococcal infection, in the case illustrated the infection is confined to deep dermis as a form of cellulitis. However the same organism at distal sites, through the production of toxins or superantigens, can cause other skin lesions such as (a) the rash of scarlet fever (b) erythema nodosum (c) guttate psoriasis and (d) an acute generalised vasculitis.

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.

Figure 330

Selective Immunoglobulin Deficiency

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 in every patient (Figure 3.35). It is a symptom that may be caused by several inflammatory diseases that disturb nail matrix keratinization. There is no clinical criterion that enables...

Local causes

Nail Disease Onychomadesis

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.

Parasites and ova

For more detailed information please refer to Chapter 5 The skin and lymphatic system. The skin should be inspected for psoriasis. Is there plaque Is it bright red rather than mauve or pink. Is it scaly Look at scalp, fingernails, natal cleft and rest of the skin for any signs of psoriasis and, importantly, has the patient ever been diagnosed with a skin condition (Seidal et al., 2002).

Yeast infections

Candida infection may occur in the flexures of infants and elderly or immobilised patients, especially below the breasts and folds of abdominal skin. It needs to be differentiated from (a) psoriasis, which does not itch (b) seborrhoeic dermatitis, a common cause of a flexural rash in infants and (c) contact dermatitis and discoid eczema, which do not have the scaling margin. Candida intertrigo is symmetrical and satellite pustules or papules outside the outer rim of the rash are typical. Yeasts, including Candida albicans, may be found in the mouth and vagina of healthy individuals. Clinical lesions in the mouth white buccal plaques or erythema may develop. Predisposing factors include general debility, impaired immunity (including AIDS), diabetes mellitus, endocrine disorders, such as Cushing's syndrome, and corticosteroid treatment. Vaginal candidosis or thrush is a common infection of healthy young women an underlying predisposition is rarely found. The infection presents with...


In addition to topical preparations, systemic steroids may be required for the treatment of severe inflammatory skin conditions such as erythroderma developing from psoriasis or eczema. They are also used in vasculitis and erythema multiforme as well as connective tissue diseases. They are often required for the treatment of pemphigoid and pemphigus together with immunosuppressant drugs.


Besides psoriasis, tazarotene is currently also available for acne treatment in the US market as a 0.5 and 0.1 gel or cream. The efficacy is comparable to adapalene, but its local tolerance by daily application is quite unfavorable and similar to tretinoin. Therefore, tazarotene was recently studied for its efficacy in a so-called short contact application manner similar to dithranol short time application from 30 s up to 5 min. In this study, three arms where compared twice daily, once daily, and vehicle. The once daily application was nearly equivalent to the twice daily and both where highly significantly better than vehicle 34-36 . The irritative potential was reduced.


These vitamin A derivatives have proved very effective in the treatment of psoriasis and acne but are not without risk of side effects. The most serious is that they are teratogenic and must be discontinued for at least three months after stopping treatment in the case of isotretinoin and five years after taking acitretin. This drug is used for severe psoriasis including pustulosis of the hands and feet. It has also been used in other forms of keratosis such as Darier's disease and pityriasis rubra pilaris.

Other drugs

These drugs are used in conjunction with long wavelength ultraviolet light as psoralen with ultraviolet A (PUVA) therapy described on page 67. It is used for the treatment of severe psoriasis. It has also proved effective in some cases of atopic eczema, T cell lymphoma of the skin, and occasionally in lichen planus. There is a risk of cataract formation, and a full blood count as well as antinuclear factor tests should be carried out.

Antibacterial drugs

All penicillins may cause allergic rashes, which may be severe, and the broad spectrum penicillins, amoxicillin, ampicillin, and co-amoxiclav, are particularly likely to cause an intense rash in patients with glandular fever. They tend to accumulate in patients with renal failure and may reduce the excretion of methotrexate which is used in the treatment of psoriasis.

Figure 1026

Cyclosporine (CyA) nephrotoxicity in nonrenal diseases. A, Patients treated with cyclosporine (7.5 mg kg) for psoriasis experienced a median decrease to 84 of the initial values in the glomerular filtration rate after 8 weeks of therapy. B, Of patients treated with cyclosporine (9.3 mg kg) for autoimmune diseases, 21 showed cyclosporine nephropathy on biopsy, with a decrease to 60 of the initial values in renal function. C, Patients with cardiac transplantation treated with high doses of cyclosporine (10 to 6 mg kg) developed a reduction to 57 of the initial values in renal function 36 months after transplantation. Patients treated with azathioprine did not show any reduction in renal function. D, Patients receiving cyclosporine (5 mg kg) for uveitis for 2 years showed a decrease in glomerular filtration rate to 65 of the initial values. (Panel A adapted from Ellis and coworkers 23 panel B adapted from Feutren and Mihatsch 24 panel C adapted from Myers and Newton 25 and panel D...


This drug is useful in severe psoriasis that is not responding to topical treatment. The main disadvantage is its adverse effect on the liver, which precludes its use in those who have alcoholic liver disease but who are often those most needing systemic treatments. Idiopathic immunosuppression can occur so a test dose must always be given and a full blood count carried out 48 hours later before treatment has started. There may be gastrointestinal upsets and osteometitis as well. This drug has proved helpful in severe psoriasis within inflammatory lesions and, secondly, in the treatment of severe atopic dermatitis. There are a number of drug interactions and it is important to check renal function and monitor both blood urea and serum creatinine.

Figure 545

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.


Involving the trunk and face (Figure 15-6). These patients may have been treated for psoriasis, pemphigus, zinc deficiency, or eczema for several years before the rash is recognized for what it is, prompting a proper diagnosis. These patients also have mild to moderate diabetes mellitus associated with anemia, weight loss, glossitis, and thrombophlebitis. The diagnosis can be proved by demonstration of an elevated serum glucagon level.

Days postinoculation

Because it has virtually no toxic effect, -941 has been engaged in phase I and phase II clinical trials in Canada and the United States for the treatment of breast, prostate, and lung carcinoma, as well as for psoriasis and age-related macular degeneration. Up to 430 cancer patients for more than 25 mo have to-date received a daily oral dose of -941. No serious adverse reactions associated with the use of -941 have been reported thus far. Most interestingly, preliminary data of clinical efficacy from lung and prostate cancer as

Systemic Treatment

Dapsone (diaminodiphenylsulfone or DDS), effectively tested on lepra, was shown to possess anti-inflammatory activity for various dermatological diseases, primarily dermatitis herpetiformis in the early 1950s and subcorneal pustular dermatosis in 1956. The sulfones have been widely used to treat other dermatological conditions including bullous diseases, vasculitis, neutrophilic dermatoses, pilosebaceous diseases, infectious diseases, as well as pustular psoriasis and relapsing polychondritis. Dap-sone has been reported to be effective in the management of nodulocystic acne, but the few studies available are based on a limited number of cases 18, 19 . In 1974, we examined 484 patients treated with oral DDS. Patients with acne characterized by papules, pustules and occasional cysts accompanied by inflammatory lesions, did not respond to the medication, although, in some, there was a slight improvement not comparable with the one obtained with tetracycline, in view of which DDS was...

Scientific Issues

Whether arsenic is a trace element essential to human health remains a subject of debate. However, many studies have proved the potential beneficial effects of arsenic (ATSDR, 1998). In traditional Chinese medicine, the arsenic compound Xionghuang(AsS) was recorded as one of the superior materials in 'Bencaojing', a famous classic work of pharmacology written during the Ming dynasty. It is reported that arsenous acid or arsenic trioxide (As2O3) is effective in cosmetology, longevity and is often used against many diseases such as psoriasis, syphilis, rheumatosis, and trypanosomiasis (Chen et al., 1995). It was in the 1970s in China that As2O3 was introduced into the treatment of acute promyelicytic leukemia (APL) and it showed a striking effectiveness. A clinical complete remission rate was reported (Sun et al., 1992 Zhang et al., 1996) from 65.6 to 84 with treatment (10 mg day, intravenous infusion for 29 to 60 days). In vitro studies suggested that As2O3 may induce the apoptosis of...

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.

Groin And Pubic Area

Anti-fungal creams but the nurse should instruct the patient on appropriate hygiene requirements to ensure eradication. Erythema of the pubic skin may also result from other dermatological conditions such as eczema, psoriasis, etc., and patients should be advised to see a general practitioner dermatologist for the management of any non-sexual skin condition.

Pityriasis rosea

Guttate Psoriasis Face

The word pityriasis is from the Greek for bran, and the fine bran-like scales on the surface are a characteristic feature. The numerous pale pink oval or round patches can be confused with psoriasis or discoid eczema. The history helps because this condition develops as an acute eruption and the patient can often point to a simple initial lesion the herald patch. In guttate psoriasis the lesions are more sharply defined and smaller (0-5-1-0 cm) and have waxy scales. Clinical features of psoriasis

Local treatment

Lupus Erythematosus Treatment

Coal tar preparations are safe and effective for the stable plaque-type psoriasis but will irritate acute, inflamed areas. However, tar may not be strong enough for thicker hyperkeratotic lesions. Salicylic acid, which helps dissolve keratin, can be used in conjunction with tar for thick plaques. Refined coal tar extracts can be used for less severe areas of psoriasis. Ichthammol, prepared from shale rather than coal tar, is less irritating and has a soothing effect on inflamed skin. It is therefore useful for unstable or inflamed psoriasis, when tar would not be tolerated. Corticosteroid preparations produce an initial clearing of psoriasis, but there is rapid relapse when they are withdrawn and tachyphylaxis (increasing amounts of the drug having a diminishing effect) occurs. Strong topical steroids should be avoided. Only weak preparations should be used on the face but moderately potent steroids can be used elsewhere (a) if there are only a few small lesions of psoriasis (b) if...


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...

Tar preparations

These are mainly used for treating psoriasis as described in chapter 3. Tar has an anti-inflammatory effect and seems to suppress the epidermal turnover in lesions of psoriasis. The various tar pastes are generally too messy to use at home and are most suitable for dermatology treatment centres. Standard tar paste contains a strong solution of coal tar 7-5 in 25 g of zinc oxide, 25 g of starch, and 50 g of white soft paraffin. There are numerous proprietary preparations that are less messy and do not stain but are not so effective. They are useful for treating less severe psoriasis at home. Examples are Alphosyl cream (Stafford-Miller), Pragmatar (Bioglan), Psoriderm (Dermal) alphosyl HC (Stafford-Miller) and Carbo-Cort (Lagap) contain hydrocortisone as well. Bath preparations are useful for dry skin and widespread psoriasis. Coal tar solution (20 ) can be used or Polytar Emollient (Stiefel) or Psoriderm. Tar shampoos are useful for treating psoriasis of the scalp. Polytar (Stiefel),...

The typical patient

Dense Psorasis Scales

Psoriasis usually occurs in early adult life, but the onset can be at any time from infancy to old age, when the appearance is often atypical. There may be a family history if one parent has psoriasis 16 of the children will have it, if both parents, the figure is 50 . Typically, psoriasis does not itch. Patients usually present with lesions on the elbows, knees, and scalp. The trunk may have plaques of variable size and which are sometimes annular. Patients with psoriasis show Koebner's phenomenon with lesions developing in areas of skin trauma such as scars or minor scratches. Normal everyday trauma such as handling heavy machinery may produce hyperkeratotic lesions on the palms. In the scalp there is scaling, sometimes producing very thick accretions. Erythema often extends beyond the hair margin. The nails show pits and also thickening with separation of the nail from the nail bed (oncholysis). Scalp psoriasis Scalp psoriasis Widespread pustular psoriasis Widespread pustular...

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.

Myopathy or myositis

Patients with HIV infection may develop psoriasis which is very difficult to treat using conventional therapy. An open-label study to determine the safety and efficacy of AZT in HIV-associated psoriasis demonstrated that 90 of 19 evaluable patients had partial (58 ) or complete (32 ) improvement of their psoriasis (54). Other studies demonstrated that clinical improvement of HIV-associated psoriasis parallels a reduction of HIV viral load (55). Interestingly, AZT has also been given to HIV-negative patients with psoriasis. In a pilot study, 33 of these persons showed improvement in their psoriasis, but no complete remissions occurred (56).

Descriptive terms

Plaque is one of those terms which conveys a clear meaning to dermatologists but is often not understood by others. To take it literally, one can think of a commemorative plaque stuck on the wall of a building, with a large area relative to its height and a well defined edge. Plaques are most commonly seen in psoriasis. The term pustule is applied to lesions containing purulent material which may be due to infection, as in the case shown or sterile pustules, which are seen in pustular psoriasis.


There may have been previous episodes because it is a constitutional condition, such as atopic eczema. In the case of contact dermatitis, regular exposure to a causative agent leads to recurrences that fit with the times of exposure and this is usually apparent from the history. Endogenous conditions such as psoriasis can appear in adults who have had no previous episodes. If there is no family history and several members of the household are affected, a contagious condition, such as scabies, should be considered. A common condition with a familial tendency, such as atopic eczema, may affect several family members at different times. Most endogenous rashes affect both sides of the body, as in the atopic child or a man with psoriasis on his knees. Of course, not all exogenous rashes are asymmetrical. A seamstress who uses scissors in her right hand may develop an allergy to metal in this one hand, but a hairdresser or nurse can develop contact dermatitis on both hands. The surface may...

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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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