Psoriasis - Clinical research Ukraine professional portal
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Psoriasis is a chronic inflammatory skin disease process involving immune-mediated cutaneous inflammation and keratinocyte proliferation. The diagnosis is based upon a combination of both history and physical examination parameters. Typically, psoriasis is characterized by scaly, erythematous patches, papules, and plaques that are often pruritic and can be painful. The disease is a chronic disease that can wax read more wane in severity and is typically improved with treatment.
Rarely, spontaneous remissions can occur. Clinical findings Gruppe in Psoriasis in Ukraine multiple subtypes may overlap in the same patient as well. They are most often located on the scalp, trunk, buttocks, and extremities, preferentially involving extensor surfaces, umbilicus, and supragluteal cleft Figure 1.
Painful fissuring may occur. Inverse psoriasis is characterized by erythematous plaques with minimal scale located in skin folds, such as the axillary, genital, Gruppe in Psoriasis in Ukraine, intergluteal, and inframammary article source. Because of the moist nature and skin on skin surfaces, the plaques are typically thinner and with minimal to no scale; topical regimens need to be selected carefully for these areas.
It is characterized by very small, 1 to 10 mm salmon-pink papules with fine overlying scale Figure 2. This form of psoriasis is typically preceded by an upper respiratory infection with group A beta-hemolytic streptococcal infection that occurs 2 to 3 weeks prior to the outbreak; as a result, a history of sore throat, cervical lymphadenopathy, fever, headache, generalized malaise, nausea, vomiting, abdominal pain, or stuffy nose should be elicited.
Other sites of a streptococcal infection may also trigger guttate psoriasis, such as perianal streptococcal Psoriasis Salbe hormonelle in children.
Nail unit psoriasis or psoriatic onychodystrophy can occur with all types of psoriasis or be the sole feature of psoriasis. Typical changes include nail pitting, onycholysis separation of the nail plate from the nail bedsubungual debris, and oil-drop discoloration. To diagnose psoriasis, often the characteristic clinical appearance and distribution of lesions is all that is necessary. In difficult cases or to confirm the diagnosis, a skin biopsy can be used.
Classic histopathologic findings include psoriasiform epidermal hyperplasia, parakeratosis with intracorneal neutrophils, hypogranulosis, a neutrophilic and lymphocytic infiltrate in the epidermis and dermis, and increased dermal papillary vessels. No routine laboratory investigation is necessary to diagnose psoriasis, but may be necessary to initiate certain therapeutic interventions.
In cases of guttate psoriasis, a culture from the throat for group A Gruppe in Psoriasis in Ukraine organisms or checking an ASO titer may be beneficial to confirm a preceding infection. Seborrheic dermatitis also characteristically affects the scalp, typically with finer scale but may be difficult to completely differentiate and the term sebopsoriasis may be used; if classic plaque psoriasis is present on rest of exam, then this would confirm psoriasis as the diagnosis.
Dermatophytoses distinguished by positive identification on potassium hydroxide KOH examination, extent of disease, thicker plaques typically seen in psoriasis. Cutaneous lupus erythematosus, specifically subacute cutaneous lupus erythematosus Gruppe in Psoriasis in Ukraine by skin biopsy and characteristic distribution of skin lesions; lupus is worsened with exposure to sunlight while psoriasis typically improves with exposure to light.
Atopic dermatitis characteristically affects flexural surfaces and is eczematous in appearance as opposed to papulosquamous. Lichen simplex chronicus differentiated by extent of involvement, clinical appearance, and preceding historyand secondary syphilis diagnosed based upon positive rapid plasm reagin RPR or fluorescent treponemal antibody-absorbed test FTA-absthinner plaques without silvery scale, and presence of plasma cells on skin biopsy or positive spirochetes identified.
Cutaneous T-cell lymphoma usually with more wrinkled, thinner scale and different anatomic location but important to biopsy when diagnosis is in doubt, especially if biologic therapies are to be initiated. Often, the classic characteristic appearance of psoriasis can differentiate between these other entities.
Psoriasis has been diagnosed in approximately 2. Peak onset of the disease is roughly bimodal, most often at ages 16 to 22 and then ages 57 to 60; however, the disease can occur at any age. Guttate psoriasis is most commonly seen in individuals younger than 30 years. Risk factors ultimately resulting in the initial presentation of psoriasis or worsening of psoriasis are poorly understood.
Koebnerization or exacerbation from physical trauma to the skin, including sunburnDiagnose von Psoriasis Karma streptococcal infection, HIV infection, certain medications click to see more as beta-blockers, lithium, chloroquine, ACE-inhibitors, terbinafine, indomethacin, and interferon-alphacigarette smoking, alcohol consumption, and emotional stress have been cited to increase risk for developing or exacerbating Gruppe in Psoriasis in Ukraine. Family history also may increase the risk for development of disease.
However, the development of psoriasis is multifactorial, resulting from genetic and environmental factors and still poorly understood.
The exact etiology and pathogenesis is unknown but immunologic, genetic, and environmental factors are all are implicated in the development of the disease. Population studies have demonstrated that the incidence of psoriasis is greater among first-degree and second-degree relatives of patients than among the general population. In addition, genetic mapping studies have identified multiple chromosomal loci linked to the development of disease.
Psoriasis susceptibility 1 PSOR1 on chromosome 6, also known as HLA-Cw6 allele, has been strongly associated with the development of psoriasis up to a fold increase in risk in the Caucasian population and associated with early onset disease. Other genetic loci PSOR2-PSOR9 and HLA-B13, -B17 also have been associated with psoriasis.
However, multifactorial inheritance mechanisms without a genetic learn more here also have not been excluded. Variants in the gene encoding the IL receptor and in the untranslated region of the IL12B p40 gene also have been Gruppe in Psoriasis in Ukraine as indicators of Gruppe in Psoriasis in Ukraine risk.
While this data is compelling for genetic mechanisms, environmental factors also are known to play a role. These environment factors are outlined above. Psoriasis is a complex inflammatory skin condition with abnormal epidermal keratinocyte differentiation and hyperproliferation. This process appears to be immunologically driven and mediated primarily by T cells in the dermis.
In the complex model of disease, the interactions of antigen-presenting cells APCs with T cells, as well as cytokines, trigger an immune response. The APCs in the skin interact with T cells, and an unidentified Gruppe in Psoriasis in Ukraine is Gruppe in Psoriasis in Ukraine to the T cells, and this interaction, along with multiple co-stimulatory signals, lead to T cell activation and the release of cytokines. The reactivation of T cells in the skin, and the local effects of cytokines such as tumor necrosis factor, interleukin IL -1 beta, and IL10 lead to inflammation, cell-mediated immune responses, and epidermal hyperproliferation.
In addition to IL12, IL23 has been recently identified as playing an important role in the establishment of chronic inflammation and in the development of a T helper Th cell subset that produces IL These Th17 cells pathway are critically important in the pathophysiology of psoriasis. There are several comorbities and associated systemic disorders that have been demonstrated to be associated with psoriasis.
The prevalence overall in the United States is Gruppe in Psoriasis in Ukraine to Gruppe in Psoriasis in Ukraine estimated to be between 0. On average, cutaneous manifestations may occur for 12 years before the development of joint symptoms. Symptoms can range from mild to severe arthritis and are characterized by morning stiffness, pain, swelling, and tenderness of the joints and surrounding ligaments: The spectrum of psoriatic arthritis ranges from peripheral to axial disease.
Hands tend to be involved more frequently than feet. Patients should be routinely questioned for symptoms of arthritis, and if positive, radiographic studies should be performed. Characteristic radiographic features of psoriatic arthritis include joint erosions, joint space narrowing, bony proliferation, osteolysis, including "pencil in cup" deformity, acro-osteolysis, ankylosis, spur formation, and spondylitis.
The course of psoriatic arthritis is variable and unpredictable and can vary from mild and nondestructive to a severe, debilitating, erosive arthropathy. Because psoriatic arthritis can be destructive, disease modifying anti-rheumatic drugs DMARDs are necessary and referral and collaboration with rheumatology may be required. The connection between obesity and psoriasis has been confirmed by multiple large studies. Metabolic syndrome is the combination of obesity, impaired glucose regulation, hypertension, hypertriglyceridemia, Gruppe in Psoriasis in Ukraine reduced high density lipoprotein, which can lead to an increase risk for cardiovascular disease.
The prevalence of metabolic syndrome in hospitalized patients with psoriasis is significantly elevated when compared to those patients without psoriasis. Some hypothesize that obesity may potentiate inflammation of psoriasis and facilitate the development of metabolic syndrome. All psoriatic patients should be counseled on diet, exercise, and management of these comorbidities, as this inflammatory state may be contributing to their disease and can lead to other significant morbidity and mortality.
There is an increased risk of cardiovascular disease, which is thought to be multifactorial. Often times, patients with psoriasis are overweight, have increased incidence of diabetes, increased incidence of hypertension, and hyperlipidemia.
Patients have an increased Gruppe in Psoriasis in Ukraine of myocardial infarction, which may be related to their underlying other comorbidities as well as the medications used to treat the psoriasis. However, after correcting for heart disease risk factors, psoriatic patients have a higher probability of myocardial infarction compared to nonaffected individuals, and there appears to be an increased relative risk seen in younger patients with more severe psoriasis.
Increased rates of depression in psoriatic patients also may lead to increased risk of cardiovascular disease. All patients should be counseled that Gruppe in Psoriasis in Ukraine are increased risk for cardiovascular disease and they should be Gruppe in Psoriasis in Ukraine to promote heart healthy behaviors.
In fact, some academic centers have established multidisciplinary centers where patients can be evaluated and more extensively counseled for behavior modification and close monitoring for the development of cardiovascular disease.
The individual susceptibility to all 3 of these diseases has been localized to a similar region of chromosome Patients should have a complete review of symptoms for any abdominal pain, diarrhea, fevers, or blood in the stool. If any of these symptoms exist, then referral to gastroenterology is appropriate.
Multiple sclerosis has been shown to be linked to psoriasis with a study that demonstrated psoriasis is more likely to occur in families of patients with multiple sclerosis. Mood disorders visit web page lack of self-esteem are increased in patients Gruppe in Psoriasis in Ukraine psoriasis.
The psychological and emotional burden of psoriasis can include not only poor self-esteem and Gruppe in Psoriasis in Ukraine, but also sexual dysfunction and anxiety.
Some studies suggest that treatment of psoriasis may help with emotional disorders resulting from the disease.
Clinicians need to consider the psychosocial aspects of disease, and if emotional symptoms warrant further Gruppe in Psoriasis in Ukraine, then referral to a psychiatrist may be appropriate. Multiple studies have demonstrated an increased prevalence of smoking among psoriatic patients.
The increased risk for incident psoriasis applied to both current and past smokers. In one study, the majority of these patients began smoking prior to the development of psoriasis. However, Gruppe in Psoriasis in Ukraine exact link between cigarette smoking and psoriasis has not been established. An increase in the amount of alcohol ingested in psoriatic patients has been established.
However, the role that alcohol consumption has in the development of psoriasis still remains uncertain. Alcohol abuse may reflect the underlying psychological burden of disease or may be click here with other associated behaviors.
Regardless, excessive alcohol intake most likely negatively impacts mortality. All patients should be questioned regarding their social behaviors, and these issues should be addressed when caring for any psoriatic patient.
Table I summarizes potential therapies for psoriasis, and the use of these therapies will be dictated by severity of psoriasis mild vs moderate to severepatient preference and presentation, and type of psoriasis see below. If risk factors such as smoking, obesity, alcohol use, diabetes, hypertension are present, counseling and efforts should be made to help the patient with these comorbidities. For patients with joint pain, referral to rheumatology should be sought.
Topical therapies are appropriate for patients with mild or limited disease but are not practical for patients with more significant disease.
They can be used both intermittently and Gruppe in Psoriasis in Ukraine a long-term basis. Topical corticosteroids and vitamin D analogues are considered first-line therapies for limited disease.
Vitamin D analogues have no apparent risk for atrophy or thinning of skin and may be better used for intertriginous areas. Topical corticosteroids are the mainstay of treatment for limited psoriasis. For continuous, long-term use, the least potent agent should be used. The efficacy of steroids is determined by the vehicle, area of usage, use of occlusion, unique degree of potency of the topical steroid. Once to twice daily dosing can be used. Mid-potency steroids such as triamcinolone 0.
When feasible, a patient should be switched to a less potent topical steroid to further minimize the risks of use. Vitamin D analogues calcipotriol or calcipotriene: Topical calcineurin inhibitors tacrolimus and Gruppe in Psoriasis in Ukraine A "black box" warning exists because of lack of long-term safety data and potential risk for development of malignancies; although no clinical evidence to date has demonstrated causality.
As a topical keratolytic, this topical is often combined with other topical therapies including topical corticosteroids and topical tacrolimus. Shampoos with salicylic acid exist to help with scalp psoriasis.
This is available in shampoo, solution, and ointment formulation and was used as Gruppe in Psoriasis in Ukraine of the modified Goeckerman formula of combining topical tar with phototherapy. If yes, Lassen Sie sich von dem Juckreiz loswerden a systemic anti-TNF agent, methotrexate, or other disease-modifying antirheumatic drug DMARD Gruppe in Psoriasis in Ukraine be necessary and coordination with rheumatology should occur.
If yes, then acitretin may be considered first-line therapy. If yes, then phototherapy should not be considered first. If yes, then exercise caution with regard to phototherapy, and acitretin is preferred for its protective effect. If yes, then consider cyclosporine as first line with transition to alternate therapy. If yes, then TNF alpha-inhibitors should be avoided if feasible. TNF inhibitors prefer to avoid given risk of loss of efficacy if stopped and need to be utilized if flares again in future.
May be dosed orally, intramuscularly, or subcutaneously. When discussing and treating any patient with psoriasis,explain the natural history of psoriasis, with an explanation that this is a chronic condition that will not be cured but can be controlled and that therapies often need 3 months to determine efficacy.
If patients are not tolerating therapy or do not respond within the expected period of time, then an alternate therapy should be sought. If patientsdevelop arthritis, then a systemic medication should be considered to help with arthritis if the patient is not on one.
Patients should be monitored for any evidence of systemic infections, arthritis symptoms, underlying malignancies on a regular basis. If patients are clear from their disease, then drug holidays may be considered, especially with treatments such as topical medicines, phototherapy, methotrexate, or acitretin.
This is more difficult with systemic biologic therapies, as antibodies with resistance may develop to these therapies, rendering them ineffective. In those patients with risk factors for liver disease, then earlier liver biopsy may be necessary. Delayed baseline liver biopsy after months of therapy to establish medication efficacy and tolerability should be considered, with repeated liver biopsies after approximately 1 to 1.
May be used in monotherapy or combination with UVB or PUVA. Works Gruppe in Psoriasis in Ukraine and is efficacious for severe psoriasis or erythrodermic psoriasis. Good for patients with co-morbidities, most types of psoriasis, including guttate psoriasis. MED determined by skin type. As lesions thin, subsequent doses Gruppe in Psoriasis in Ukraine lowered until clearing is achieved.
Patients should be Gruppe in Psoriasis in Ukraine twice weekly. There is no known maintenance option for the laser protocol. Dose increments based on skin type ranging Gruppe in Psoriasis in Ukraine 0. Due to treatment failure or resistance, it is occasionally necessary to use alternate therapies for psoriasis.
When discussing and treating any patient with psoriasis, explain the natural history of psoriasis, also explaining that that this is a chronic condition that will not be cured but can be controlled and that therapies often need 3 months to determine efficacy.
If patients develop arthritis, click to see more a systemic medication should be considered to help with arthritis if the patient is not on one. Patients should also be encouraged to maintain as close to an ideal body weight as is possible.
Caution should be used with topical corticosteroids in order to prevent skin atrophy in these patients. For treatment-resistant or severe disease, systemic therapies can be considered.
For older children, limited courses of phototherapy eliminate some of the side please click for source associated with using systemic immunosuppressants. Methotrexate and cyclosporine have been used to safely control disease in children; close monitoring should be employed.
Biologic therapies are not approved for use in children, although etanercept has been the best studied for psoriasis in pediatric population with overall good safety and isolated cases of severe infection. During pregnancy, special care must be used due to potential teratogenic effects of commonly used treatments. Often, psoriasis may improve during pregnancy http://larpring.de/ausgehaertete-psoriasis-guttata.php to hormonal changes.
The safest therapy is NBUVB. Topical corticosteroids and topical calcipotriene also considered safe. Methotrexate is contraindicated as it can lead to oligospermia, although no fetal malformation has been demonstrated.
Conception should be delayed for 3 months after methotrexate use. With rspect to use of systemic retinoids: Methotrexate Gruppe in Psoriasis in Ukraine not be prescribed due to hepatotoxicity. Because Gruppe in Psoriasis in Ukraine B reactivation has been observed in patients undergoing therapy with TNF alpha-inhibitors and ustekinumab, screening for hepatitis B should occur prior Gruppe in Psoriasis in Ukraine initiation of therapy.
In hepatitis B positive Gruppe in Psoriasis in Ukraine with inactive disease, a course of antivirals for weeks should be initiated prior to anti-TNF therapy. At this time, it is unknown if treatment with antivirals makes use of ustekinumab safe in this population. Etanercept may act as an Gruppe in Psoriasis in Ukraine to standard antiviral therapy in treating hepatitis C. Adalimumab, infliximab, and ustekinumab have been less well studied, but probably may be utilized in reamberin Psoriasis Forum Gruppe in Psoriasis in Ukraine setting as Gruppe in Psoriasis in Ukraine. Cyclosporine also may be a treatment option in this patient population as in vitro evidence suggests that cyclosporine suppresses the replication of the hepatitis C virus.
The primary treatment is that of underlying HIV itself with anti-retrovirals. Phototherapy is considered a first-line systemic agent for treatment of psoriasis in this patient population. Topical therapies also should be used first-line, although they typically are of limited success given the extent of involvement in this patient population.
Acitretin is considered a second line systemic therapies; caution with hyperlipidemia with acitretin and other antiretrovirals should be used. For more refractory and severe disease, extremely cautious use of systemic immunosuppressants such as methotrexate, cyclosporine, or biologic therapies may be considered with collaboration with infectious disease specialists; however, these should be rarely used. Gottlieb, A, Korman, NJ, Gordon, KB, Feldman, SR, Lebwohl, M, Koo, JY.
J Am Acad Dermatol. Kalb, RE, Bagel, J, Korman, NJ, Lebwohl, MG, Young, M, Horn, EJ. Kimball, AB, Gladman, D, Gelfand, JM, Gordon, K, Horn, EJ, Korman, NJ. Lebwohl, M, Bagel, J, Gelfand, JM, Gladman, D, Gordon, KB, Hsu, S. Menon, K, Van Voorhees, AS, Psoriasis an weiblichen Organ, BF, Gladman, DD, Hsu, S, Addiction Sivas Psoriasis Wundheilung, RE.
Menter, A, Gottlieb, A, Feldman, SR, Van Voorhees, AS, Leonardi, CL, Gordon, KB. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics". Menter, A, Korman, NJ, Elmets, CA, Feldman, SR, Gelfand, JM, Gordon, KB.
Guidelines of care for the management of psoriasis and psoriatic arthritis. Guidelines of care for the management please click for source treatment of psoriasis with topical therapies".
Menter, A, Korman, NJ, Elmets, CA, Feldman, SR, Gelfand, JM, Gordon, K. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents".
Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy". Rosenbach, M, Hsu, S, Korman, NJ, Lebwohl, MG, Young, M, Bebo, BF. Kalb, RE, Fiorentino, DF, Lebwohl, MG. Langley, RG, Elewski, BE, Lebwohl, M. N Engl J Med. Thaci, D, Blauvelt, A, Reich, K. CLEAR, a randomized, controlled trial". Paul, C, Cather, J, Gooderham, M. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC.
The Licensed Content is the property of and copyrighted by DSM. Find all of the news and departments you love from the print issue archived for easy online access, along Gruppe in Psoriasis in Ukraine special Web-only content. My Practice Practice Management Legal Advisor Beyond Rx: Derm Dx Ortho Dx Image of the Week Clinical Challenge.
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Who is at Risk click here Developing this Disease? What is the Cause of the Disease? Systemic Implications and Complications Treatment Options Optimal Therapeutic Approach for this Disease Patient Management Unusual Clinical Scenarios to Consider in Patient Management. Psoriasis Are You Confident of the Diagnosis? Clinical picture of guttate psoriasis. Expected results of diagnostic studies No routine laboratory investigation is necessary to diagnose psoriasis, but may be necessary to initiate certain therapeutic interventions.
Diagnosis confirmation The differential diagnosis of psoriasis includes 1. Seborrheic dermatitis also characteristically affects the scalp, typically with finer scale but may be difficult to completely differentiate and the Gruppe in Psoriasis in Ukraine sebopsoriasis may be used; if classic plaque psoriasis is present on rest of exam, then this would confirm psoriasis as the diagnosis 2. Dermatophytoses distinguished by positive identification on potassium hydroxide KOH examination, extent of disease, thicker plaques typically seen in psoriasis 3.
Cutaneous lupus erythematosus, specifically subacute cutaneous lupus erythematosus distinguished by skin biopsy and characteristic distribution of skin Gruppe in Psoriasis in Ukraine lupus is worsened with exposure to sunlight while psoriasis typically improves Gruppe in Psoriasis in Ukraine exposure to light 4.
Atopic dermatitis characteristically affects flexural surfaces http://larpring.de/dexamethason-injektionen-fuer-psoriasis-bewertungen.php is eczematous in appearance as opposed to papulosquamous 5. Lichen simplex chronicus differentiated by extent of involvement, clinical appearance, and preceding historyand secondary syphilis diagnosed based upon positive rapid plasm reagin RPR Gruppe in Psoriasis in Ukraine fluorescent treponemal Gruppe in Psoriasis in Ukraine test FTA-absthinner plaques without silvery scale, and presence of plasma cells on skin biopsy or positive spirochetes identified 7.
Etiology Population studies have demonstrated that the incidence of psoriasis is greater among first-degree and second-degree relatives of patients Gruppe in Psoriasis in Ukraine among the general population.
Pathophysiology Psoriasis is a complex inflammatory skin condition with abnormal epidermal keratinocyte differentiation and hyperproliferation. Systemic Implications and Complications There are several comorbities and associated systemic disorders that have been demonstrated to be associated with psoriasis. Read article disease There is an increased risk of cardiovascular disease, which is thought to be multifactorial.
Psychiatric illness Mood disorders and lack of self-esteem are increased in patients with psoriasis. Treatment Options Table I summarizes potential therapies for Gruppe in Psoriasis in Ukraine, and the use of these therapies will be dictated by severity of psoriasis mild vs moderate to severepatient preference and presentation, and type of psoriasis see below. AdalimumabEtanerceptInfliximabUstekinumabAlefaceptSecond-line lower quality evidence: AzathioprineFumaric acid estersHydroxyureaLeflunomideMycophenolate mofetilSulfasalazineTacrolimus6-Thioguanine Phototherapy: Powered By Decision Support in Medicine.
Pylori may affect psoriasis severity Additional evidence of link between psoriasis, kidney disease Novel drug may be effective for psoriasis Diet, alcohol consumption effect psoriasis symptoms Psoriasis linked to increased chronic kidney disease, glomerulonephritis risk.
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MethotrexateAcitretinCyclosporineTumor necrosis factor TNF alpha inhibitors: AzathioprineFumaric acid estersHydroxyureaLeflunomideMycophenolate mofetilSulfasalazineTacrolimus6-Thioguanine.
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