Most Effective Psoriasis Home Remedies

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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Author: Dan Crawford
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Highly Recommended

I started using this book straight away after buying it. This is a guide like no other; it is friendly, direct and full of proven practical tips to develop your skills.

As a whole, this ebook contains everything you need to know about this subject. I would recommend it as a guide for beginners as well as experts and everyone in between.

Psoriasis

The hands and feet are common sites of involvement in psoriasis. Two types of psoriasis are seen. The first is psoriasis vulgaris or plaque-type psoriasis. Often, these patients have disease involvement of other areas especially the elbows, knees, scalp, and gluteal cleft. Sometimes, however, the hands or the feet may be the only involved site. The second type of psoriasis involving the palms and soles is palmoplantar pustulosis. This is a rare form of pustular psoriasis confined to the palms and soles.

What is special about dermatology

Extensive disorders affecting the skin may disrupt its homeostatic functions, ultimately resulting in skin failure, needing intensive care. This is rare but may happen, for example with extensive bullous disorders or exfoliative dermatitis. The most frequent health consequences of skin disorders are connected with the discomfort of symptoms such as itching and burning or pain, which frequently accompany skin lesions and interfere with everyday life and sleep, and the loss of confidence and disruption of social relations that visible lesions may cause. Feelings of stigmatisation, and major changes in lifestyle caused by chronic skin disorders such as psoriasis or leg ulcers have been repeatedly documented in population surveys.13,14

Extremely common disorders

Skin diseases are very common in the general population. Prevalence surveys have shown that skin disorders may affect 20-30 of the general population at any one time.16 The most common diseases are also the most trivial ones. They include such conditions as mild eczematous lesions, mild to moderate acne, benign tumours and angiomatous lesions. More severe skin disorders which can cause physical disability or even death, are rare or very rare. They include, among others, bullous diseases such as pemphigus, severe pustular and erythrodermic psoriasis, and malignant tumours such as malignant melanoma and lymphoma. The disease frequency may vary according to age, sex and geographical area. In many cases, skin diseases are trivial health problems in comparison with more serious medical conditions. However, as already noted, because skin manifestations are visible they cause greater distress than more serious medical problems. The issue is complicated because many skin disorders are not a...

What evidencebased dermatology is not

Contrary to popular belief, the prime purpose of EBM is not to cut costs. Like any information source, selective use of evidence can be twisted to support different economic arguments. Thus, the lack of randomised clinical trial (RCT) evidence for the efficacy of methotrexate in psoriasis should not imply that methotrexate should not be used purchased for patients with severe disease when there is so much other evidence and long-term clinical experience to support its use. But this is not to say that a clinical trial comparing methotrexate and ciclosporin, acitretin or fumarates would not be desirable at some stage.6

The hazards of quick searches

Medline searches have inherent limitations that make their reliability less than ideal.11 For example, Spuls et al. conducted a systematic review of systemic treatments for psoriasis.12 Treatments analysed included UVB, PUVA, methotrexate, ciclosporin A and retinoids. The authors used an exhaustive strategy to find relevant references, including Medline searches, contacting pharmaceutical companies, polling leading authorities, reviewing abstract books of symposia and congresses, and reviewing textbooks, reviews, editorials, guideline articles and the reference lists of all papers identified. Of 665 studies found, 356 (54 ) were identified by a Medline search (range 30-70 for different treatment modalities).12

Back to the individual patient

What is the risk of extraspinal hyperostosis in a patient with psoriasis treated for several months with acitretin Does PUVA therapy increase the risk of non-melanoma skin cancer in a patient being treated for mycosis fungoides What is the chance of severe depression in an adolescent taking 13-c s-retinoic acid for acne To address these questions, physicians must effectively search for evidence and must be able to assess prescribing a particular drug, the excess risk (or risk difference) is a more informative measure than is the relative risk. In the context of RCTs, Sackett et al. proposed a method for converting risk differences into a more intuitive quantity. This quantity was named the number needed to treat (NNT 1 excess risk).25 It is the number of people who must be treated in order that one clinical event is prevented by the treatment at issue (for example the number of people to be treated to avoid one patient experiencing a relapse of psoriasis) or one additional beneficial...

Does PASI mean anything to you

You Is the scale linear (i.e. does a PASI score of 30 mean twice as bad as a score of 15) as in other continuous variables such as height and weight Should different components of these scales be added or multiplied by extent Does a lot of psoriasis over the covered areas of the body mean more distress than a little bit of psoriasis on the backs of the hands and face

Number needed to treat

Because many interventions in medicine are of only modest effect, their apparent benefit may not be that noticeable after one has tried the intervention on a few patients. One way to understand the magnitude of benefit in relation to baseline risk is to use the concept of number needed to treat (NNT).17 This refers to the number of patients that on average you would need to treat in order to see one additional success in the new treatment when compared with standard treatment. NNT is calculated simply as the reciprocal of the difference in success rates between the treatments being compared. Thus, a new treatment that results in clearing of psoriasis in 40 of patients compared with 30 for the conventional It is also important that the dermatologist and patient decide for themselves as to what might constitute a useful NNT, rather than blindly accepting the sort of conventions that have been derived from acute medicine where the stakes are perhaps higher. So, although it may be...

Skin Surface Analysis

Microanatomy The Epidermis

Skin surface analysis is often tailored to the goals of restorative surgery or nonsur-gical treatments. Patients undergoing scar revisions require analyses to include the resting skin tension lines. In the patient undergoing nasal reconstructive surgery after Mohs' resection, an analysis of the topographical units of the face is important. If cutaneous resurfacing is planned, an analysis of skin type and reaction to solar damage are also needed. Koebner's phenomenon is also an important consideration. This phenomenon describes the tendency for some skin diseases such as psoriasis, lichen planus, discoid lupus erythematosus, and herpes simplex to localize to areas of recent surgery or scars.

Background Definition

Psoriasis is an inflammatory disease of the skin characterised by an accelerated rate of epidermal turnover, with hyperproliferation and defective maturation of epidermal keratinocytes. In the majority of cases psoriasis is a chronic disease which, in its most common form -chronic plaque psoriasis - manifests itself as well-demarcated, often symmetrically distributed, thickened, red, scaly plaques. These may vary considerably both in size and in number and may involve any part of the skin, although they are found most typically on the extensor surfaces of the knees and elbows, in the sacral area and on the scalp. Appearances may be modified by the site of involvement, with flexural areas showing beef-red shiny plaques without scale (flexural or inverse psoriasis), palms and soles showing marked hyperkeratosis and fissuring, and nails becoming distorted by thimble-pits, thickening and nail-plate detachment. Up to 8 of people with psoriasis may have an associated inflammatory...

Relevant outcomes

Outcomes should reflect the above aims and will therefore most importantly address patient satisfaction with treatment and changes in disease-related quality of life. Outcomes should thus include proportions of patients reporting good or excellent response to treatment and reporting that treatment is worthwhile. Similarly, proportions of patients achieving clearance or near clearance of disease are more robust outcomes than are absolute or relative changes in disease severity scoring systems such as the psoriasis area and severity index (PASI). Adverse effects and their frequency are equally important because they may limit the utility of otherwise effective interventions.

Phototherapy and photochemotherapy

Many different schedules for delivery of phototherapy to people with psoriasis are in current use. One systematic review of treatments for severe psoriasis25 concluded that photochemotherapy (PUVA) using a combination of either oral or topical psoralen with UVA was effective in clearing psoriasis UVA alone did not clear psoriasis broad-band 290-320 nm ultraviolet B (BBUVB) was effective in clearing psoriasis PUVA is of similar efficacy to daily anthralin dressings in clearing psoriasis There is little evidence to support the use of balneophototherapy in which phototherapy is combined with bathing in various mineral or salt waters.27 Heliotherapy using natural sunlight is effective at clearing psoriasis28 but is associated with an increased risk of skin cancer.29 The main risks of PUVA therapy are photoageing (premature skin ageing) and skin cancer, notably squamous cell carcinoma30 and, to a lesser extent, malignant melanoma.31 It is therefore advisable to limit the number of...

Systemic retinoid monotherapy

Systemic retinoids are widely used for treating chronic palmoplantar pustular psoriasis. Most of the available studies were carried out when etretinate was available but this has now been replaced by acitretin. The review108 found that the two drugs are of comparable efficacy and that about two in five patients achieve a good or excellent response. There is evidence that improvement may be maintained by continuing therapy at a lower dose. Retinoid therapy is more effective than photochemotherapy (PUVA).

TABLE 785 Pruritus

Dermatologic conditions contributing to this symptom complex include atopic dermatitis, lichen planus, psoriasis, and seborrheic dermatitis. Any of the anal margin neoplasms, particularly Bowen's disease and extramammary Paget's disease, may initially manifest itself as pruritus.

Clinical Features

Other noninfectious causes of paronychia include psoriasis, dermatitis, and even certain medications including Accutane. Because of injury to the proximal nail fold and cuticles, these patients are at risk of developing secondary infection as well. A clue to the diagnosis is sudden exacerbation of the nail disease without exacerbation of other cutaneous disease.

Clinical Conditions in Prepubertal Children

DERMATOLOGIC LESIONS Children with seborrhea and psoriasis may present with bleeding after minor trauma. Lichen sclerosus is seen in hypoestrogenic females. The etiology is unknown. Characteristically, lichen sclerosus appears as an hourglass-shaped depigmented area on the vulva, perianal, and adjacent skin. The skin is thin and atrophic, with tiny ivory papules that coalesce. The patches are usually dry and itchy. Mild forms of lichen sclerosus may be treated with sitz baths and 1 hydrocortisone cream for symptomatic relief. More serious cases should be referred to a dermatologist.

Reviews always end with the phrase insufficient evidence

A common criticism of Cochrane skin reviews by dermatology trainees, is that they always end up with the same conclusion of insufficient evidence to inform current practice. Whilst this may be true for some reviews, a glance at those reviews on the Cochrane Database of Systematic Reviews shows that at least 50 of those relevant to a practising dermatologist make specific and clear recommendations for therapy.21 Even null reviews that do not find any good evidence to make specific treatment recommendations have their uses. Thus, a recent systematic review evaluating the evidence for antistreptococcal treatments for guttate psoriasis found no reliable evidence despite confident textbook recommendations in favour of such a treatment approach.11 Not only does this identify a major gap needing research, it also reassures doctors and their patients that they are not missing some important study. It empowers doctors to feel more confident in relying on other levels of evidence such as case...

The immunological role of calcitriol

Because a large number of undifferentiated or low differentiated cancer cells have been shown to differentiate toward normal cell phenotypes, efforts to treat cancer with calcitriol have been developed. A potentially important clinical application of the antiproliferative effects of calcitriol on monocytes has been in the development of antileukemic agents. The use of vitamin D metabolites in myeloproliferative disorders in vivo has, so far, been less successful than related agents such as retinoic acid. This idea has stimulated an interest in the possible use of calcitriol in the treatment of other proliferative diseases such as psoriasis and also in the treatment of autoimmune disorders and in the prevention of graft rejection. However, the therapeutic application of calcitriol is limited by its potent effects on calcium metabolism which may result in development of hypercalciuria, hypercalcemia and soft tissue calcifications. A wide range of new vitamin D analogs are currently...

Mechanisms of the skin immune response

The elicitation phase of the contact allergic response is less well understood. Probably, allergen is taken up by local antigen-presenting cells, such as epidermal or dermal dendritic cells, which activate allergen-specific T cells that have settled in the skin after sensitization. Upon activation these cells produce mediators, allowing the further entry of circulating contact allergen-specific T cells. Various chronic inflammatory skin diseases are associated with infiltrates of CD4+ T cells. Whereas allergen-specific CD4+ T cells have been identified in contact allergy and constitutional eczema, the antigen-specificity of the CD4' T cells in diseases such as psoriasis and pityriasis rosea are unknown.

Bare lymphocyte syndrome type II

Tion responses without immunosuppression, presumably because class I antigens are expressed by these patients along with, in some cases, low levels of class II molecules. Thus, the success of bone marrow transplantation is reduced in these individuals compared with other patients suffering from combined immunodeficiencies. Total numbers of peripheral blood T cells are normal in BLS type II patients, with very low numbers of circulating CD4+ T lymphocytes and enhanced levels of CD8+ T cells. This observation differs from the phenomena observed in mice lacking class II structural genes, where no single positive CD4 T cells mature. Possible explanations may include low expression of class II antigens on thymic cells in BLS type II patients, resulting in limited CD4* T cell selection. Alternatively in humans, class I molecules in the thymus may play a role in the selection of CD4+ T cells. Most interestingly, following bone marrow transplantation of these patients, the circulating levels...

TABLE 1872 Risk Factors for Serious Heat Injury Heatstroke

By diminishing sweating ability, many skin diseases can decrease the ability to disperse heat. Scleroderma, cystic fibrosis, eczema, psoriasis, and burns decrease sweating ability. Congenital diseases, such as ectodermal dysplasia, involving the sweat glands increase risk of heat injury. Interestingly, even the presence of simple heat rash has been shown to decrease sweating. Histologic studies of skin with heat rash have demonstrated obstruction of sweat gland ducts by keratin debris, resulting in significantly lower sweating rates and decreased tolerance time in a hot environment. 13

Emollients and occlusive dressings

Psoriatic plaques are dry, scaly and frequently itchy. Emollients may help to soften psoriatic scale by increasing its water content, either by forming an occlusive layer on the skin surface (for example white soft paraffin) or by an osmotic effect (for example urea containing creams). Most topically applied therapies for psoriasis are formulated in emollient bases but emollients on their own are frequently advocated for psoriasis. They are claimed to reduce dryness, scaling and itch. There is little published evidence documenting the efficacy of emollient therapy alone in the management of psoriasis, although many studies have compared the effects of emollient bases with the same bases containing active ingredients. Some evidence suggests that emollients may have a steroid-sparing effect in psoriasis managed with topical corticosteroids. Many studies have shown an improvement over baseline after regular application of emollient creams or ointments. In one open-label study in which...

TABLE 2316 Some Common Topical Otic Preparations

Specific treatment of otomycosis consists of antifungal agents such as clotrimazole. Aspergillus is not sensitive to most oral antifungals with the exception of itraconazole.17 With noninfectious OE, removal of the offending agent is the first step in treatment. Topical steroid drops may be used for seborrhea and psoriasis.

Physiological Functions of atRA

Incidence of spontaneous and carcinogen-induced cancer. Chemopreventive trials in humans show some promise for retinoids in actinic keratoses, oral premalignant lesions, laryngeal leukoplakia, and cervical dysplasia. The US Food and Drug Administration has approved retinoids for acute promyelocytic leukemia and for non-life-threatening diseases, such as cystic acne and psoriasis. Retinoids also provide the active ingredients in agents to treat sun age-damaged skin.

Costeffectiveness analysis

Comparisons with non-dermatological problems. Another problem with CEA is that the outcomes are not weighted according to their importance. For instance, assume that new therapies for scalp psoriasis, onychomycosis and venous ulcers were cost-effective compared with their respective current therapies. Policymakers may not be able to incorporate all the therapies into their formulary because of budgetary constraints. They would need to decide which is the most important outcome clear scalp, smooth nails or healed ulcer. A better situation would be to have the outcomes standardised and weighted according to value so that policymakers could compare CEAs results across disease processes.

Consumers and research

PSGs do fund research, but the sums available from this source are modest compared with other disease areas. Among the UK skin groups. the biggest funder of research is the Psoriasis Association. Like many other PSGs, the association has a Medical and Research Committee to vet projects for research funding. The lay members on this committee help to ensure that the patient's perspective is included in their discussions. Projects are always referred to the National Council for a final decision and at this stage are sometimes passed back to the

The advantages of wellbuilt clinical questions

What criteria might be used best to specify a question at the dermatology consultation The answer to this question might vary according to patient attributes such as age, sex, past therapy and allergies. A question can be as only as good as the initial evaluation of the patient, which includes a detailed history and examination in order to obtain an accurate diagnosis. An exploration of which factors are important to the patient in terms of expectation of treatment outcome, willingness to put up with inconvenience of frequent medication, and tolerance of potential side-effects is also crucial at such an initial consultation. Specifying an outcome that means something to the dermatologist and patient is also important. For example, consider a 28-year-old man with psoriasis who is desperate for a remission of the visible plaques on his body because he is planning a once-in-a-lifetime holiday to the coast, where he wants to expose

Cutaneous Manifestations

Intertriginous infections with either Candida or Trichophyton are often seen in patients with HIV and can be diagnosed by microscopic examination of potassium hydroxide preparations of lesion scrapings. Treatment includes topical imidazole creams, such as clotrimazole, miconazole, or ketoconazole. Scabies occurs in about 20 percent of HIV-infected patients, but classic intertriginous lesions are less common. Any patient with a scaly, persistent pruritic eruption should have lesions scraped and examined histologically for scabies mites. Treatment is with permethrin 5 cream or lindane lotion. Human papillomavirus infections occur with increased frequency in immunocompromised patients. Treatment is cosmetic or symptomatic and may include cryotherapy, topical therapy, or laser therapy. Other dermatologic conditions that occur with increased frequency among HIV-infected patients include psoriasis, atopic dermatitis, and alopecia. Referral for dermatologic consultation is appropriate.

The role of consumers

Consumer involvement has been a strong feature of the CSG from the very beginning. This is because skin disease greatly affects the quality of life of the individual and because much of the trial work in skin disease has been dominated by answering questions that are important to the pharmaceutical industry. Consumers help us to redress that imbalance. At present (Autumn 2002) the skin group has 55 groups working on topics, both common and rare, such as acne, alopecia, bullous pemphigoid, eczema, excessive sweating, psoriasis, skin cancer and vitiligo. About 30 active consumers are involved at many

Working things out on the basis of mechanism and logic

Many physicians base clinical decisions on an understanding of the aetiology and patho-physiology of disease and logic.10,11 This paradigm is problematic because the accepted hypothesis for the aetiology and pathogenesis of disease changes over time, and so the logically deduced treatments change too. For example, in the past 20 years, hypotheses about the aetiology of psoriasis have shifted from a disorder of keratinocyte proliferation and homeostasis, to abnormal signalling of cyclic AMP, to aberrant arachidonic acid metabolism, to aberrant vitamin D metabolism, to the current favourite a T-cell-mediated autoimmune disease. Each of these hypotheses led to logically deduced treatments. The efficacy of many of these treatments has been substantiated by rigorous RCTs, whereas other treatments are used even in the absence of systematically collected observations. We thus have many options for treating patients with severe psoriasis (for example UVB, Goeckerman treatment, psoralen-UVA,...

The visible nature of skin disease

All the above roles are relevant to dermatology, but not special to it. What distinguishes skin disease from other kinds of illnesses is that it is much more visible to the world. This means that its social effects are often far greater than for other illnesses of comparable seriousness, and that the patient's self-image is often harmed. Healthy people, including many health professionals, do not sufficiently understand these aspects, and do not cope adequately with them. Consumers and patients can help them understand and learn what matters to people with various skin conditions. In the case of vitiligo, for example, doctors sometimes base treatment decisions on how they perceive the degree of distress. Many think that white patients suffer less than those with darker skins, but studies as well as anecdotal experience have shown that this may not be true.1 Nor is the extent of the disease always the most important factor in the patient's suffering. Self-esteem, self-image, the site...

Susceptibility gene identification

To test whether or not high-density single nucleotide polymorphism (SNP) mapping could detect a susceptibility locus within a large region, GlaxoWellcome scientists constructed a SNP map of 2 megabases (mb) on either side of APOE (Lai et al 1998). We asked the question whether a SNP map analysis could detect the location of the APOE locus for AD, if we did not know it was there. The locus was narrowed to less than 100 kilobases (kb), which included the APOE locus, in a very short time frame. This process has since been employed within GlaxoWellcome for other disease susceptibility gene searches through large linkage regions, including psoriasis, diabetes mellitus, migraine, chromosome 12-linked AD and others. These experiments will define the practical density of SNP maps useful for narrowing the large linkage areas to 50 200 kb, containing far fewer candidate genes that could then be tested for disease association (Martin et al 2000).

Patients preferences

One alleged difficulty with conducting randomised clinical trials in dermatology is the visibility of skin lesions and the consideration that, much more so than in other areas, patients self-monitor their disease and may have preconceptions and preferences about specific treatment modalities.22 The decision to treat is usually dictated by subjective issues and personal feelings. There is a need to educate physicians and the public about the value of randomised trials to assess interventions in dermatology. Motivations and expectations are likely to influence clinical outcomes of all treatments, but they may have a more crucial role in situations where soft endpoints matter, as in dermatology. Commonly, more than 20 of patients with psoriasis entering randomised clinical trials experience improvement on placebo independently of the initial disease extent. Motivations are equally important in pragmatic trials where different packages of management are evaluated, such as in the...

Selfcontrol design

Within-patient control studies (i.e. crossover and self-controlled studies) or simultaneous within-patient control studies are often used at a preliminary stage in drug development.28 They are also used in dermatology, albeit improperly, at a more advanced stage. In a survey of more than 350 published RCTs of psoriasis (unpublished data), a self-controlled design accounted for one-third of all the studies examined and was relied on at some stage in drug development. The main advantage of a within-patient study over a parallel concurrent study is a statistical one. A within-patient study obtains the same statistical power with far fewer patients, and at the same time reduces variability between the populations being compared. Within-patient studies may be useful when studying conditions that are uncommon or show a high degree of patient-to-patient variability. On the other hand, within-patient studies impose restrictions and artificial conditions which may undermine validity and...

Medline searches

Medline searches have inherent limitations that make their reliability less than ideal.2 For example, Spuls et al. conducted a systematic review of systemic treatments for psoriasis.6 Treatments analysed included UVB, PUVA, methotrexate, ciclosporin A and retinoids. The authors used an exhaustive strategy to find relevant references, including Medline searches, contacting pharmaceutical companies, polling leading authorities, reviewing abstract books of symposia and congresses, and reviewing textbooks, reviews, editorials, guideline articles and the reference lists of all papers identified. Of 665 studies found, 356 (54 ) were identified by the Medline search (range 30-70 for different treatment modalities). No references beyond those identified by Medline searching were provided by the 17 of 23 authorities who responded.6

Pooling results

Effect are the difference in response rate and its reciprocal, the number needed to treat (NNT).1711 The NNT represents the number of patients one would need to treat to achieve one additional cure. Whereas the interpretation of NNT might be straightforward within one trial, interpretation of NNT within a systematic review requires some caution as this statistic is highly sensitive to baseline event rates. For example, if treatment A is 30 more effective than treatment B for clearing psoriasis, and 50 of people on treatment B are cleared with therapy, then 65 will be cleared with treatment A. This corresponds to a rate difference of 15 (65-50) and an NNT of 7 (1 0-15). This sounds quite worthwhile clinically. However, if the baseline clearance rate for treatment B in another trial or setting is only 30 , the rate difference will be only 9 and the NNT now becomes 11. If the baseline clearance rate is 10 , then the NNT for treatment A will be 33, which is perhaps less worthwhile. In...

Costbenefit analysis

We10 compared Goeckerman therapy with methotrexate for psoriasis using CBA in addition to the CUA described above. We queried a sample of society for the amount that they would be willing to pay for each therapy if their insurance company did not provide cover for it. We found that there was no net benefit of Goeckerman therapy over methotrexate for mild, moderate and severe psoriasis. When we compared each therapy with a do nothing approach for all three severity levels of psoriasis, only methotrexate produced net benefits for severe psoriasis.

Communicating risks

How to communicate risk presents its own problems, with different conclusions being reached by doctors and their patients depending on how the information is presented in terms of relative or absolute risk.21 Even when the risks are understood, weighing up the pros and cons of an intervention is a highly variable affair. Not only does this depend on the type of information presented to the patient, but also on the way the information is presented. Thus, a doctor who believes that a patient with psoriasis needs ciclosporin A may play down the possibility of permanent kidney damage by his or her body language and by saying that he or she has treated hundreds of patients without any problem. However, for another patient who has requested the same treatment, but for whom the doctor considers ciclosporin A inappropriate, he or she may use the very same potential adverse event as a threat to dissuade the patient.

Methods of search

The search strategy Psoria* or Acrodermatitis continua of Hallopeau or (Impetigo and herpetiformis) or ((Palm* or Plant* or Sole* or Bacterid) and (Pustul* or Psoria*)) or Acropustulosis was used to search the Cochrane Central Register of Controlled Trials (Issue 3, 2001) and the European Dermato-Epidemiology Network (EDEN) database of psoriasis trials, and filtered using the Cochrane optimal search strategy for randomised controlled trials (RCTs),10 Medline and Embase (both to August 2001). The results were crosschecked against the Salford Database of Psoriasis Trials developed for the systematic review published in 2000.11

Vitamin D analogues

The vitamin D analogue calcipotriol was introduced in the early 1990s as a topical treatment for mild-to-moderate plaque psoriasis. Since then other vitamin D derivatives have been studied. One systematic review of calcipotriol found that it was at least as effective as potent topical corticosteroids, calcitriol, short-contact anthralin (dithranol) therapy and coal tar. Its main drawback is that it may cause skin irritation. Much less evidence is available for other vitamin D analogues, including tacalcitol and maxacalcitol.

Ciclosporin

The immunosuppressive drug ciclosporin has been used for treating severe psoriasis since the early 1980s. One systematic review concluded that ciclosporin is more effective at inducing remission at 5 mg kg day than at 2-5 mg kg day.59 Further increases in the dose produce little extra benefit and are limited by side-effects, particularly on renal function. Continuous therapy is usually required to maintain remission furthermore, doses below 2-5 mg kg day appear to be insufficient to achieve this. Ciclosporin appears to be more effective than etretinate. It appears to achieve more rapid improvement of psoriasis than methotrexate but produces similar benefit by 16 weeks.

Methotrexate

Methotrexate has been widely used to treat severe psoriasis since the 1960s. It was the first potent systemic antipsoriatic agent to be introduced into practice and has continued to play a vital role in the management of severe psoriasis, despite the advent of newer treatments. It has not been subjected to the same rigorous evaluation as some newer agents and a recent systematic review found no RCT in which standard methods of methotrexate administration for psoriasis were compared with placebo or with any alternative treatment modality in patients with chronic plaque psoriasis.78 Evidence from case series supports the place of methotrexate as one of the most powerful drugs in common use for severe psoriasis. Only recently has it been formally compared with another systemic agent. No significant difference in response at 16 weeks was found in 85 patients randomised to receive either methotrexate or ciclosporin, although the latter appeared to act more rapidly (Spuls P,

Fumarates

For some 20 years a mixture of dimethyl and monoethyl esters of fumaric acid has been used widely in Northern Europe, particularly in German-speaking countries, as a systemic treatment for severe psoriasis. The evidence for the efficacy of oral fumaric acid therapy has been considered in a systematic review59 which concluded that it is an effective systemic treatment for psoriasis. Of the constituents of the standard compound fumaric acid ester therapy in use in Northern Europe (Fumaderm), dimethylfumarate appears to be the principal active component although only the compound mixture has thus far been licensed for clinical use. Formal comparisons with topical or with other systemic therapies have not been performed. The incidence of symptomatic side-effects is high.

Comments

We found no RCT of treatments for this uncommon but disabling pustular form of psoriasis, which can cause marked destruction of fingernails, toenails and surrounding tissues. The greatest number of published case reports in which successful response to treatment is claimed is for ciclosporin, although acitretin, methotrexate and dapsone have been reported in individual case reports to produce resolution.

Hydroxyurea

Hydroxyurea is a systemic therapy for severe psoriasis which is mainly used as a substitute for more commonly used systemic drugs such as ciclosporin or methotrexate when these are contraindicated. The evidence for its efficacy has been considered in a systematic review.59 Hydroxyurea has not been directly compared with other systemic therapies. Side-effects include bone-marrow suppression and teratogenicity. There is a need for high-quality RCTs of hydroxyurea both against placebo and against other systemic agents.

Systemic retinoids

Systemic therapy with retinoic acid derivatives has been used for treating psoriasis since the late 1970s. Most clinical studies have been of etretinate and its hydrolysis product acitretin, which has now replaced it. One systematic review has examined the use of retinoids for psoriasis.68 It concluded that relatively high doses (approximately 1 mg kg day) are needed for monotherapy to show superiority over placebo and that the responses achieved are less than those achieved with low-dose ciclosporin. Combinations of retinoids with PUVA, UVB, topical corticosteroids and topical calcipotriol have been shown to be more efficacious than the individual components of each combination. The use of retinoids is limited by their liability to cause birth defects in women of child-bearing potential and by the high incidence of symptomatic mucocutaneous side-effects. Nevertheless they retain an important place in the management of severe psoriasis.

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Focusing more closely on discovery, we see that there are essentially five main steps target identification and validation, and lead identification, optimization, and validation. Figure 4.3 provides a description of these five steps. To illustrate these steps, we'll consider two different examples, a small molecule to treat AIDS and an antibody to treat psoriasis. The disease AIDS (acquired immunodeficiency syndrome) is caused by infection with HIV (the human immunodeficiency virus). Psoriasis is an autoimmune disease characterized by activated immune cells. Normally, the immune system acts as an internal security system, protecting the body from infection and injury. With psoriasis, however, T cells become overactive. This activity sets off a series of events that eventually make skin cells multiply so fast, they begin to pile up on the surface of the skin, forming characteristic plaques (red, scaly patches on the surface of the skin). Thus, agents that interfere with the function of...

Vaccination

Human vaccination against leishmaniasis is feasible, as individuals cured of disease remain resistant to reinfection. Indeed, a form of vaccination against leishmaniasis has existed for centuries. Inhabitants of the Middle East would expose the bottoms of their infants to bites from the sandfly vector in order to produce a lesion in a hidden part of the body and thus avoid a potential disfiguring facial scar from later infection. Parasites taken from human lesions, and latterly from in vitro cultures, have similarly been administered. There are a number of problems associated with this method when considering large-scale vaccination. Complications accompanying live vaccinations are numerous and serious around 2-3 of individuals develop large or nonhealing lesions that require treatment. Even in individuals who do not develop these problems the lesions persist for a minimum of 4-5 months. In addition, vaccination of immunosuppressed individuals by this method may have potentially fatal...

Photoimmunology

The solar spectrum, particularly the mid-UV or UVB (290-320 nm) region. UVB radiation is responsible for much of the biological activity associated with sunlight exposure, including tanning, sunburn, skin cancer and immune alterations. Wavelengths in the short UV or UVC (200-290 nm) region of the spectrum, are also immunologically active, but they receive much less attention because of their absence from natural sunlight. Long-wave UV, or UVA (320-400 nm) radiation is important because it triggers photoallergic reactions in humans and it is used in combination with photosensitizing drugs for the treatment of a variety of skin diseases, such as psoriasis and cutaneous T cell lymphoma. Recent findings have suggested that UVA may cooperate with UVB in the induction of skin cancers in mice.

Onychomycosis

Dermatophyte fungi are the most frequent cause of nail plate invasion, with T. rubrum being the most common organism. Other organisms that can lead to nail infection include Scopulariopsis brevicaulis, Scytalidium species, Aspergillus species, Acremonium species, and Candida. The elderly, patients with psoriasis, diabetics, and immunocompromised individuals are more prone to developing onychomycosis.1112, 3 and14 Nail infections usually spread from surrounding infected skin. The infection can be either under or within the nail plate. If allowed to progress, these infections lead to severe disturbances in nail growth. The affected toenails appear opaque, discolored, and, at times, hyperkeratotic. Treatment of this disease process is complicated by the fact that topical antifungals are poorly absorbed through the nail. Newer oral antifungals (itraconazole, terbinafine, and fluconazole) have become the preferred first-line agents used in the treatment of onychomycosis. Continuous (daily...

Tinea Pedis

Tinea infections must be differentiated from other lesions that affect the foot. Juvenile plantar dermatosis is a lesion frequently confused with tinea. Affected children have dry, cracked, red scaly patches on the toe pads and anterior plantar surface of the feet the toe webs and insteps are spared. Treatment consists of lubricants and occlusion, with socks at night. Contact dermatitis is characterized by involvement of the dorsal surface of the feet, with well-demarcated, red patches that may contain tiny vesicles. Psoriasis presents as thick scaly lesions that spare the web spaces and affect the heel. Erythrasma is a low-grade chronic infection that may involve the web spaces. Symmetric patches are also present in the groin and axillae. These lesions fluoresce bright coral red under Wood's lamp examination. Pitted keratolysis is a diphtheroid bacterial infection which produces marked hyperkeratosis with multiple 1- to 3-mm punched-out pits on the plantar surface of the foot. Id...

Functional Tests

Folate functional tests are the plasma homocys-teine, urinary formiminoglutamic acid (FIGLU), lymphocyte deoxyuridine (dU) suppression, and hypersegmentation of neutrophilic granulocytes assays. Folate and, to a lesser extent, vitamins B12 and B6 are involved in tHcy metabolism. Plasma homocysteine concentration, in the absence of vitamin B12 and B6 deficiencies, is considered a test of folate status. Because an elevated plasma tHcy concentration is associated with an increased risk of cardiovascular diseases, the determination of this amino acid in plasma has become very common. Various methods are available for tHcy determination. The most commonly used is the HPLC method with fluorescence or ultraviolet (UV) detection, which presents some problems for standardization. Capillary electrophoresis methods with laser fluorescent or UV detection have several advantages. Immunoassay methods are all automated, not time-consuming, and easy to use because of the availability of commercial...

Corns And Calluses

Keratotic lesions may be an indication of more severe underlying disease, deformity, local foot disorder, or mechanical problem. Other causes of keratotic lesions include syphilis, psoriasis, arsenic poisoning, rosacea, lichen planus, basal cell nevus syndrome, and, rarely, malignancies. 3

Overreliance on RCTs

Figure 54.4 A recent Cochrane systematic review found no good evidence to support the use of antistreptococcal interventions (prolonged antibiotics or tonsillectomy) for treating guttate psoriasis. Sometimes such a negative systematic review can be useful by empowering patients to question doctors on the evidential basis for their treatment decisions Figure 54.4 A recent Cochrane systematic review found no good evidence to support the use of antistreptococcal interventions (prolonged antibiotics or tonsillectomy) for treating guttate psoriasis. Sometimes such a negative systematic review can be useful by empowering patients to question doctors on the evidential basis for their treatment decisions

Corticosteroids

Urticaria, angioedema, and toxicodendron and other contact allergic dermatitides are potential indications for systemic corticosteroids. Other dermatologic syndromes, such as erythema multiforme, toxic epidermal necrolysis, and vasculitis, are best treated with systemic steroids only after consultation with a dermatologist. Eczema and psoriasis, both of which are chronic dermatologic conditions, are likely to rapidly improve after systemic steroid therapy. Both will also rebound as rapidly with discontinuation of treatment further, such management increases the possibility of development of pustular psoriasis. Oral prednisone has been used successfully in urticaria patients. In a recent small study, the addition of prednisone burst therapy (40 mg daily for 4 days) markedly reduced the pruritus and hastened the clinical improvement. The authors of this study felt that the patients' conditions improved more rapidly and more completely, and without apparent adverse effects, when...

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