Treatment of Inverse Psoriasis with the 308 nm Excimer Laser

BACKGROUND: The treatment of inverse psoriasis can be both challenging and frustrating. Conventional topical and systemic treatments can be limited in terms of efficacy, acceptability and safety. The 308 nm excimer laser has been shown to be effective in the treatment of psoriatic plaques. METHODS: A patient with chronic inverse psoriasis was treated with 308 nm excimer laser using a 3.5 cm spot, a dosage of 2 minimal erythema doses and a pulse width of 30 ns. RESULTS: Complete clearance of the psoriatic lesions was obtained after 3 weeks of treatment. Remission duration was at least 6 months. CONCLUSION: The 308 nm excimer laser is safe and effective for the treatment of inverse psoriasis. Treatments are well tolerated with minimal side effects.     

Diagnostic dilemma: crusted scabies superimposed on psoriatic erythroderma in a patient with acquired immunodeficiency syndrome

A 45-year-old man with AIDS presented with extensive erythema and scaling involving the face, trunk, and upper and lower extremities, and mild nail dystrophy. The patient had been diagnosed with psoriasis 2 years previously, and at the time of presentation was using emollients and topical corticosteroid creams with little improvement. He was receiving zidovudine, lamivudine, trimethoprim/sulfamethoxazole, acyclovir, rifabutin, and hydroxyzine. Pertinent laboratory data included CD4 lymphocytes (10 cells/mm(3)), viral load (32,000 copies per mL) white blood cell count (3.4 x 10(3)/microL), hemoglobin (13.5 g/dL), and platelets (204 x 10(3)/microL). Because of the extensive eruption and lack of response to topical agents, the patient was started on acitretin 25 mg daily. The patient had shown no signs of improvement 4 weeks later and was noted to have brownish gray crusted plaques involving the beard area, neck, upper part of the back, arms, trunk, genitals, and thighs in addition to his erythroderma (Figure 1 and Figure 2). Microscopic examination of scales from the upper part of the back revealed numerous scabies mites and eggs. He was then treated with lindane shampoo on the scalp and beard area and permethrin 5% cream to the body. The patient returned 2 weeks later with some improvement after thrice-weekly applications of this regimen; however, scrapings from the trunk once again revealed live scabies mites. Microscopic examination of scales that had fallen on the examination table revealed multiple mites and eggs. The patient was then given permethrin 5% cream, which he applied 3 times a week for 2 weeks, and 1 dose of oral ivermectin, 200 micro/kg. This resulted in a marked decrease in crusting and scaling. With resolution of the scabies lesions, the patient displayed marked erythema and scaling of the trunk and extremities consistent with generalized psoriasis (Figure 3). Treatment with acitretin resulted in gradual resolution of the erythroderma. A few months later, the patient presented with nodules on the upper part of the back, which on biopsy revealed a scabies mite (Figure 4).     

Improvement in psoriasis with rosiglitazone in a diabetic and a nondiabetic patient

The authors conducted a prospective, open-label, pilot trial of the effects of the antidiabetic thiazolidinedione (TZD) rosiglitazone in two patients with moderate to severe plaque psoriasis. Case 1: A lean, euglycemic 43-year-old nondiabetic man with a 2-year history of plaque psoriasis presented with lesions involving 10% of his body surface (Figures 1A, 1B, 1C). He had no other chronic or acute medical problems. He had previously been managed sporadically with topical triamcinolone acetonide, an intermediate-strength glucocorticoid, and was off antipsoriatic medication for 5 months. He was started on rosiglitazone p.o., 8 mg q.d. After 10 weeks on rosiglitazone, the lesions developed increased erythema, spreading, and shedding of scale (Figures 2A, 2B, 2C). After an additional 26 weeks, the lesions had largely disappeared (Figures 3A, 3B, 3C). The patient remained euglycemic throughout the study. His liver function enzymes (alanine transferase [ALT] and aspartate transferase [AST]) remained normal throughout the study: ALT, 23 IU/L; AST, 47 IU/L before treatment; ALT, 25 IU/L; AST, 33 IU/L after treatment. There were no adverse events. Case 2: An overweight 68-year-old woman (body mass index, 29 kg/m2; with a 12-year history of type 2 diabetes and 5-year history of psoriasis presented with generalized plaque psoriasis over 20% of her body, including two large, thick, silvery plaques with the texture of leather over the lower part of the back (Figure 4A). She was given rosiglitazone p.o., 4 mg b.i.d. for 24 weeks, which resulted in significant improvement in psoriasis (Figure 4B). After an additional 26 weeks on rosiglitazone, the plaques had cleared on her back (Figure 4C) and over her entire body, including scalp, ears, and posterior forearms (not shown). Her glycemic control improved (hemoglobin A1c decreased from 7.7% to 7.2%) and liver function remained normal throughout the study (ALT, 24 IU/L; AST, 14 IU/L before treatment; and ALT, 26 IU/L; AST, 15 IU/L after treatment). There were no adverse events.     

IgA nephropathy associated with psoriasis vulgaris: a contribution to the entity of 'psoriatic nephropathy'

BACKGROUND: It is generally accepted that there is no higher prevalence of renal disease in psoriatic patients, except in the case of secondary renal amyloidosis in psoriatic arthropathy. Contrary to this, however, some authors suggest that kidney diseases in psoriasis vulgaris may be more common and they presume the existence of 'psoriatic nephropathy'. METHOD: We report a case of IgA nephropathy in a patient with psoriasis vulgaris as a contribution to the ongoing discussion concerning this entity of 'psoriatic nephropathy'. RESULT: A 62-year-old man with a history of psoriasis vulgaris, without evidence of psoriatic arthropathy, was admitted to hospital for nephrotic proteinuria 6.74 g/day and a moderate decrease of glomerular filtration rate with a serum creatinine level of 213 micromol/L and creatinine clearance of 0.95 ml/s. Kidney biopsy revealed IgA nephropathy with vascular nephrosclerosis and tubulointerstitial nephritis. After 1 month of treatment with prednisone 1 mg/kg/day, proteinuria decreased to 2.45 g/day, and skin lesions almost completely resolved. CONCLUSION: About 10 cases of IgA nephropathy associated with psoriasis are referred to in the literature. We report an-other interesting case of IgA nephropathy in a psoriatic patient, as a contribution to the discussion regarding the hypothetical conception of 'psoriatic nephropathy'. We recommend routine urinalysis, careful examination of kidney function and a wider application of renal biopsy in psoriatic patients.     

Psoriasis triggered by mefloquine

A 46-year-old Caucasian man living on the central Mediterranean island of Gozo (Malta) was started on mefloquine 250 mg once weekly before a trip to lower Egypt. He took his medication 1 week before starting his holiday and was advised to continue it for 4 weeks after returning. He did not take any other medication and enjoyed the holiday, which he initially intended to repeat in the near future. His medical history revealed a number of episodes of psoriasis for which he sought dermatologic advice. He had been given systemic therapy on at least one occasion, but the condition had been fairly quiescent for some time and he had not needed to consult a dermatologist for more than 4 years. Soon after the third tablet of mefloquine and effectively just after his return home to Gozo, the patient noticed that the psoriasis was "creeping back." He noted progressive deterioration in his skin problem but nevertheless finished the recommended course of therapy considering that "being sure about not developing malaria was far more important than a touch of psoriasis." The psoriasis worsened to the extent that he had taken off work for 2 weeks from his job as a self-employed carpenter at the time of referral. On examination, clearly there was a significant flare up of his psoriasis with severe involvement of the hands (Figure 1) and feet and less so over the rest of his body. He had been off work and matters were steadily getting worse in spite of topical treatment with a combination of calcipotriol-betamethasone ointment. Oral methotrexate 15 mg once weekly was commenced together with topical therapy with good results (Figure 2).     

2940-nm Er:YAG fractional laser enhanced the effect of topical drug for psoriasis

We observed the promoting effects of the 2940-nm erbium:YAG (Er:YAG) fractional laser in topical drug delivery for psoriasis. A total of five (four males and one female) recalcitrant psoriasis patients were given laser treatment eight times at 1-week intervals with the following parameters: 5–11% spot density and 100-μm energy depth. The psoriatic skin lesions on the left knee and the corresponding lesions at the right ones of each psoriasis patient were randomly divided into two groups: laser + topical drug group (L) and drug alone group (D). The psoriatic lesions in both groups were treated with the same topical treatment (calcipotriol ointment). The corresponding psoriatic lesions in the L group received extra 2940-nm Er:YAG laser irradiation before topical treatment. The photos of psoriatic lesions were taken before each treatment. The final photos were obtained from the patients at the seventh day after the final treatment. Drug alone or in combination with laser Er:YAG both reduced psoriatic lesions. However, with the increase in the number of treatments, increasing differences were observed between the treatment and the control sides. The therapeutic outcomes in the L groups were better than those in the D groups. Psoriasis area and severity index (PASI) scores for five cases of both groups were decreased. However, the scores in the L groups were lower than those in the D groups. The use of 2940 nm Er:YAG promoted the absorption of topical drugs for psoriasis, improving the therapeutic effect.     

Response of psoriasis to red laser light (630 nm) following systemic injection of hematoporphyrin derivative

Systemically injected hematoporphyrin derivative (HPD) in combination with red laser light (630 nm) was used to treat a patient with intraepithelial neoplasia of the vulva. Since the patient had psoriasis in the mons pubis area this region also was exposed to the red light. The psoriasis treatment area was divided into two regions receiving 40 and 20 J/cm2. Both psoriatic zones responded vigorously to the HPD + light treatment, forming eschars by 1 week postirradiation. All three treatment zones (the neoplastic area and the two psoriatic areas) underwent normal reepithelialization by 17 days.     

Targeted phototherapy using 308 nm Xecl monochromatic excimer laser for psoriasis at difficult to treat sites

Psoriasis is a chronic inflammatory multisystem disease involving skin and joints affecting 1–3 % of the world population. The 308-nm excimer laser has been recently used in the treatment of psoriasis, especially localized psoriasis of scalp and palm and soles. The objective of the study is to evaluate the therapeutic efficacy and safety of a 308-nm excimer laser for the treatment of scalp and palmoplantar psoriasis. A total of 41 adult patients (25 males and 16 females) were enrolled in this study, of which 26 patients had lesions localized to scalp, and 15 patients had involvement of palm and soles. The mean age was 44.5 years (range 18–73). And, the mean duration of psoriasis in our patients was 15 years. They were treated with a 308-nm excimer laser. The initial dose was based on multiples of a predetermined minimal erythema dose, twice weekly for a maximum 12 weeks. Twenty-two of the 23 patients with scalp psoriasis showed improvement, while one patient showed no change; none experienced worsening of symptoms. The mean minimal erythema dose (MED) was found to be 383 mJ/cm² (range 180–650 mJ/cm²). The cumulative dose of irradiation was 1,841 mJ/cm² (range 600–2,500). The percentage improvement from baseline in PSSI score was 78.57 %. Side effects were seen in 20 patients (86.96 %) mainly in the form of erythema. Four patients developed mild relapse at the end of 6 months after the therapy. In 15 patients with palmoplantar psoriasis, the mean MED was found to be 415 mJ/cm² (range 200–950 mJ/cm²). The cumulative dose of irradiation was 28.4–115.5 J?cm² (mean 59.1 J?cm²). The mean number of treatments to achieve clearance (equal to 90 % reduction of PSI score) was 16. Two patients relapsed at the end of 6 months after the therapy. The 308-nm excimer laser is an effective, safe, easy, and relatively quicker method for the treatment of psoriasis at difficult to treat sites, with good results in a somewhat short time.     

Anesthetic management of a patient with non-bullous congenital ichthyosiform erythroderma

Non-bullous congenital ichthyosiform erythroderma is a disorder in the cornification of the skin, histopathologically characterized by hyperkeratosis. Previous reports mentioned that the fixation of endotracheal tubes and ECG electrodes to the skin was likely to be infirm in the patients with this disorder, and that the patients' body temperatures were easily affected by the environment. A 3-year-old girl with non-bullous congenital ichthyosiform erythroderma underwent two operations separately under general anesthesia. We used Hollister Skin Gel to fix the endotracheal tube. This gel helped prevent the irritation associated with the application and removal of adhesives. The patient became severely hypothermic during the first operation. Fortunately, the intraoperative body temperature could be maintained at a normal level during the second operation with the use of a forced-air warming system. Careful perioperative consideration is required for the fixation of endotracheal tubes and the management of body temperature in patients with non-bullous congenital ichthyosiform erythroderma.     

Serum lipid level in Iraqi patients with psoriasis

Psoriasis is a chronic inflammatory and proliferative dermatosis. Previous studies have demonstrated that patients with psoriasis may have an increased risk of occlusive vascular disease. High serum lipid level has been suggested in the pathogenesis of this phenomenon. In this study, the authors assess the lipid profile in Iraqi patients with psoriasis and compare it with that of nonaffected persons. This study was designed and conducted as a cross-sectional study with 50 cases in the patient group and 50 patients in the control group. It was performed in the department of dermatology at Al-Sadr Teaching Hospital in Najaf, Iraq. The lipid profile, including serum levels of triglycerides, total cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein, were assessed in both groups. The patient and control groups each consisted of 39 men and 11 women. The serum triglyceride, cholesterol, LDL, and very LDL levels were significantly higher in psoriatic patients (P < .05) but not for high-density lipoprotein (P >.05). Serum lipid level was found to be significantly higher in Iraqi patients with psoriasis. It may be useful to do early screening and treatment ofhyperlipidemia in psoriasis to prevent atherosclerosis and its complications.     

Acitretin-induced enthesitis in a patient with psoriatic arthritis

A patient with psoriatic arthritis and cutaneous psoriasis took acitretin for 10 years to treat his skin lesions. Radiographs disclosed exuberant ossifications in several entheses. Their features were not typical for psoriatic arthritis but were consistent with acitretin-induced hyperostosis. Retinoids are known to induce hyperostosis, most notably when they are used in high dosages and over long periods. The concomitant presence of two conditions affecting the entheses may explain the exuberant nature of the ossifications in our patient.     

Pulsed-dye Laser Versus Intralesional Steroid in the Management of Nail Psoriasis: A Randomized,Intra-patient,Comparative, Controlled Study

BackgroundIntralesional injection of corticosteroid (ILIS) and pulsed-dye laser (PDL) have been used in nail psoriasis treatment with variable outcomes.ObjectiveWe sought to compare the efficacy of ILIS to PDL for the treatment of psoriatic fingernails using a dermoscope in the assessment and follow-up.MethodsThis study included 30 patients with bilateral nail psoriasis. The fingernails of one hand were treated with PDL, whereas ILIS was used to treat the fingernails of the other hand. One psoriatic nail was left alone as a control. Every patient received four treatment sessions once every month. Efficacy was recorded clinically using the Nail Psoriasis Severity Index (NAPSI) and by a dermoscope before treatment (baseline) and at eight, 24, and 36 weeks after treatment.ResultsThe assessment by NAPSI revealed improvements of 22.24% and 24.11% occurred in the laser group and the intralesional steroid group, respectively. Also, the dermoscopic assessments revealed an improvement of 18.33% in the laser group versus that of 21.69% in the ILES. No significant difference was found between the two groups.ConclusionBoth PDL and ILIS are considered safe treatments for nail psoriasis, yielding nearly equal results. The dermoscope is a reliable tool for the diagnosis and follow-up of nail psoriasis treatment.     

Long-term enalapril and verapamil in rats with reduced renal mass

The effect of long-term treatment with either enalapril or high dose verapamil on survival, proteinuria, blood pressure and renal morphology was studied in female Wistar rats with markedly reduced renal mass. Four weeks were allowed for remnant kidney hypertrophy before determining the response to renal ablation of individual animals regarding proteinuria and hypertension. At this time, five groups of 18 rats were formed with equal levels of proteinuria and hypertension. Groups E1 and E2 were treated with enalapril, groups V1 and V2 with verapamil, and one group served as control. The daily food allowance was 14 g/rat of a standard rat diet, containing 30% protein and 100 mmol NaCl/kg food in groups E1 and V1. NaCl content was reduced to 20 mmol/kg food in groups E2, V2 and control. The drugs were added to the drinking water, enalapril at a dose of 0.1 g/liter, verapamil at 0.5 to 0.7 g/liter. Drug intake thus amounted to 10 to 25 mg/kg for enalapril and 50 to 140 mg/kg for verapamil. Treatment was continued for 15 weeks. Three of the 18 control rats did not survive up to 15 weeks. Mortality was lower in the enalapril treated groups with a single nonsurvivor in group E1. In contrast, mortality was higher in the verapamil treated animals with seven nonsurvivors in group V1 and eight in group V2. Blood pressure control was excellent in both enalapril treated groups. and proteinuria decreased in most animals of group E1 and all of group 22. Glomerulosclerosis did not develop in the majority of the enalapril treated animals. Despite the high dose, verapamil barely lowered blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Giant gouty tophi of the hand and wrist

Gout is an inflammatory-rheumatic disease characterized by an elevated serum urate concentration and recurrent flares, including painful, hot, red, and swollen joints and surrounding tissue. Untreated gout often develops into a chronic disease with tophi and destruction of joint surfaces. Giant tophi are often resistant to medication and change in diet.This article presents a case of a 44-year-old man with giant gouty tophi at his hand and wrist. The last acute gout flare in his left wrist was approximately 3 years prior. For 2 years he had refused adequate nutrition, such as a low-purine diet, and had refused to take any preventive medication. Blood urate level was elevated to 8.7 mg/dL (normal range, 3.4-7.0 mg/dL). In time, the tophi led to a massive limitation of motion and use of especially the left wrist and thumb. Under the condition that the patient changed his diet and took the medication for his underlying disease, we surgically removed the almost skin-perforating tophi. Surgical debulking significantly improved joint function and cosmetic appearance.The best treatment for gouty tophi is prevention by ensuring adequate nutrition, treating the underlying causes, and taking effective medication. In the case of massive limitation of joint motion, skin breakdown with risk of infection, and compression of neurovascular structures, surgical debulking of the tophi should be considered.     

生物标志物应用于银屑病关节炎的研究进展

银屑病是一种慢性的、免疫相关的炎症性疾病,20％～30％的银屑病患者最终会发展为银屑病关节炎(PsA),如果患者处于活动期,则可能出现关节破坏,最终致残.现阶段尚无用于PsA早期检测的有效手段,所以能发现用于早期诊断和治疗PsA的潜在生物标志物具有重要的临床意义,本文对此做一综述.     

Coexistent psoriasis and bullous pemphigoid responding to mycophenolate mofetil monotherapy

A 73-year-old woman with a 50-year history of psoriasis was referred to our clinic with a 4-month duration of tense bullae on erythematous base and erosions localized on her lower extremities and torso (Figure 1A). Neither the oral nor the ocular mucosa had been involved. The lesions were intensively pruritic, significantly affecting the quality of her life. At the time of the examination, the patient presented with psoriatic plaques with adherent scales confined on the scalp (Figure 2A). According to the patient's history, her limited psoriasis was partially controlled with occasional topical medications (topical corticosteroids, calcipotriol, and tar shampoo). She also had insulin-dependent diabetes mellitus, asthmatic bronchitis, and partially controlled hypertension with hyperlipidemia. A biopsy specimen was taken from lesional skin on her feet, and a histological examination showed a subepidermal blister with an inflammatory cell infiltrate in the upper dermis. No drugs were incriminated, and diagnosis of bullous pemphigoid was confirmed by Western immunoblotting of serum. Laboratory investigation revealed mild thrombocytopenia of 110,000/mm(3), cholesterol 279 mg/dL, and triglycerides 210 mg/dL. The patient could not tolerate prednisolone and cyclosporine because of hypertension and diabetes, or azathioprine because of the mild thrombocytopenia; she did not consent to receiving biologics. Mycophenolate mofetil (MMF) was then considered a choice. The patient agreed, and she was initially administered 1000 mg/d. After 2 weeks, the dosage increased to 1000 mg twice a day because of the formation of new blisters. Within 8 weeks of treatment with MMF 2000 mg/d, marked improvement was observed and her pruritus resolved. Complete remission of bullous pemphigoid and psoriasis was achieved within 3 and 4 months, respectively. Routine laboratory studies were performed before treatment and every month during therapy, and MMF was tolerated without side effects. The treatment was continued for 6 months with no subsequent relapse of the dermatoses (Figure 1B and Figure 2B).     

Candida Endocarditis Complicating Glucose Total Intravenous Nutrition

A case of Candida albicans endocarditis is reported. The endocarditis occurred in a patient with a chronic illness who received intermittent glucose total intravenous nutrition for approximately 10 weeks. The patient developed severe aortic insufficiency with his valvular endocarditis and required emergency aortic valve replacement. Aggressive surgery and medical treatment appear to be the treatment of choice for these critically ill patients.     

Familial juvenile generalized pustular psoriasis: response to methotrexate

Two siblings with generalized pustular psoriasis were admitted to the hospital. Case 1: A 7-year-old girl presented with recurrent episodes of multiple pinhead-sized pustules all over her body since the age of 3. The current episode began a week prior to the onset of the lesions. On cutaneous examination, she had generalized erythema topped with tiny pustules, scales, and crusting (Figure 1A). A Gram stain performed from the pustule and cultures taken from the pus and blood were sterile. Histopathology of the pustule was suggestive of pustular psoriasis (Figure 2). Hemoglobin was 8.8 g%. Other hematologic, microbiologic, and radiologic investigations were normal. Treatment was started with methotrexate, to which she responded dramatically with reduction in appearance of new lesions, erythema, and scaling. After 4 weeks of treatment, there was almost 90% clearance of skin lesions. Case 2: A 3-year-old boy, brother of the patient in case 1, presented with similar complaints for the past week. The episode was preceded by high-grade fever. He had generalized erythema, scaling, and edema and multiple pinhead-sized pustules, some of which were arranged in an annular configuration (Figure 1B). All investigations, as in case 1, were normal except for hypocalcemia (Ca2+ = 8.8 g%) and generalized rarefaction on x-rays of both the ankle joints. Treatment was started with prednisolone (because of poor general condition) and methotrexate. Following therapy, significant improvement was evident with reduction in erythema and cessation of appearance of new pustules. The dose of prednisolone was gradually tapered after 3 weeks and then stopped.     

A basal cell carcinoma mimicking a sign of rosacea

A 55-year-old Caucasian man presented to a plastic surgeon for the treatment of two lesions on his nose, first a chronic indented area with some telangiectasia on the proximal nasal bridge (Figure 1) and second a hyperkeratotic nodule with central crusting on the ala nasi that developed rapidly over several weeks (Figure 2). The surgeon appropriately diagnosed the ala nasi nodule as a squamous cell carcinoma, keratoacanthoma type, but requested an opinion from dermatology for the proximal nasal bridge indentation that he suspected to be a morpheaform or erosive basal cell carcinoma possibly requiring Mohs micrographic surgery. Upon further questioning, the patient revealed that he has had persistent erythema and problems with facial flushing for many years, particularly with alcohol, coffee, and moderate exercise. He infrequently develops papulopustular lesions. Closer clinical inspection revealed a mild erythema, telangiectases, and a hypertrophied nose. He noted that he wore an old heavy pair of glasses every day. He was notified of a coexisting diagnosis of rosacea, and various treatment options were discussed. He was pleased that he would not need any further surgery to his nose.