Psoriasis. Definition and Etiology. Psoriasis is a common; typically chronic papulosquamous skin disease that may be associated with a seronegative spondyloarthropathy. The etiology of psoriasis is unknown. Back to Top. Prevalence and Risk Factors. Psoriasis affects 2% of the U. S. Psoriasis may begin at any age however generally there are two peaks of onset, the first at 2. Men and women are equally affected. U. S. Additionally, certain medications, notably lithium, antimalarials, beta blockers, interferon, and ethanol (if abused) have been reported to induce psoriasis or exacerbate preexisting disease in some patients. Emotional stress may also lead to psoriasis flares. Back to Top. Associations. Psoriasis is associated with the metabolic syndrome and cardiovascular (CV) disease. Psoriasis patients are not only more likely to have CV risk factors but severe psoriasis may serve as an independent risk factor for CV mortality. Back to Top. Pathophysiology. Psoriatic skin lesions are the result of inflammation in the dermis and hyperproliferation with abnormal differentiation of the epidermis. The primary pathologic process is most likely dysregulation of activated T cell interactions with antigen- presenting cells and overproduction of pro- inflammatory cytokines such as interferon- . Evidence for this theory derives from the dramatic improvement of severe psoriasis in patients treated with immunosuppressive therapies such as cyclosporine (a potent T cell inhibitor used to prevent transplant rejection) or with TNF- . The U. S Food and Drug Administration (FDA) has recently approved a novel therapy for psoriasis targeting Il- 1. IL- 2. 3, which will be discussed in the therapy section. Back to Top. Signs and Symptoms. Although considered a single disease, psoriasis has several morphologic expressions and a full range of severity. Plaque- type psoriasis, or psoriasis vulgaris, is the most common form, occurring in about 8. A typical lesion is a well- demarcated, red- violet plaque with adherent white silvery scales (Fig. Lesions are typically symmetrical and the face is usually spared. The most commonly involved areas are the elbows and knees, scalp, sacrum, umbilicus, intergluteal cleft, and genitalia. In addition to physical trauma (Koebner phenomenon), other causes of cutaneous injury such as viral exanthems or sunburn may elicit the formation of any type of psoriatic lesion. About 7. 0% of patients complain of pruritus, skin pain, or burning, especially when the scalp is involved. A characteristic finding, coined Auspitz sign, is pinpoint bleeding when psoriatic scale is lifted and correlates with histologic elongation of dermal papillae vessels in combination with suprapapillary epidermal thinning. Guttate psoriasis (Fig. This type is more common among children and young adults and is more likely to involve the face. Patients frequently have a history of a preceding upper respiratory tract infection or pharyngitis, particularly Group A Streptococcus. Some cases of acute guttate flares following streptococcal infection are precipitated by its superantigen exotoxin. Pustular psoriasis (Fig. B) accounts for approximately 1. It is characterized by sterile pustules, which may be generalized or localized to the palms and soles. There is a female predominance in localized pustular psoriasis, however the incidence is equal in men and women in the generalized type. The average age at onset for pustular psoriasis is 5. Pregnancy and rapid tapering of systemic corticosteroids are known triggers. Generalized pustular psoriasis in pregnancy is also known as impetigo herpetiformis. Impetigo herpetiformis and generalized pustular psoriasis must be treated more aggressively because untreated, may lead to serious complications such as sepsis and bacterial superinfection. Inverse psoriasis involves intertriginous areas (i. Plaques are typically pink to red and minimally scaly. Lesions may mimic cutaneous candidiasis however satellite lesions (if present) distinguish candidiasis from inverse psoriasis. Consider inverse psoriasis if candidiasis is recalcitrant to appropriate therapies. The least common form of psoriasis is exfoliative dermatitis or psoriatic erythroderma, which accounts for 1% to 2% of all cases. Erythroderma is defined as a scaling pruritic, erythematous inflammatory skin eruption that involves over 9. WebMD looks at the connection between diet and psoriasis. Psoriasis is a chronic skin condition that can cause red, scaly patches of skin to appear. Learn more about what it is, why it appears and how it’s treated. A gallstones diet sheet would effectively help you to dissolve your gallstones and would also help to considerably reduce down the pain that one tends to suffer from. Dr Pagano diet for psoriasis is one of the most searched item on the internet by the people who are looking for natural healing of psoriasis. Erythrodermic psoriasis may develop gradually or acutely during the course of chronic plaque- type psoriasis, but it may be the first manifestation of psoriasis, even in children. Psoriasis is the most common cause of erythroderma in adults and the second (following drug eruptions) in children. The mean age at onset is approximately 5. Men with the condition outnumber women, and concomitant psoriatic arthropathy is common. The most common precipitating factor is the withdrawal of potent topical, oral, and intramuscular corticosteroids. Although psoriasis patients are typically thought to be at decreased risk of cutaneous infection, those with erythrodermic psoriasis may be at risk for Staphylococcus aureus septicemia as a result of their compromised skin barrier therefore it is important for emergent evaluation by a dermatologist. Additionally, erythroderma may result in temperature dysregulation, hypoalbuminemia, and high output cardiac failure. The nails (Fig. 4) are involved in up to 5. Ps. A), the prevalence exceeds 8. Pitting of the nail plate is the most common manifestation and is the result of damage to the proximal nail matrix. The pits tend to be large, deep, and randomly dispersed on the nail plate. Yellow- brown dyschromia (oil droplet sign) of the nail bed corresponds to psoriasis in that location and is the result of abnormal keratinization of the nail bed. Ps. A affects up to one third of patients with psoriasis and is a destructive arthropathy and enthesopathy. Although Ps. A may share clinical features with rheumatoid arthritis (involving small and medium sized joints), it most commonly presents as inflammation of the proximal and distal interphalangeal joints in the hands and feet. Arthritis occurs after the onset of skin involvement in two thirds of cases however in 1. The severity of skin and nail involvement does not correlate with the severity of joint disease in patients with Ps. A. Early recognition and intervention is important as Ps. A may lead to loss of function. For this reason, patients with joint involvement are typically treated with more aggressive therapies such as a TNF inhibitor. Back to Top. Diagnosis. A clinical diagnosis is usually sufficient for classic skin and nail lesions. The differential diagnosis is expansive however with several dermatologic conditions, which may present similarly including: atopic dermatitis, pityriasis rubra pilaris, drug reactions, tinea corporis, secondary syphilis, and cutaneous T cell lymphoma (mycosis fungoides variant). Therefore, it may be necessary to perform skin biopsy, potassium hydroxide (KOH) examination of scales, and serologic evaluations such as RPR and CBC with differential, blood smear and immunophenotyping (CD 4 to CD 8 ratio). Back to Top. Therapy. The choice of treatment depends on the severity of disease and response in the individual patient. Table 1: Treatment for Psoriasis. Topical Therapies. Phototherapy. Systemic Therapy. Cholangitis, Gallstones & Strictures in the Bile Ducts. The multidisciplinary team of physicians at Froedtert & the Medical College of Wisconsin have significant. Want to know what to eat or avoid if you have gallbladder disease? Ask Joanne Larsen, registered dietitian and nutrition therapist. Psoriasis Medical Images. Red, itchy, and scaly skin? Discover common skin conditions like psoriasis, rashes, and more in the collection of medical photos. Biologic Immunomodulators. Class I or 2 corticosteroids: Clobetasol propionate 0. Temovate)Betamethasone dipropionate 0. Diprolene)Fluocinonide 0. Lidex)Desoximetasone 0. Topicort)Narrow band. UVBPUVA*Methotrexate. Cyclosporine (Gengraf, Neoral, Sandimmune)Acitretin (Soriatane). Alefacept (Amevive)Ustekinumab (Stelara)Steroid Sparing Agents: TNF- alpha inhibitors: Vitamin D analogues: Calcipotriol (Dovonex)calcipotriene (Dovonex)Calcitriol (Vectical)Infliximab (Remicade)Etanercept (Enbrel)Adalimumab (Humira)Retinoids. Tacrolimus ointment (Protopic)* *(PUVA) Psoralen combined with ultraviolet A. Topical Treatments: Patients with limited disease (affecting less than 5% body surface area), not significantly involving the hands, feet or genitalia are treated primarily with class I or II topical corticosteroids. Steroid sparing agents such as calcipotriene, calcitriol (Vitamin D analogues), pimecrolimus and tacrolimus (calcineurin inhibitors) may also be used as monotherapy or in combination with a topical corticosteroid. Patients may complain of burning with application. FDA currently recommends pimecrolimus and tacrolimus as second- line agents given potential cancer risk. Phototherapy: Phototherapy is a first line therapy for moderate to severe psoriasis. It may be used as monotherapy or in combination with topical or systemic therapies. There are several disadvantages to this treatment method as it is costly, requires special equipment and necessitates two or three office visits per week. It is advantageous for patients with additional comorbidities that preclude initiation of systemic therapies. Narrow band UVB therapy is the most commonly utilized form of phototherapy. Although more effective toward long term remission of psoriasis, psoralen plus UVA (PUVA) therapy is less utilized given increased risk of melanoma and non- melanoma skin cancers. Caution must also be taken in patients with fair skin, those who are taking photosensitizing medications, those with a history of skin cancer, and those who are chronically immunosuppressed after organ transplantation (as these patients are already at increased risk of non melanoma skin cancer). Systemic Treatments: Systemic therapy is effective, in treating severe disease (affecting more than 5% body surface area) and disease significantly involving the hands, feet or genitalia, however they have greater potential for toxicity. Systemic treatments for psoriasis are generally prescribed after consultation with a dermatologist. Methotrexate (MTX) is the antimetabolite most often prescribed by dermatologists for moderate- to- severe psoriasis. Hepatotoxicity is the primary clinical concern when planning long- term methotrexate therapy. Gallstones Diet Sheet. Among the many organs of the human body, the gallbladder is a very important organ that aids the process of digestion, especially in the smaller intestine. Though the gallbladder is always said to be an important organ, it is also a non- vital organ. You may have heard of many cases where the gallbladder has been removed for some or the other reason like gallstones or infection. Gallstones Formation. Gallstones or the condition of Cholelithiasis is the formation of deposits of crystalline concentration which form stone- like structure. Medical experts have the notion that gallstones are basically caused as a result of variable factors such as body chemistry, movement of the gallbladder, influence of body and most important of all, cholesterol. The gallstones are basically classified into two types, namely, the ones occurring from Porphyria (erythropoietic protoporphyria) and the ones occurring as a result of concentration of cholesterol in the bile, which reduces the quantity of bile fats that causes the formation of gallstones. Medical science has not yet established any concrete connections between the formation of gallstones and intake of low fiber and high cholesterol diets. However, the following diet sheet helps in reducing cholesterol intake and has certainly helped gallstones patients by relieving their pain to a great extent. Functions of Gallbladder. The basic function of this organ is to store the bile that is produced by the liver. The gallbladder is located between the gallbladder fossa, that lies near the concavity of the liver. An average gallbladder measures about 8 cm in length and has a diameter of about 4 cm. The neck of the gallbladder is a part of the binary tree and is connected to the cystic duct. The cystic duct is connected to the common hepatic duct. The whole connection is known as the common bile duct. The functioning of the gallbladder is very simple. The gallbladder is capable of storing about 5. When the food containing fat travels down into the digestive system, the bile emulsifies the fats. As it is stored in the gallbladder, over a period of time, the potential and concentration of the bile considerably increases. The enzymes and bile, further break down the food in the smaller intestine. Essential Changes in Diet. The gallstones diet can be followed before and after the surgery. There will be of course a small difference between the two. But on the whole, the basics of gallbladder surgery diet remain the same. Small amounts of healthy fat is to be consumed on a regular basis, however the volume and quality needs to be highly regulated. You doctor will provide you with better inputs. Eating fresh and varied, raw and cooked (without oil or fat) fruits and vegetables is essential. Amount of meat consumed should be significantly lowered and fat and oily meat or even fish should be strictly avoided. Breads and cereals, rice and other carbohydrates concentric foods can be consumed in appropriate quantity, however, the amount of fat, protein and other related nutrients which are likely to cause gallstones should be cut down to the bare minimum level. Before and after the surgery or any treatment regarding gallstones, your doctor will make it a point to advise you regarding dietary changes, in order to control, LDL, HDL cholesterol, fats and proteins, or any other nutrients which can trouble the gallbladder. It is very, very important to follow these recommendations and diet changes, with absolute diligence. Gallstones Diet Sheet. The following diet sheet would help you to reduce down the consumption of cholesterol and would also help you to make the best diet for gallstones. This diet, if followed regularly and with very good discipline, would help you to prevent your gallstones from growing bigger and would also help you to get your gallstones dissolved or removed quickly. Food Group. What not to Consume. What to Consume. 1. Meatsanything with oil on it, corned beef, pies, sausage, burgers, fried and grilled food, pork, beef, hams, anything with cheese and butter on it, duck, lamblean ground beef, small quantities of chicken, lean beef or pork in small quantities, Canadian bacon, boiled ham, poultry without skin, eggs without any oil, fat or cheese (note: preferably the meat should be trimmed and fat removed)2. Fruitsavocado or decorative sugar, it is also good to avoid canned fruits or any kind of cream or decoration included thereinall fresh fruits. Beveragesanything which is made from dairy products and sugars, avoid cream based products, no alcoholic drinks, no strong coffee or tea, dairy products such as latte which contain concentrated fats, proteins and related nutrients, anything with chocolate in itanything made from fresh milk in moderation, consumption of decaf coffee in moderation, low- fat milk products such as skimmed and low- fat milk, zero fat cheese or butter in moderation, low- fat yogurt. Fishfish prepared with oil or fish such as tuna, sardines, mackerel, kippers, etc.'light' fish such as haddock, shellfish, salmon, plaice, white fish, which should be cooked without oil or the least possible oil. Soups and other liquidsfat containing soups, broths, cream based soups, soups based in high fat meats, soups which have high volumes of meat in it. Simple, plain boiled soups. Vegetablesvegetables based in cream cheese or butter, or the ones which are prepared using oilplain boiled vegetables, some garnish and decoration, very, very little oil if inevitable. Desserts and Sweets anything with chocolate, pastries and high sugar quantities, dough- nuts and creamy dessertsfat, chocolate and cream- free desserts, desserts made with skimmed milk or the ones containing fruits and fruit juices. There is often a point of confusion regarding the diet. Now, in the above diet fat, cholesterol, carbohydrates and proteins are recommended to be cut down. However it does not mean that these nutrients are totally cut- off. Their consumption simply becomes reduced. Your doctor too will brief you upon some points regarding the diet. Your doctor would probably recommend some small changes in the diet which suit your body, which would help you to properly cope with the gallstones. You may also use this table to make your own gallstones diet plan and have a less painful ordeal. The key to use the diet sheet successfully, is to maintain discipline and be regular.
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