How does guttate psoriasis manifest on the skin. What are the main triggers for guttate psoriasis outbreaks. Can guttate psoriasis be effectively treated. How long does a typical guttate psoriasis flare-up last. What are the differences between guttate and plaque psoriasis.

Understanding Guttate Psoriasis: A Comprehensive Overview

Guttate psoriasis is a distinct form of psoriasis characterized by small, teardrop-shaped, red, and scaly spots on the skin. This condition, while less common than plaque psoriasis, affects approximately 30% of individuals with psoriasis. Guttate psoriasis typically emerges during childhood or young adulthood and presents unique challenges in terms of management and treatment.

As an autoimmune disorder, guttate psoriasis occurs when the body’s immune system mistakenly attacks its own cells, leading to rapid skin cell turnover and the formation of characteristic lesions. While some individuals may experience a single episode, others may face recurrent flare-ups throughout their lives.

Key Characteristics of Guttate Psoriasis

• Small, teardrop-shaped lesions
• Red or pink in color
• Covered with fine scales
• Usually appears on the trunk, arms, and legs
• Can spread to face, ears, and scalp
• Rarely affects palms, soles, or nails

The Distinct Stages of Guttate Psoriasis

Guttate psoriasis progresses through several stages, each with varying degrees of severity. Understanding these stages is crucial for effective management and treatment.

Mild Stage

In the mild stage, only a few spots appear, covering approximately 3% of the skin’s surface. These lesions may be less noticeable and cause minimal discomfort.

Moderate Stage

The moderate stage is characterized by lesions covering 3-10% of the skin. At this point, the condition becomes more visible and may start to impact daily activities.

Severe Stage

In severe cases, lesions cover 10% or more of the body, potentially affecting the entire skin surface. This stage can significantly interfere with quality of life and require more aggressive treatment approaches.

It’s important to note that the classification of severity can also depend on how much the condition affects an individual’s daily life and activities. For instance, psoriasis on visible areas like the face or scalp, even if covering a small percentage of the body, may be classified as severe due to its impact on appearance and social interactions.

Triggers and Causes of Guttate Psoriasis Outbreaks

Identifying the triggers of guttate psoriasis is crucial for managing the condition effectively. While the exact cause remains unclear, several factors have been associated with the onset and exacerbation of symptoms.

Primary Trigger: Bacterial Infections

The most common trigger for guttate psoriasis is a bacterial infection, particularly streptococcus, which causes strep throat. This infection can set off an immune system reaction that leads to the characteristic skin lesions.

Other Potential Triggers

1. Upper respiratory infections
2. Sinus infections
3. Influenza
4. Tonsillitis
5. Stress
6. Skin injuries (cuts, burns, or insect bites)
7. Certain medications (antimalarials and beta-blockers)

Genetic factors also play a role in the development of guttate psoriasis. Individuals with a family history of the condition are at a higher risk of developing it themselves.

Diagnosing Guttate Psoriasis: From Symptoms to Confirmation

Accurate diagnosis of guttate psoriasis is essential for appropriate treatment and management. Healthcare providers employ various methods to confirm the presence of this condition.

Initial Assessment

The diagnostic process typically begins with a thorough medical history review and physical examination. During this stage, the healthcare provider will inquire about recent illnesses, medications, and family history of psoriasis.

Visual Examination

A visual inspection of the skin is often sufficient for an experienced dermatologist to diagnose guttate psoriasis. The characteristic appearance of small, teardrop-shaped lesions provides valuable diagnostic information.

Additional Diagnostic Tools

In some cases, further tests may be necessary to confirm the diagnosis or rule out other conditions. These may include:

• Blood tests to check for signs of infection or inflammation
• Throat culture to detect streptococcal infection
• Skin biopsy to examine skin cells under a microscope

These additional tests help healthcare providers make a definitive diagnosis and develop an appropriate treatment plan.

Effective Treatment Strategies for Guttate Psoriasis

While guttate psoriasis often resolves on its own within 2 to 3 weeks, treatment can help manage symptoms, prevent complications, and reduce the risk of future outbreaks. The choice of treatment depends on the severity of the condition and individual patient factors.

Topical Treatments

Topical treatments are often the first line of defense against mild to moderate guttate psoriasis. These include:

• Corticosteroid creams to reduce inflammation and itching
• Coal tar-based lotions to soothe the skin
• Moisturizers to combat dryness
• Vitamin D analogues to slow skin cell growth
• Salicylic acid preparations to help remove scales

Systemic Medications

For more severe cases or when topical treatments prove ineffective, systemic medications may be prescribed. These include:

• Oral corticosteroids
• Biologics (e.g., guselkumab, ixekizumab)
• Apremilast (Otezla)
• Deucravacitinib (Sotyktu)
• Methotrexate

Phototherapy

Light therapy, or phototherapy, can be an effective treatment for guttate psoriasis. This approach involves exposing the skin to controlled amounts of ultraviolet light. Natural sunlight can also have beneficial effects, but should be approached cautiously to avoid skin damage.

Living with Guttate Psoriasis: Lifestyle Modifications and Self-Care

Managing guttate psoriasis extends beyond medical treatments. Lifestyle modifications and self-care practices can play a crucial role in minimizing flare-ups and improving overall skin health.

Stress Management

Given that stress is a known trigger for guttate psoriasis, implementing stress-reduction techniques can be beneficial. These may include:

• Regular exercise
• Meditation or mindfulness practices
• Adequate sleep
• Engaging in hobbies or relaxing activities

Dietary Considerations

While no specific diet has been proven to cure guttate psoriasis, some dietary changes may help manage symptoms:

• Increasing intake of omega-3 fatty acids (found in fish, nuts, and seeds)
• Reducing consumption of processed foods and saturated fats
• Maintaining a healthy weight
• Limiting alcohol consumption

Skincare Routine

Developing a gentle skincare routine can help maintain skin health and reduce irritation:

• Use mild, fragrance-free cleansers
• Apply moisturizer regularly, especially after bathing
• Avoid hot showers and opt for lukewarm water
• Pat skin dry instead of rubbing
• Wear soft, breathable fabrics

The Prognosis and Long-Term Outlook for Guttate Psoriasis

Understanding the long-term outlook for guttate psoriasis is crucial for patients and healthcare providers alike. While the condition can be challenging, many individuals experience positive outcomes with proper management and treatment.

Remission and Recurrence

For many people, guttate psoriasis is a temporary condition that resolves within a few weeks to months. However, it’s important to note that recurrences are possible, especially if triggers are not adequately managed.

Transition to Other Forms of Psoriasis

In some cases, individuals who experience guttate psoriasis may later develop other forms of psoriasis, such as plaque psoriasis. Regular follow-ups with a dermatologist can help monitor for any changes in the condition.

Quality of Life Impact

While guttate psoriasis can affect quality of life, especially during active flares, many individuals lead normal, healthy lives with proper management. Emotional support and education about the condition can significantly improve coping strategies and overall well-being.

Emerging Research and Future Treatments for Guttate Psoriasis

The field of psoriasis research is continuously evolving, with new treatments and management strategies on the horizon. These advancements offer hope for improved outcomes for individuals living with guttate psoriasis.

Targeted Therapies

Researchers are developing more targeted therapies that aim to address specific components of the immune system involved in psoriasis. These treatments may offer more effective relief with fewer side effects.

Personalized Medicine

Advances in genetic research are paving the way for personalized treatment approaches. By understanding an individual’s genetic makeup, healthcare providers may be able to tailor treatments more effectively in the future.

Microbiome Research

Studies investigating the role of the skin microbiome in psoriasis may lead to new treatment strategies. Manipulating the skin’s bacterial environment could potentially help manage symptoms and prevent flares.

As research progresses, individuals with guttate psoriasis can look forward to an expanding array of treatment options and improved management strategies. Staying informed about these developments and maintaining open communication with healthcare providers can help ensure the best possible outcomes for those living with this condition.

Rash, Causes, Stages, Symptoms, Treatment

Written by WebMD Editorial Contributors

• What Is Guttate Psoriasis?
• Symptoms of Guttate Psoriasis
• Stages of Guttate Psoriasis
• Causes and Triggers of Guttate Psoriasis
• Diagnosis of Guttate Psoriasis
• Treatment for Guttate Psoriasis
• More

Guttate psoriasis is a type of psoriasis that shows up on your skin as red, scaly, small, teardrop-shaped spots. It doesn’t normally leave a scar. You usually get it as a child or young adult. Less than a third of people with psoriasis have this type. It’s not as common as plaque psoriasis.

It’s an autoimmune disease, meaning your body treats your own cells like invaders and attacks them. You might get it only once, or you could have several flare-ups. In some cases, this type of psoriasis doesn’t go away. With the help of your doctor, you can find a treatment to keep your symptoms under control.

The spots you get from guttate psoriasis aren’t as thick as the ones from plaque psoriasis. You can sometimes have both kinds of psoriasis at once. You probably would get them on your arms, legs, and upper body.

It can sometimes spread from there to your face, ears, and scalp. But it doesn’t show up on your palms, the soles of your feet, or nails like other forms of psoriasis can. You’re more likely to have a flare-up during the winter, when the air is dry. Your symptoms may clear up more quickly in summer.

There are three:

• Mild. Only a few spots cover about 3% of your skin.
• Moderate. Lesions cover about 3%-10% of your skin.
• Severe. Lesions cover 10% or more of your body and could cover your entire body.

The stage can also be based on how much they interfere with your daily life and activities. For example, psoriasis on your face or scalp can affect only 2%-3% of your total body surface area, but it could be classified as severe because it affects your appearance and livelihood. Psoriasis on your hands might only cover 2% total body surface area, but could affect your livelihood if you work with your hands. In that case it would be classified as moderate to severe.

An outbreak is usually triggered by a bacterial infection — typically streptococcus (strep throat). It sets off an immune system reaction that causes the spots on your skin.

In some cases, guttate psoriasis is genetic. If someone in your family has it, your chances of getting it go up.

Other triggers include:

• Upper respiratory infections
• Sinus infections
• Flu
• Tonsillitis
• Stress
• Cuts, burns, or bites on your skin
• Some drugs you take (antimalarials and beta-blockers)

Your doctor will want to know your medical history, especially what kinds of medications you may be taking. They’ll look at your skin. Usually, a physical exam gives your doctor enough information to diagnose or rule out guttate psoriasis.

If they need more information, your doctor may take a blood sample or a throat culture to check for strep. It’s also common for doctors to perform a skin biopsy when they want to know for sure what you have.

In most cases, an outbreak of guttate psoriasis lasts 2 to 3 weeks. But your doctor may want to treat your symptoms and help prevent other infections in your body.

• Medications. There are several over-the-counter or prescription options for the itchy, flaky skin, as well as the dryness and swelling. They include:
  • Cortisone cream for itching and swelling
  • Dandruff shampoo for your scalp
  • Lotions with coal tar to soothe your skin
  • Moisturizers
  • Prescription medicines with vitamin A
  • If your case is more serious, your doctor may give you a prescription to take by mouth. These include:
    • Corticosteroids
    • Biologics (guselkumab, ixekizumab)
    • Apremilast (Otezla)
    • Deucravacitib (Sotyktu)
    • Methotrexate
• Phototherapy. Also known as light therapy, this is another option. Your doctor will shine ultraviolet light onto your skin during this treatment. They may also give you medication to make your skin react more quickly to light. Sometimes, just going out into the sunshine can help.

Top Picks

Rash, Causes, Stages, Symptoms, Treatment

Written by WebMD Editorial Contributors

• What Is Guttate Psoriasis?
• Symptoms of Guttate Psoriasis
• Stages of Guttate Psoriasis
• Causes and Triggers of Guttate Psoriasis
• Diagnosis of Guttate Psoriasis
• Treatment for Guttate Psoriasis
• More

Guttate psoriasis is a type of psoriasis that shows up on your skin as red, scaly, small, teardrop-shaped spots. It doesn’t normally leave a scar. You usually get it as a child or young adult. Less than a third of people with psoriasis have this type. It’s not as common as plaque psoriasis.

It’s an autoimmune disease, meaning your body treats your own cells like invaders and attacks them. You might get it only once, or you could have several flare-ups. In some cases, this type of psoriasis doesn’t go away. With the help of your doctor, you can find a treatment to keep your symptoms under control.

The spots you get from guttate psoriasis aren’t as thick as the ones from plaque psoriasis. You can sometimes have both kinds of psoriasis at once. You probably would get them on your arms, legs, and upper body.

It can sometimes spread from there to your face, ears, and scalp. But it doesn’t show up on your palms, the soles of your feet, or nails like other forms of psoriasis can. You’re more likely to have a flare-up during the winter, when the air is dry. Your symptoms may clear up more quickly in summer.

There are three:

• Mild. Only a few spots cover about 3% of your skin.
• Moderate. Lesions cover about 3%-10% of your skin.
• Severe. Lesions cover 10% or more of your body and could cover your entire body.

The stage can also be based on how much they interfere with your daily life and activities. For example, psoriasis on your face or scalp can affect only 2%-3% of your total body surface area, but it could be classified as severe because it affects your appearance and livelihood. Psoriasis on your hands might only cover 2% total body surface area, but could affect your livelihood if you work with your hands. In that case it would be classified as moderate to severe.

An outbreak is usually triggered by a bacterial infection — typically streptococcus (strep throat). It sets off an immune system reaction that causes the spots on your skin.

In some cases, guttate psoriasis is genetic. If someone in your family has it, your chances of getting it go up.

Other triggers include:

• Upper respiratory infections
• Sinus infections
• Flu
• Tonsillitis
• Stress
• Cuts, burns, or bites on your skin
• Some drugs you take (antimalarials and beta-blockers)

Your doctor will want to know your medical history, especially what kinds of medications you may be taking. They’ll look at your skin. Usually, a physical exam gives your doctor enough information to diagnose or rule out guttate psoriasis.

If they need more information, your doctor may take a blood sample or a throat culture to check for strep. It’s also common for doctors to perform a skin biopsy when they want to know for sure what you have.

In most cases, an outbreak of guttate psoriasis lasts 2 to 3 weeks. But your doctor may want to treat your symptoms and help prevent other infections in your body.

• Medications. There are several over-the-counter or prescription options for the itchy, flaky skin, as well as the dryness and swelling. They include:
  • Cortisone cream for itching and swelling
  • Dandruff shampoo for your scalp
  • Lotions with coal tar to soothe your skin
  • Moisturizers
  • Prescription medicines with vitamin A
  • If your case is more serious, your doctor may give you a prescription to take by mouth. These include:
    • Corticosteroids
    • Biologics (guselkumab, ixekizumab)
    • Apremilast (Otezla)
    • Deucravacitib (Sotyktu)
    • Methotrexate
• Phototherapy. Also known as light therapy, this is another option. Your doctor will shine ultraviolet light onto your skin during this treatment. They may also give you medication to make your skin react more quickly to light. Sometimes, just going out into the sunshine can help.

Top Picks

Guttate psoriasis.

What is guttate psoriasis?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Guttate psoriasis is a type of psoriasis, the distinguishing features of which are the absence of damage to the nail plates and the spontaneous, unpredictable spread of skin rashes associated with the presence of an infection in the body. The primary element is a pink teardrop-shaped papule. The appearance of a papule is accompanied by itching. Initially, the rash is localized on the trunk and extremities, but subsequently spreads over the entire skin, with the exception of the palms and soles. The disease is diagnosed clinically when the psoriatic triad is detected, using histological data. The most effective methods of treatment are PUVA therapy and plasmapheresis.

• Causes of guttate psoriasis
• Classification of guttate psoriasis
• Symptoms of guttate psoriasis
• Diagnosis of guttate psoriasis
• Treatment of guttate psoriasis
• Prices for treatment

General

Guttate psoriasis is a rather rare form of scaly lichen of autoimmune coloration with a chronic course. Dermatosis has no gender or racial differences, does not have a clear seasonality, and is not endemic. Most often, guttate psoriasis is diagnosed in school-age children, young men and women. In the world, more than 4% of the population suffer from psoriasis, teardrop-shaped accounts for about 2 million people. Guttate psoriasis is organ-specific, often combined with somatic pathology, acute or exacerbated chronic infections. It is assumed that such combinations are due to a violation of the protective properties of the skin and easy penetration into the body of infectious agents, which are one of the main triggers in the trigger mechanism for the development of the disease.

It is believed that disseminated guttate psoriasis shortens the life of a woman by 3 years, men – by 1.5 years. The reason for the shortening of life is autoimmune disorders. The development of guttate psoriasis is adversely affected by bad habits, especially smoking and a high atherogenic dietary profile. Smoking a pack of cigarettes a day increases the risk of guttate psoriasis by 2 times. Eating a large amount of fish (a natural source of polyunsaturated fatty acids) reduces the likelihood of the disease by 3 times. The urgency of the problem is associated with the severe course of the psoriatic process, which significantly worsens the quality of life of patients.

Guttate psoriasis

Causes of guttate psoriasis

The vast majority of dermatologists consider the main cause of the development of guttate psoriasis to be an infection of any etiology: influenza, tonsillitis, pneumonia, acute respiratory diseases of the upper respiratory tract, mucosal candidiasis. In favor of the infectious theory, the presence of pathogenic pathogens in a scraping from a teardrop-shaped plaque testifies. An infectious disease either leads to the debut of the pathology, or exacerbates the course of other forms of psoriasis and stimulates their transformation into guttate psoriasis. The background of pathological changes is stress, overwork, decreased immunity, hereditary predisposition, or a combination of several of these factors. Despite the fact that a pathogenic pathogen is determined in scrapings from plaques, guttate psoriasis is not an infectious disease, it is not contagious.

In the pathogenesis of guttate psoriasis, the leading role belongs to autoimmune reactions. The presence of infection activates the genes responsible for the development of the disease, stress affects neuropeptides that can stimulate keratinocytes, which, in turn, release cytokines. Cytokines activate lymphocytes of the immune system and histiocytes of the connective tissue component of the skin, which attract eosinophils. There are three stages in the development of guttate psoriasis: sensitization, latent existence and effector. In the first phase, the mechanism of the antigen-antibody reaction is launched, where pathogenic microorganisms that penetrate the skin act as antigens, and cells of the immune and reticuloendothelial system act as antibodies. In the second phase, there is a latent accumulation of antibodies produced by dermal cells and lymphocytes of the immune system. Antibodies, due to an overabundance, bind not only foreign particles, but also endogenous skin structures.

Finally, in the third phase, a manifest rash of primary elements begins on the surface of the skin. The time of the onset of the final phase cannot be predicted, since the duration of the latent period depends on the virulence of the pathogen or the cytotoxicity of another pathogen, its quantity and the resistance of the organism. It should be noted that in the case of guttate psoriasis, genetic predisposition does not play a decisive role, since there are many genes responsible for the development of guttate psoriasis, and the genetic transmission of any form of psoriasis does not obey Mendel’s laws. It is impossible to consider guttate psoriasis as genodermatosis, one can only speak of a genetically determined heterogeneous disease.

Guttate psoriasis classification

In dermatology, it is customary to classify guttate psoriasis according to severity, taking into account the prevalence of skin lesions. Distinguish:

Severe guttate psoriasis is a common rash that covers more than 10% of the skin. They are localized everywhere, seriously disrupt the patient’s condition, require medical intervention in a specialized hospital and treatment according to an individual program until the primary psoriatic elements completely regress.

Symptoms of guttate psoriasis

The disease has an undulating course, remissions are replaced by relapses, especially frequent in the autumn-winter period. Clinical manifestations of guttate psoriasis occur spontaneously. The primary element is a bright red teardrop-shaped papule, 3 to 10 mm in diameter, covered with a silvery scale. Papules grow along the periphery, merge and turn into plaques. When injured, the elements are prone to ulceration and transformation into exudative psoriasis. The rash is accompanied by itching. The rash is located on the trunk and limbs – this is a typical localization of the primary elements of guttate psoriasis. The face almost always remains free, the nail plates are not affected. The rash may resolve on its own or transform into a more severe form of psoriasis. The disappearance of the rash is not a guarantee of recovery.

Diagnosis of guttate psoriasis

When making a diagnosis of guttate psoriasis, data on a recent infection, complaints, and the presence of a specific diagnostic triad: stearin stain, terminal film, and dewdrop bleeding are taken into account. In the KLA, an increased ESR and leukocytosis are determined, according to biochemistry, the presence of a rheumatoid factor is detected. Children who have had a streptococcal infection are given serological tests with the detection of an increased titer of antistreptolysin-O and antideoxyribonuclease, a swab is taken from the nasopharynx with bacteriological examination for hemolytic streptococcus.

Histology is typical for drip psoriasis, morphological changes indicate the immaturity of the epidermal cells, the presence of T-lymphocytes in the biopsy, and the phenomena of hyperkeratosis. The disease is differentiated with other varieties of psoriasis, pink lichen, secondary syphilis, drug toxicoderma, dermatitis and viral exanthema.

Treatment of guttate psoriasis

Dermatosis is resistant to ongoing therapy, requires patience from both the patient and the dermatologist. The treatment is complex, depending on the severity of the process, it is carried out on an outpatient or inpatient basis. First of all, sanation of foci of chronic infection is carried out, residual effects of acute forms of acute respiratory infections and acute respiratory viral infections are treated, and concomitant somatic pathology is corrected. The dermatologist selects an individual program of anti-atherogenic nutrition profile with the use of polyunsaturated fatty acids. Simultaneously carry out symptomatic therapy. For guttate psoriasis, PUVA therapy is most effective when given in small doses under medical supervision. The use of plasmapheresis can reduce the frequency of relapses.

Medications for guttate psoriasis are used for different purposes and according to different therapeutic regimens. For example, hormonal ointments, taking into account the area of ​​\u200b\u200bdamage to the skin, are used only in short courses; Antibacterial therapy against the inoculated hemolytic streptococcus is carried out by prescribing long cycles of antibiotic therapy using cephalosporins. The longest time is the intake of immunomodulators.

Vitamin therapy (A, D, C, E, group B) and preparations containing monoclonal antibodies are shown. If the growths of the primary elements are significant and continue to progress, retinoids are used internally and ointments with calcitriol externally. Assign sedative, antipruritic and antihistamine therapy. Baths with bran give a good effect. The prognosis is relatively favorable, taking into account the undulating course of guttate psoriasis and a decrease in the quality of life of patients.

You can share your medical history, what helped you in the treatment of guttate psoriasis.

Sources

1. self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

   Treatment of acute guttate psoriasis in addition to drugs directed against streptococcal infection

   Survey question

   The purpose of this review is to find out how well different non-streptococcal agents (i.e. drugs that do not target streptococcal infection) work for acute guttate psoriasis or guttate flare-ups of chronic psoriasis in adults and children, and how safe they are compared with placebo (identical but inactive agent) or other treatment. This topic is important because there is a lack of information and evidence regarding the best way to treat guttate psoriasis. We collected and analyzed all relevant studies to answer this question and found one study.

   Relevance

   Psoriasis is a chronic skin disease characterized by red, scaly patches (known as plaques). About 2% of people suffer from psoriasis. Guttate psoriasis is characterized by smaller lesions and is more common in children and young adults. Treatment for guttate psoriasis aims to clear the skin of lesions for as long as possible and includes topical (applied to the skin) or oral (taken by mouth) drugs, phototherapy (i.e., ultraviolet light therapy), and biologics (through which a living the body produces the active substance). It is not known which of these options is better at eliminating lesions in guttate psoriasis, and whether they are safe.

   Study profile

   We found one relevant study comparing the effects of intravenous injections of two different lipid (fat) emulsions twice a day for 10 days: one emulsion (two or more liquids that often do not mix) was derived from fish oil, and the other is from soybean oil. The follow-up period for participants was 40 days. The study was conducted in Germany among 21 adults (18 men and 3 women) aged 21 to 65 years. The average area of ​​skin lesions was 25%. Participants were hospitalized for acute guttate psoriasis. The study was funded by an oil emulsion company.

   Main results

   Treatment options for which we did not find evidence include phototherapy and topical, oral, and biologic agents. The only study found did not assess two main outcomes: the percentage of treated people whose skin cleared (or nearly cleared) of lesions, and side effects or harm from treatment.

   Most secondary outcomes were also not assessed, including worsening of guttate psoriasis or recurrence within six months of completing treatment, and the percentage of participants who achieved a Psoriasis Area and Severity Index of 75 or a Physician’s Overall Score of 1 or 2. The included study did not report about the assessment of harm from treatment; however, the study authors reported rare skin irritation at the injection site, but did not state the number of participants who experienced it.

   Study participants self-assessed several outcomes, including skin lesions, impact on daily life, itching, burning and pain.