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Psoriasis infected: Pictures, Symptoms, Triggers, and Treatments

Pictures, Symptoms, Triggers, and Treatments

Knowing which kind of psoriasis you have helps you and your doctor make a treatment plan. Most people have only one type at a time. Sometimes, after your symptoms go away, a new form of psoriasis will crop up in response to a trigger.

In general, most types of psoriasis result from the same triggers:

Other things that may trigger psoriasis include:

Here’s how you can spot the 7 types of psoriasis and what you can do to treat them.

Plaque Psoriasis

This is the most common type. About 8 in 10 people with psoriasis have this kind. You may hear your doctor call it “psoriasis vulgaris.”

Symptoms:
Plaque psoriasis causes raised, inflamed, red skin covered with silvery, white scales. These patches may itch and burn. It can appear anywhere on your body, but it often pops up in these areas:

  • Elbows
  • Knees
  • Scalp
  • Lower back

Treatments:

  • Topical treatments: These go on your skin and are usually the first thing doctors try. Some have steroids; others don’t. Prescription products slow skin cell growth and ease inflammation.
  • Phototherapy: This treatment uses ultraviolet light. You’ll get it at your doctor’s office or at home with a phototherapy unit.
  • Systemic medications: These prescription drugs work throughout your body. You’ll get them if you have moderate to severe psoriasis that doesn’t respond to other treatments. You could take them by mouth or get them as a shot or IV. This category includes drugs called biologics, which target specific parts of your immune system that play a role in the inflammatory process. Learn more about systemic treatments for psoriasis.

 

 

Guttate Psoriasis

This type often starts in children or young adults. It happens in less than 2% of cases.

Guttate psoriasis causes small, pink-red spots on your skin. They often appear on your:

  • Trunk
  • Upper arms
  • Thighs
  • Scalp

This type of psoriasis may go away within a few weeks, even without treatment. Some cases, though, are more stubborn and require treatment.

Inverse Psoriasis

This type usually found in these locations:

  • Armpits
  • Groin
  • Under the breasts
  • Skin folds around the genitals and buttocks

Symptoms include:

  • Patches of skin that are bright red, smooth, and shiny, but don’t have scales
  • Getting worse with sweating and rubbing

Common triggers are:

 

Pustular Psoriasis

This kind of psoriasis is uncommon and mostly appears in adults. It causes pus-filled bumps (pustules) surrounded by red skin. These may look infectious, but are not.

This type may show up on one area of your body, such as the hands and feet. Sometimes it covers most of your body, which is called “generalized” pustular psoriasis. When this happens, it can be very serious, so get medical attention right away.

Continued

Symptoms include:

Triggers include:

  • Topical medicine (ointments you put on your skin) or systemic medicine (drugs that treat your whole body), especially steroids
  • Suddenly stopping systemic drugs or strong topical steroids that you used over a large area of your body
  • Getting too much ultraviolet (UV) light without using sunscreen
  • Pregnancy
  • Infection
  • Stress
  • Exposure to certain chemicals

 

Erythrodermic Psoriasis

This type is the least common, but it’s very serious. It affects most of your body and causes widespread, fiery skin that appears to be burned.

Other symptoms include:

  • Severe itching, burning, or peeling
  • A faster heart rate
  • Changes in body temperature

If you have these symptoms, see your doctor right away. You may need to get treated in a hospital. This type of psoriasis can cause severe illness from protein and fluid loss. You may also get an infection, pneumonia, or congestive heart failure.

Triggers include:

Erythrodermic psoriasis may also happen if your psoriasis is hard to control.

Nail Psoriasis

Up to half of those with psoriasis have nail changes. Nail psoriasis is even more common in people who have psoriatic arthritis, which affects your joints.

Symptoms:

  • Pitting of your nails
  • Tender, painful nails
  • Separation of the nail from the bed
  • Color changes (yellow-brown)
  • Chalk-like material under your nails

You’re also more likely to also have a fungal infection.

Psoriatic Arthritis

Psoriatic arthritis is a condition where you have both psoriasis and arthritis (joint inflammation). In 70% of cases, people have psoriasis for about 10 years before getting psoriatic arthritis. About 90% of people with it also have nail changes.

Symptoms:

  • Painful, stiff joints that are worse in the morning and after rest
  • Sausage-like swelling of the fingers and toes
  • Warm joints that may be discolored

 

Psoriasis in pictures: Types, causes, and symptoms

Psoriasis is an inflammatory disease that involves skin changes. It can also affect the joints.

Recognizing psoriasis and getting an early diagnosis can help a person access effective treatment, manage symptoms, and possibly reduce the frequency and severity of flares.

Psoriasis results from a problem with the immune system. It leads to an overgrowth of skin cells, among other physical changes.

As the skin cells grow too fast, they accumulate on the surface, forming lesions or plaques of thickened, scaly skin that can be painful or itchy.

Depending on the type of psoriasis, skin changes often affect the:

  • elbows
  • knees
  • hands
  • feet
  • face
  • scalp
  • genitals
  • other areas where the skin folds

However, psoriasis can affect any area of the skin. These symptoms tend to come and go. When symptoms get worse for a period, doctors refer to this as a flare.

What does psoriasis look like on black skin? Find out here.

Other symptoms of psoriasis

Psoriasis does not only affect the skin. It is a multisystem condition that can have other effects.

About 30 percent of people with psoriasis develop psoriatic arthritis, which involves inflammation, pain, and swelling in the joints. Psoriatic arthritis can also cause fatigue. Without treatment, it can lead to permanent joint damage.

A person with psoriasis is more likely to experience other inflammatory conditions, including cardiovascular disease, diabetes, and obesity. Current guidelines recommend regular screening for these issues.

The exact cause of the condition is unclear, but it appears to involve both genetic and environmental factors. Even if a person inherits these genetic factors, they may never develop psoriasis, unless they encounter a trigger.

Triggers may include certain infectious diseases, such as strep throat. The issues below can both trigger the initial appearance of psoriasis and cause existing symptoms to flare:

  • stress
  • injury to the skin
  • the use of certain medications
  • skin infection
  • smoking
  • alcohol consumption
  • cold weather

Psoriasis is not contagious — one person cannot pass it one to another.

A range of treatments can help manage symptoms and reduce the risk of flares.

The best course of treatment depends on the type of psoriasis and the severity of symptoms. Topical treatments are often enough to manage mild symptoms.

For moderate to severe symptoms, current guidelines recommend a relatively new type of drug, called a biologic.

Biologics target specific components of the immune system and can help reduce the frequency of flares and the severity of psoriasis symptoms. They are for long-term use. These drugs are proving to be effective, but they may not suit everyone, as they can increase the risk of infections.

Other treatments — such as steroids — are for short-term use. They can treat symptoms as they arise.

A doctor will discuss the treatment options and help determine the best choices.

The range of psoriasis treatments includes:

  • Topicals: These include ointments, creams, moisturizers, and emollients that can contain corticosteroids and other effective ingredients. Some are available over the counter.
  • Moisturizers and emollients: Ask a pharmacist about options. Thicker products that are hypoallergenic and fragrance-free are usually best.
  • Phototherapy: Regular exposure to ultraviolet (UV) light or controlled sun exposure may help. Laser therapy is another option.
  • Systemic drugs: A person can take these orally or via injection. They include steroids, methotrexate, cyclosporine, and retinoids, such as acitretin.
  • Biologics: A doctor may prescribe these, depending on the type of psoriasis and the severity of symptoms.
  • Lifestyle changes: Avoiding known triggers and promptly treating triggers such as strep throat can reduce the frequency and severity of outbreaks.
  • Complementary and alternative remedies: A 2018 review found that Indigo naturalis, curcumin, fish oil, dietary changes, meditation, and acupuncture may reduce symptoms.

New discoveries are leading to new treatment options. Anyone who already has a treatment plan may wish to speak to their doctor about the latest options.

Ask a pharmacist for advice when choosing an over-the-counter topical treatment for psoriasis. Thicker products that are hypoallergenic and fragrance-free are usually best.

How can a gluten-free diet help some people with psoriasis? Click here to find out more.

Getting a psoriasis diagnosis is the first step toward effective treatment. It is also important to seek medical attention when symptoms change.

See a doctor if:

  • There are new symptoms or existing symptoms worsen.
  • Seemingly unrelated symptoms occur, especially a fever, weakness, chills, or intense pain.
  • There are signs of infection, such as oozing pus.
  • Red lines spread from the lesions, as this can indicate a rapidly spreading infection.
  • There are signs of erythrodermic or guttate psoriasis.
  • Skin changes are widespread.
  • Psoriasis treatment is not working or is causing serious side effects.

Also, consult a doctor about any changes in the pattern of psoriasis symptoms. For example, if a flare usually lasts 1 week, see a doctor if symptoms persist beyond 2 weeks.

Psoriasis in pictures: Types, causes, and symptoms

Psoriasis is an inflammatory disease that involves skin changes. It can also affect the joints.

Recognizing psoriasis and getting an early diagnosis can help a person access effective treatment, manage symptoms, and possibly reduce the frequency and severity of flares.

Psoriasis results from a problem with the immune system. It leads to an overgrowth of skin cells, among other physical changes.

As the skin cells grow too fast, they accumulate on the surface, forming lesions or plaques of thickened, scaly skin that can be painful or itchy.

Depending on the type of psoriasis, skin changes often affect the:

  • elbows
  • knees
  • hands
  • feet
  • face
  • scalp
  • genitals
  • other areas where the skin folds

However, psoriasis can affect any area of the skin. These symptoms tend to come and go. When symptoms get worse for a period, doctors refer to this as a flare.

What does psoriasis look like on black skin? Find out here.

Other symptoms of psoriasis

Psoriasis does not only affect the skin. It is a multisystem condition that can have other effects.

About 30 percent of people with psoriasis develop psoriatic arthritis, which involves inflammation, pain, and swelling in the joints. Psoriatic arthritis can also cause fatigue. Without treatment, it can lead to permanent joint damage.

A person with psoriasis is more likely to experience other inflammatory conditions, including cardiovascular disease, diabetes, and obesity. Current guidelines recommend regular screening for these issues.

The exact cause of the condition is unclear, but it appears to involve both genetic and environmental factors. Even if a person inherits these genetic factors, they may never develop psoriasis, unless they encounter a trigger.

Triggers may include certain infectious diseases, such as strep throat. The issues below can both trigger the initial appearance of psoriasis and cause existing symptoms to flare:

  • stress
  • injury to the skin
  • the use of certain medications
  • skin infection
  • smoking
  • alcohol consumption
  • cold weather

Psoriasis is not contagious — one person cannot pass it one to another.

A range of treatments can help manage symptoms and reduce the risk of flares.

The best course of treatment depends on the type of psoriasis and the severity of symptoms. Topical treatments are often enough to manage mild symptoms.

For moderate to severe symptoms, current guidelines recommend a relatively new type of drug, called a biologic.

Biologics target specific components of the immune system and can help reduce the frequency of flares and the severity of psoriasis symptoms. They are for long-term use. These drugs are proving to be effective, but they may not suit everyone, as they can increase the risk of infections.

Other treatments — such as steroids — are for short-term use. They can treat symptoms as they arise.

A doctor will discuss the treatment options and help determine the best choices.

The range of psoriasis treatments includes:

  • Topicals: These include ointments, creams, moisturizers, and emollients that can contain corticosteroids and other effective ingredients. Some are available over the counter.
  • Moisturizers and emollients: Ask a pharmacist about options. Thicker products that are hypoallergenic and fragrance-free are usually best.
  • Phototherapy: Regular exposure to ultraviolet (UV) light or controlled sun exposure may help. Laser therapy is another option.
  • Systemic drugs: A person can take these orally or via injection. They include steroids, methotrexate, cyclosporine, and retinoids, such as acitretin.
  • Biologics: A doctor may prescribe these, depending on the type of psoriasis and the severity of symptoms.
  • Lifestyle changes: Avoiding known triggers and promptly treating triggers such as strep throat can reduce the frequency and severity of outbreaks.
  • Complementary and alternative remedies: A 2018 review found that Indigo naturalis, curcumin, fish oil, dietary changes, meditation, and acupuncture may reduce symptoms.

New discoveries are leading to new treatment options. Anyone who already has a treatment plan may wish to speak to their doctor about the latest options.

Ask a pharmacist for advice when choosing an over-the-counter topical treatment for psoriasis. Thicker products that are hypoallergenic and fragrance-free are usually best.

How can a gluten-free diet help some people with psoriasis? Click here to find out more.

Getting a psoriasis diagnosis is the first step toward effective treatment. It is also important to seek medical attention when symptoms change.

See a doctor if:

  • There are new symptoms or existing symptoms worsen.
  • Seemingly unrelated symptoms occur, especially a fever, weakness, chills, or intense pain.
  • There are signs of infection, such as oozing pus.
  • Red lines spread from the lesions, as this can indicate a rapidly spreading infection.
  • There are signs of erythrodermic or guttate psoriasis.
  • Skin changes are widespread.
  • Psoriasis treatment is not working or is causing serious side effects.

Also, consult a doctor about any changes in the pattern of psoriasis symptoms. For example, if a flare usually lasts 1 week, see a doctor if symptoms persist beyond 2 weeks.

Psoriasis in pictures: Types, causes, and symptoms

Psoriasis is an inflammatory disease that involves skin changes. It can also affect the joints.

Recognizing psoriasis and getting an early diagnosis can help a person access effective treatment, manage symptoms, and possibly reduce the frequency and severity of flares.

Psoriasis results from a problem with the immune system. It leads to an overgrowth of skin cells, among other physical changes.

As the skin cells grow too fast, they accumulate on the surface, forming lesions or plaques of thickened, scaly skin that can be painful or itchy.

Depending on the type of psoriasis, skin changes often affect the:

  • elbows
  • knees
  • hands
  • feet
  • face
  • scalp
  • genitals
  • other areas where the skin folds

However, psoriasis can affect any area of the skin. These symptoms tend to come and go. When symptoms get worse for a period, doctors refer to this as a flare.

What does psoriasis look like on black skin? Find out here.

Other symptoms of psoriasis

Psoriasis does not only affect the skin. It is a multisystem condition that can have other effects.

About 30 percent of people with psoriasis develop psoriatic arthritis, which involves inflammation, pain, and swelling in the joints. Psoriatic arthritis can also cause fatigue. Without treatment, it can lead to permanent joint damage.

A person with psoriasis is more likely to experience other inflammatory conditions, including cardiovascular disease, diabetes, and obesity. Current guidelines recommend regular screening for these issues.

The exact cause of the condition is unclear, but it appears to involve both genetic and environmental factors. Even if a person inherits these genetic factors, they may never develop psoriasis, unless they encounter a trigger.

Triggers may include certain infectious diseases, such as strep throat. The issues below can both trigger the initial appearance of psoriasis and cause existing symptoms to flare:

  • stress
  • injury to the skin
  • the use of certain medications
  • skin infection
  • smoking
  • alcohol consumption
  • cold weather

Psoriasis is not contagious — one person cannot pass it one to another.

A range of treatments can help manage symptoms and reduce the risk of flares.

The best course of treatment depends on the type of psoriasis and the severity of symptoms. Topical treatments are often enough to manage mild symptoms.

For moderate to severe symptoms, current guidelines recommend a relatively new type of drug, called a biologic.

Biologics target specific components of the immune system and can help reduce the frequency of flares and the severity of psoriasis symptoms. They are for long-term use. These drugs are proving to be effective, but they may not suit everyone, as they can increase the risk of infections.

Other treatments — such as steroids — are for short-term use. They can treat symptoms as they arise.

A doctor will discuss the treatment options and help determine the best choices.

The range of psoriasis treatments includes:

  • Topicals: These include ointments, creams, moisturizers, and emollients that can contain corticosteroids and other effective ingredients. Some are available over the counter.
  • Moisturizers and emollients: Ask a pharmacist about options. Thicker products that are hypoallergenic and fragrance-free are usually best.
  • Phototherapy: Regular exposure to ultraviolet (UV) light or controlled sun exposure may help. Laser therapy is another option.
  • Systemic drugs: A person can take these orally or via injection. They include steroids, methotrexate, cyclosporine, and retinoids, such as acitretin.
  • Biologics: A doctor may prescribe these, depending on the type of psoriasis and the severity of symptoms.
  • Lifestyle changes: Avoiding known triggers and promptly treating triggers such as strep throat can reduce the frequency and severity of outbreaks.
  • Complementary and alternative remedies: A 2018 review found that Indigo naturalis, curcumin, fish oil, dietary changes, meditation, and acupuncture may reduce symptoms.

New discoveries are leading to new treatment options. Anyone who already has a treatment plan may wish to speak to their doctor about the latest options.

Ask a pharmacist for advice when choosing an over-the-counter topical treatment for psoriasis. Thicker products that are hypoallergenic and fragrance-free are usually best.

How can a gluten-free diet help some people with psoriasis? Click here to find out more.

Getting a psoriasis diagnosis is the first step toward effective treatment. It is also important to seek medical attention when symptoms change.

See a doctor if:

  • There are new symptoms or existing symptoms worsen.
  • Seemingly unrelated symptoms occur, especially a fever, weakness, chills, or intense pain.
  • There are signs of infection, such as oozing pus.
  • Red lines spread from the lesions, as this can indicate a rapidly spreading infection.
  • There are signs of erythrodermic or guttate psoriasis.
  • Skin changes are widespread.
  • Psoriasis treatment is not working or is causing serious side effects.

Also, consult a doctor about any changes in the pattern of psoriasis symptoms. For example, if a flare usually lasts 1 week, see a doctor if symptoms persist beyond 2 weeks.

Psoriasis in pictures: Types, causes, and symptoms

Psoriasis is an inflammatory disease that involves skin changes. It can also affect the joints.

Recognizing psoriasis and getting an early diagnosis can help a person access effective treatment, manage symptoms, and possibly reduce the frequency and severity of flares.

Psoriasis results from a problem with the immune system. It leads to an overgrowth of skin cells, among other physical changes.

As the skin cells grow too fast, they accumulate on the surface, forming lesions or plaques of thickened, scaly skin that can be painful or itchy.

Depending on the type of psoriasis, skin changes often affect the:

  • elbows
  • knees
  • hands
  • feet
  • face
  • scalp
  • genitals
  • other areas where the skin folds

However, psoriasis can affect any area of the skin. These symptoms tend to come and go. When symptoms get worse for a period, doctors refer to this as a flare.

What does psoriasis look like on black skin? Find out here.

Other symptoms of psoriasis

Psoriasis does not only affect the skin. It is a multisystem condition that can have other effects.

About 30 percent of people with psoriasis develop psoriatic arthritis, which involves inflammation, pain, and swelling in the joints. Psoriatic arthritis can also cause fatigue. Without treatment, it can lead to permanent joint damage.

A person with psoriasis is more likely to experience other inflammatory conditions, including cardiovascular disease, diabetes, and obesity. Current guidelines recommend regular screening for these issues.

The exact cause of the condition is unclear, but it appears to involve both genetic and environmental factors. Even if a person inherits these genetic factors, they may never develop psoriasis, unless they encounter a trigger.

Triggers may include certain infectious diseases, such as strep throat. The issues below can both trigger the initial appearance of psoriasis and cause existing symptoms to flare:

  • stress
  • injury to the skin
  • the use of certain medications
  • skin infection
  • smoking
  • alcohol consumption
  • cold weather

Psoriasis is not contagious — one person cannot pass it one to another.

A range of treatments can help manage symptoms and reduce the risk of flares.

The best course of treatment depends on the type of psoriasis and the severity of symptoms. Topical treatments are often enough to manage mild symptoms.

For moderate to severe symptoms, current guidelines recommend a relatively new type of drug, called a biologic.

Biologics target specific components of the immune system and can help reduce the frequency of flares and the severity of psoriasis symptoms. They are for long-term use. These drugs are proving to be effective, but they may not suit everyone, as they can increase the risk of infections.

Other treatments — such as steroids — are for short-term use. They can treat symptoms as they arise.

A doctor will discuss the treatment options and help determine the best choices.

The range of psoriasis treatments includes:

  • Topicals: These include ointments, creams, moisturizers, and emollients that can contain corticosteroids and other effective ingredients. Some are available over the counter.
  • Moisturizers and emollients: Ask a pharmacist about options. Thicker products that are hypoallergenic and fragrance-free are usually best.
  • Phototherapy: Regular exposure to ultraviolet (UV) light or controlled sun exposure may help. Laser therapy is another option.
  • Systemic drugs: A person can take these orally or via injection. They include steroids, methotrexate, cyclosporine, and retinoids, such as acitretin.
  • Biologics: A doctor may prescribe these, depending on the type of psoriasis and the severity of symptoms.
  • Lifestyle changes: Avoiding known triggers and promptly treating triggers such as strep throat can reduce the frequency and severity of outbreaks.
  • Complementary and alternative remedies: A 2018 review found that Indigo naturalis, curcumin, fish oil, dietary changes, meditation, and acupuncture may reduce symptoms.

New discoveries are leading to new treatment options. Anyone who already has a treatment plan may wish to speak to their doctor about the latest options.

Ask a pharmacist for advice when choosing an over-the-counter topical treatment for psoriasis. Thicker products that are hypoallergenic and fragrance-free are usually best.

How can a gluten-free diet help some people with psoriasis? Click here to find out more.

Getting a psoriasis diagnosis is the first step toward effective treatment. It is also important to seek medical attention when symptoms change.

See a doctor if:

  • There are new symptoms or existing symptoms worsen.
  • Seemingly unrelated symptoms occur, especially a fever, weakness, chills, or intense pain.
  • There are signs of infection, such as oozing pus.
  • Red lines spread from the lesions, as this can indicate a rapidly spreading infection.
  • There are signs of erythrodermic or guttate psoriasis.
  • Skin changes are widespread.
  • Psoriasis treatment is not working or is causing serious side effects.

Also, consult a doctor about any changes in the pattern of psoriasis symptoms. For example, if a flare usually lasts 1 week, see a doctor if symptoms persist beyond 2 weeks.

Psoriasis and Skin Infections – Psoriasis Center

Howard Chang, 40, has had guttate psoriasis since he was 7 years old. Guttate psoriasis is the second most common type (after plaque) and is characterized by widespread, small red spots on the skin. But Chang says it’s not just the psoriasis that makes him uncomfortable in his own skin. In 33 years of living with the chronic autoimmune condition, the California resident has found that he’s also more prone to infections such as cellulitis.

Cellulitis is a skin infection that starts when bacteria, often a variety of staph or strep, get into the deeper layers of the skin. In someone with psoriasis, irritated, flaky, inflamed areas — especially if those areas are frequently touched or scratched — are the perfect entry points for these bacteria. There’s also some evidence that psoriasis medications that suppress the immune system may increase a person’s risk for cellulitis.

“There does appear to be an increased risk for infections such as cellulitis in patients taking TNF (tumor necrosis factor) blockers such as Enbrel, Humira, and Remicade,” says Bruce Bebo Jr., PhD, director of research and medical programs for the National Psoriasis Foundation. “There are warnings in the prescribing information for this.”

Bebo notes, however, that most, if not all, of the data on TNF and cellulitis come from those taking the drugs for rheumatoid arthritis, not psoriasis.

Symptoms of cellulitis include:

  • Swelling
  • Redness
  • Tenderness
  • Warmth over the reddened area
  • Fever

Cellulitis needs to be addressed early. If left untreated, it can progress to a collection of pus (called an abscess), or the infection can spread through the bloodstream — a very serious condition.

Chang also has eczema, or atopic dermatitis, which may further increase his incidence of skin infections. “My dermatologist says I’m more vulnerable because I have psoriasis on top of everything else,” he says.

Treatments for Skin Infections

If you have psoriasis and a tendency toward skin infections, here are some steps you can take to reduce their recurrence:

  • Wash with antibacterial soaps. “One of the easiest things you can do is to use antibacterial soaps such as Dial or Lever 2000,” says Linda Wong, MD, of Kaiser Permanente-Dermatology in Baldwin Park, Calif.
  • Use benzoyl peroxide. If antibacterial soaps don’t seem to help, you can wash with a benzoyl peroxide cleanser, which is used to treat mild or moderate acne. Benzoyl peroxide, well known for its antibacterial action, is available in liquid, bar, lotion, cream, and gel form in various strengths. Start with the lowest strength first. “Use it once a day and see how your skin reacts,” Dr. Wong advises.
  • Take a bath with chlorine bleach (sodium hypochlorite). Twice a week — three times, at most — fill a bathtub with at least a foot of water (40 gallons) and add a quarter to a half cup of chlorine bleach. Soak in the tub for 10 to 15 minutes — no more. “This will reduce the bacterial load on the skin,” Wong says. Be sure to shower to rinse off the chlorine when you’re done, and apply moisturizers — the thicker and greasier, the better. “I was worried that the bleach would burn, but it didn’t,” Chang notes. “It does dry out my skin, but I use moisturizers afterward, and they help.”
  • Change your clothes regularly. “I used to want to save my wife [from doing] laundry, so I’d wear clothes over and over again,” Chang says. “But apparently bacteria can stay on your clothes and get on your skin. So now I change my clothes — and my towels — frequently to help stave off skin infections.”
  • See your doctor for medication. Antibiotics are the usual treatment for cellulitis. “If I get an infection, I’ll call my doctor and she’ll prescribe a course of antibiotics for me,” Chang says. Don’t wait for it to go away on its own: If the infection progresses to an abscess, you will likely need an incision and drainage to open the skin and remove the infected material.

If you have psoriasis and are prone to skin infections, take precautions and talk with your doctor about how best to prevent them. And if you do get an infection, be sure to have it treated immediately.

Psoriasis and infection. A clinical practice narrative

The Australasian Psoriasis Collaboration has developed a clinical practice narrative with respect to the relationship between psoriasis, its treatment and infection. The cutaneous microbiome of patients with psoriasis is different to those without psoriasis, although the significance of this is unclear. Whilst a wide range of microorganisms has been associated with psoriasis (including β-haemolytic streptococci, Staphylococcus aureus, Porphyromonas gingivalis, Candida albicans, Chlamydia psittaci, human immunodeficiency virus and hepatitis C virus), there is limited evidence that antimicrobial therapy is of direct benefit in preventing flares of psoriasis. Psoriasis is independently associated with an increased risk of serious infection, but the absolute risk is low. The risk of serious infections is further increased with immune-modulatory treatments. The decision whether to, and when to, stop or resume immune-modulatory treatment after a serious infection has occurred depends on risk assessment for that patient, taking into account the infection being treated, the risk of recurrent infection, any interventions that can modify the risk and the need for psoriasis control. Live vaccines (e.g. MMR, varicella, zoster and yellow fever) are generally contraindicated in patients with psoriasis on immune-modulatory agents, but this depends on the degree of immune suppression and individual risk factors. Wound healing in psoriasis is normal. Treatment with infliximab, adalimumab, etanercept, methotrexate and ciclosporin can safely be continued through low-risk surgical procedures. For moderate- and high-risk surgeries, a case-by-case approach should be taken based on the patient’s individual risk factors and comorbidities.


Keywords:

infection; psoriasis; surgery; therapy; vaccine; wound healing.

90,000 PSORIASIS IN HIV-INFECTED PATIENTS: FEATURES OF THE COURSE | Nemchaninova

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90,000 Disease that cannot be cured – Nyagan District Hospital

Wednesday,
28
October
2020

On October 29, events are held all over the world, the main goal of which is the fight against psoriasis and the dissemination of correct information about this disease .

According to recent studies, psoriasis affects 2 to 4 percent of the world’s population, that is, about 250 million people.The incidence in our country is as high as in other countries. Psoriasis can occur at any age (cases of psoriasis are described in both infants and very old people), but most often it affects people aged 16 to 30 years.

Psoriasis is a chronic autoimmune skin disease that occurs due to a malfunction of the immune system and manifests itself as severely flaky red or white rashes. Numerous studies that study the causes of the disease still cannot figure out one single cause of its occurrence.Stress, infections, poor diet, skin irritation, cold and dry air, the use of certain medications, alcohol abuse and smoking can worsen the condition of patients.

If you are “lucky” to get to know psoriasis personally, then, unfortunately, you will not be able to say goodbye to it forever. It is a chronic disease that cannot be cured. But the good news is that it can be effectively managed.

Practical advice for patients with psoriasis:

Wear loose, breathable clothing.

Protect your skin, avoid mechanical irritation.

Don’t dress too warmly.

Avoid contact with caustic cleaning agents and solvents whenever possible.

For body care, only mild soaps are allowed, sparing the acidic mantle of the skin.

The shower or bath you take should not be hot and long. It is best to take a short to moderately warm shower.

Try not to rub yourself too hard with a washcloth while washing and with a towel when drying.

Control your emotions.

Communication with other patients can be of additional help.

Exercising will help improve the condition, yoga is especially recommended.

A balanced diet and healthy gut microflora will improve the condition of your skin.

Groundless fears give rise to myths.

The first myth . Psoriasis affects fertility in women.

This is a complete misconception : psoriasis is not an obstacle to pregnancy. It is possible to have a genetic predisposition to this disease, but the propensity to the disease is not inevitable yet! Even if both parents have psoriasis, there is still a chance that the child will not inherit the disease. It should be remembered that a calm and “positive” mother is much more likely to give birth to a healthy baby than a mother who will constantly worry and worry that the disease will be inherited.

Psoriasis does not affect the development of the child in any way. Since this disease is non-infectious, you can safely breastfeed your baby. But most of the medicines used by women for treatment can be dangerous for the baby, because they are toxic. Therefore, when planning a pregnancy, the expectant mother should warn a dermatologist about this in advance, who will advise changes in the treatment regimen.

The second myth .Psoriasis is spread through body contact.

This is a delusion. In fact, psoriasis is caused not by pathogens, but by the leukocytes of the patient himself, so it is not transmitted by direct contact with patients, through the use of common household items and hygiene, by air or sex. Consequently, patients with psoriasis can safely visit swimming pools, baths, and other public places without posing a threat of infection. Unfortunately, not everyone knows that psoriasis is not a contagious disease, and it is not transmitted by contact.This ignorance leads to conflict, ridicule, discrimination and, as a result, suffering for people who are already suffering from a serious illness.

The third myth . The disease can be “outgrown” – and it will pass.

This is a delusion.
Psoriasis itself does not go away. At best, he “falls asleep” for a certain period, sometimes even for many years. But at some point, stress or another unfavorable factor can again provoke an exacerbation.It is impossible to get rid of psoriasis forever, but it can still be controlled by increasing the duration of the periods of remission. Today there are many drugs and methods that can reduce or even completely eliminate the external manifestations of psoriasis. Unfortunately, they cannot affect its underlying cause and reduce the activity of immune cells forever, so the effect of their use is temporary.

The fourth myth . It is not worth treating psoriasis – all the same, you will not be cured.

It is necessary to be treated . And it is better to start doing this at the first signs of the disease, because neglected psoriasis leads to undesirable complications, in particular, it can provoke psoriatic arthritis, which, without adequate timely therapy, can lead to disability, causing serious damage to the joints.

Psoriasis treatment is a long-term process aimed at controlling the disease and improving the patient’s quality of life.To determine the best therapeutic method of treatment, it is necessary to take into account the form of the course of psoriasis, the severity of the process, the area of ​​the lesion, as well as gender, age, general condition, heredity, the state of the nervous and endocrine systems, experience of previous treatment, the patient’s response to certain drugs and concomitant diseases … Treatment methods are selected by a dermatologist for each patient individually.

The fifth myth . The disease responds well to treatment with folk methods.

Alas, the effectiveness of traditional medicine in the treatment of psoriasis has not been proven. Folk methods are quite numerous and sometimes simply amaze with their ingenuity, absolutely everything is involved – from baby cream and numerous herbal tinctures to fish scales, copper sulfate and cow urine in the most bizarre combinations. In the bulk, the maximum that such “preparations” can give is only a cosmetic effect. Although in some cases, individual folk recipes can be very useful as adjuncts to traditional treatment.

In addition, having decided to resort to the methods of alternative medicine, people, alas, often come across scammers who offer to “cure” an incurable disease with the help of “miracle drugs”, shamelessly robbing patients to a penny.

V. A. Burdakov

Dermatovenerologist, Nyagan District Hospital

Immunological and clinical features of psoriasis in HIV-infected patients

1 FBSI “Central Research Institute of Epidemiology” Rospotrebnadzor, Moscow, Russia;
2 FSBEI HE “Moscow State University of Medicine and Dentistry.A.I. Evdokimov ”Ministry of Health of Russia, Moscow, Russia

Psoriasis is a systemic chronic, immunologically mediated, genetically determined disease that depends on external factors. It is detected in 2-3% of the world’s population. The review presents a modern view of the etiology, pathogenesis and features of the course of psoriasis in HIV-infected patients, as well as the methods of treatment and the possibility of their use in this category of patients. The influence of HIV infection on the key links in the pathogenesis of psoriatic disease has been noted.The methods of psoriasis therapy, the approach to the selection of its options are displayed. Used photos of HIV-infected, suffering from psoriasis vulgaris, from the personal archive of the authors. In addition to HIV infection, these patients often have comorbid diseases that affect the course of psoriasis. The review is made using available sources in the search engines PubMed Services, Clinical Queries, MEDLINEPlus. Unfortunately, the etiological and pathogenetic causes of the disease studied to date are not definitive.In this regard, the methods of psoriasis therapy will continue to change and improve, which indicates the importance of continuing research on this pathology in patients with HIV infection and developing new methods of treatment.

Epidemiology

Psoriasis affects more than 150 million people and is one of the most common dermatoses in the world. The disease is ubiquitous, with prevalence ranging from 0.25 to 3.5% in different populations. In Europe, the largest number of patients with psoriasis is noted in Norway (8.5%), while in Northern Europe the average number of patients is 2%, in the United States – 2.4%, and 140,000–160,000 new cases are registered annually [1].

Psoriasis is unevenly distributed in populations and on continents: the disease is more common in East Africa among white emigrants, less often in West Africa among indigenous people – 1.2 and 2.5%, respectively. According to researchers, the lowest incidence was noted among the Indians of South America (0.1%). No gender differences were found in psoriasis [2].

The disease occurs at any age, extremely rarely – in children under 1 year of age. When studying the prevalence of psoriasis among children, it was found that its frequency in the UK was 0.55% in the age group 0-9 years and 1.37% in the group of children 10-18 years old [3]; in the USA – 40.8 per 100 thous.children under the age of 18 [4].

There are 2 age peaks in the development of psoriasis: the first at 20–40 years old, the second at 40–60 years old.

Patients with psoriasis with moderate to severe clinical course are at increased risk of death due to comorbidity with cardiovascular diseases [5].

One of the most severe manifestations of psoriasis is psoriatic arthritis (PSA). According to various sources, its frequency in patients with psoriasis ranges from 20 to 30%. So, when examining 330 children (average age – 9.4 years) and 2000 adults (average age – 48.5 years) with psoriasis, in France the frequency of PSA was 4.2% among children and 21% among adults [6] …Studies in Denmark with 13,000 PSA patients have shown that the number of PSA patients is increasing. If in 1997 7 cases of PSA were detected per 100 thousand population, then in 2010 – already 30 [7]. In psoriasis, the inflammatory process often involves the nail plates, which occurs in 70% of patients with PSA and is considered a pathognomonic sign of PSA [8].

In patients with psoriasis, comorbid diseases (Crohn’s disease, depressive disorders, uveitis, metabolic syndrome), as well as cardiovascular pathology, non-alcoholic liver dystrophies and erectile dysfunctions are more often detected [9, 10].

Treatment requires significant financial costs. According to the National Psoriasis Foundation of America, in 2015 the average cost of treating one patient with psoriasis exceeded $ 25,000, which amounted to more than $ 135 billion for all insured patients with psoriatic disease in the United States [1].

The incidence of psoriasis in HIV-infected people is different. When examining 2000 patients with HIV infection in San Francisco, psoriasis was diagnosed in 2.5% of patients, while in Berlin, when examining 700 patients with HIV infection, it was diagnosed in 5% [11].Against the background of HIV infection, severe forms of psoriasis vulgaris, pustular psoriasis, psoriatic erythroderma and PSA are more common. In the late stages of HIV infection in patients with psoriatic disease, inflammatory lesions of the eyes, damage to the central and peripheral nervous systems, signs of heart and renal failure are noted [12].

Etiology and pathogenesis

Psoriasis is a multifactorial disease with a hereditary predisposition characterized by increased proliferation of epidermal cells, impaired keratinization and an inflammatory response in the dermis caused by activated T-lymphocytes and the synthesis of pro-inflammatory cytokines [13].

The genetic factor plays an important role in the development of the disease; the probability of its inheritance is estimated at 60–90% [14].

There are 9 PSORS regions (1–9) located on different genes (1q21, 3q21, 4q31) and associated with the inheritance of psoriasis. In addition, other chromosomes are examined for links with the disease. The allele HLA-Cw6 (PSORS1) located on chromosome 6 is the most associated with psoriasis: it is associated with the development of the disease in 10% of carriers of this locus [14].

According to most researchers, DNA methylation and changes in gene expression, as well as the relationship of the KIR3DS1 genotype and HLA-Bw4-80I, which encodes the activation of the CD8 + receptor on natural killer cells and its ligand, significantly increase the risk of psoriasis in HIV-infected patients [15 , sixteen].

Concordance to psoriasis in monozygotic twins ranges from 35 to 75%. This indicator does not reach 100%, which indicates the presence of other causes of the development of psoriatic disease that are not related to human genetics [17].

The factors that most often lead to the manifestation and exacerbation of the disease are psychoemotional stress, infectious diseases of the oropharynx, medications (β-blockers, lithium salts, INF-α-2b), alcohol and smoking [18].

Psoriasis is considered an autoimmune inflammatory disease …

Evdokimov E.Yu., Sundukov A.V., Gorelova E.A.

Pustular psoriasis and urethrooculosinovial syndrome in HIV-infected patients. Clinical and pathogenetic parallels | Bakhlykova E.A., Goloviznin M.V.

The article is devoted to the problem of pustular psoriasis and urethrooculosinovial syndrome in HIV-infected patients.

In recent years, due to the large-scale increase in the incidence of infection caused by the human immunodeficiency virus (HIV), clinicians and immunologists from around the world have been accumulating clinical material on the features of the clinical picture of this disease and its various complications. It is now clear that HIV-associated disease goes through several stages over time.A detailed clinic of the terminal stage of HIV infection – acquired immunodeficiency syndrome (AIDS) was described in the mid-80s of the twentieth century. as a combination of atypical pneumocystic pneumonia and a rare tumor of Kaposi’s sarcoma in patients with very low levels of T-helper lymphocytes carrying the CD4 receptor, which later became known to be a ligand for some HIV proteins. At the same time, in the same years, reports began to appear about rheumatological manifestations of AIDS with signs of autoimmune reactions.The autoimmune manifestations of HIV infection may seem paradoxical, since HIV ultimately causes the death of T helper cells (CD4 + lymphocytes), which are also responsible for autoimmune reactions. However, as evidenced by the facts, against the background of the manifestation of AIDS, autoimmune expansion can be carried out by other immunocompetent cells, which also have an autoreactive potential. In addition, with HIV infection, there is a pronounced decrease in the so-called T-regulatory cells, the main function of which is to suppress autoimmune reactions.Perhaps, in this regard, during the primary phase of HIV infection, numerous inflammatory cytokines, such as tumor necrosis factor, interleukin-6, interleukin-12, and interferon-gamma, can be detected in the blood serum. All autoimmune syndromes (AS) in HIV infection, including those with cutaneous manifestations, can be divided into 2 unequal groups. The first group of AS includes isolated reactive arthritis, Sjogren’s syndrome, diffuse infiltrative lymphocytosis, etc. These nosologies are pathogenetically manifested by increased production of autoantibodies, immune complexes and pro-inflammatory cytokines that activate B-lymphocytes.They are characteristic of the early stages of HIV infection, the so-called AIDS-associated complex, or pre-AIDS. In the later stages of AIDS, these diseases (along with rheumatoid arthritis (RA)) usually subside. The second group of AS, which will be discussed to a greater extent in this message, includes all types of psoriasis, ankylosing lesions of the spine and some systemic vasculitis. The manifestation of these nosologies occurs more often in the advanced stage of AIDS with a pronounced decrease in the level of T cells carrying the CD4 receptor, and a frequent combination with infectious diseases that also manifest in HIV-infected patients.A sharp increase in the incidence of spondyloarthritis with and without reactive arthritis and, to a lesser extent, psoriatic arthritis has been noted, in particular, in connection with the spread of the HIV pandemic in Africa. This suggests a pathogenic role for HIV infection in these diseases. Clinical, diagnostic, and radiological signs of HIV-associated spondyloarthritis are indistinguishable from typical AS associated with HLA-B27, although HIV-infected patients have a higher overall incidence of uveitis, keratoderma and onycholysis and often a worse prognosis than HIV-negative patients.It should be noted that spondyloarthritis is usually associated with HLA-B27 positivity in Caucasians, but not in Africans [1].
Psoriatic arthritis (with or without skin involvement) is common in HIV-infected individuals. The prevalence of psoriatic skin changes and psoriatic arthritis in HIV-infected patients is about the same as in uninfected patients (1 to 2%), but the severity of psoriasis and psoriatic arthritis associated with HIV is usually more pronounced.Feet and ankle joints in HIV infection with suspected psoriasis are most often and severely affected. Arthritis is accompanied by intense enthesopathies and dactylitis. Enthesopathies are one of the main causes of limited mobility. Joint effusion is less common but can be found in the ankle and subtalar, metatarsophalangeal, and interphalangeal joints of the feet. Involvement of the sacroiliac joint and spine is possible. In this case, the X-ray picture can mimic classic psoriatic arthritis, even in the absence of typical skin manifestations.Nail involvement occurs in most patients with HIV-associated psoriatic arthropathy.
Urethrooculosinovial syndrome (US, Reiter’s syndrome ) was the first rheumatologic syndrome found in patients with HIV infection. It also occurs in asymptomatic patients, but more often with clinically pronounced immunodeficiency. In the case of manifestation of US without other manifestations of immunodeficiency, their appearance should be expected within the next 2 years. The classic triad: urethritis, arthritis and conjunctivitis – occurs in some HIV-infected patients, but more often there is an incomplete clinical picture.A common symptom of US is oligoarthritis of large joints (usually ankles or knees). Extra-articular manifestations include balanitis (balanitis circinata), keratoderma (keratoderma blennorrhagicum), stomatitis, and uveitis. Enthesopathies, involvement of the Achilles tendon, plantar fascia, calf tendons, and multiple dactylitis in the case of upper limb involvement are common enough for HIV infection. Synovitis of the wrist, elbow, and shoulder joints is rare, but can lead to contractures and ankylosis.Enthesopathies can involve the medial and lateral epicondyle. Clinicians should recommend HIV testing for all patients with US with a life history suggesting an increased risk of HIV infection. Symptoms such as weight loss, general malaise, lymphadenopathy and diarrhea may be early manifestations of AIDS in them [1].
Pustular skin lesions with HIV infection in individuals with and without autoimmune syndromes are also extremely common.In the first case, HIV infection can be a trigger factor for pustular psoriasis. AIDS can also proceed under the guise of other forms of pustular dermatoses, which presents certain difficulties for differential diagnosis, as well as for the treatment of patients. Usually, diseases are severe, have a widespread nature, an acute course, especially for various forms of pustular psoriasis, subcorneal pustular dermatosis Sneddon – Wilkinson, deep forms of pyoderma, blennorrheic keratoderma.In HIV-infected people, these nosologies have a number of features, namely: they arise in unusual age and sex groups, are difficult, and do not respond well to therapy. The addition of sexually transmitted infections (STIs) in this contingent of patients also causes a more malignant course of the disease [2].
It is practically indistinguishable from pustular psoriasis in HIV-infected persistent pustular acrodermatitis Allopo – a disease of unknown origin, characterized by pustular non-bacterial rashes in the distal extremities.It is a rare condition with pustular, sterile eruptions on the fingers or toes that slowly spreads to the lower legs and forearms. In the future, prolonged pustulation leads to destruction of the nail and atrophy of the distal phalanx. The provoking factors of Allopo acrodermatitis are trauma, pyoderma, zinc deficiency. The disease develops at any age, more often in men. Clinically manifested by lesions of the terminal phalanges of the fingers of the hands, less often of the feet, of a pustular, vesicular or erythematous-squamous nature and a gradual transition to the adjacent areas of the hands and feet without proximal spread.The rash makes its debut on the terminal phalanges of the fingers, less often the legs, gradually spreading to other areas of the skin of the palms and soles. In rare cases, the process takes on a generalized nature. The nail folds are sharply hyperemic, edematous, infiltrated, and pus is released from under them. In the future, pustules or vesicles appear on the skin of the entire surface of the nail phalanx, which, drying out, become covered with crust-scales. The fingers are deformed, take a bent position, the terminal phalanges increase sharply in size.The first signs of the disease appear in the form of small pustules, after which a shiny surface remains on the erythematous background, new pustules develop on it. In some cases, secondary atrophic changes in the skin are observed. Pathognomonic damage to the nails, usually one finger, leading to the involvement of the nail bed in the pathological process, to onycholysis and onychomadesis. Features of clinical manifestations mainly depend on the intensity of exudation processes. If they are insignificant, erythematous-squamous changes are found in the lesions with increased redness along the periphery, layering of dry shiny scales, and multiple superficial cracks.If pustular eruptions dominate the clinical picture, the disease is more severe. With a long process, signs of atrophy of the skin and muscles of the fingers appear, mutating changes due to trophic disorders. The prognosis for life is favorable. However, the course is long, often relapsing, resistant to therapy. Spontaneous improvement is rare, and episodes of acute pustulization are observed for no apparent reason [3].
Late diagnosis of skin and joint diseases, lack of full examination of HIV-infected patients, irrational treatment at the initial stages, underestimation of concomitant pathology can lead to a severe course of the underlying and concomitant diseases.

Observation 1

Patient B., 23 years old, in November 2012 was delivered by an ambulance to the regional dermatovenerologic dispensary (OKVD) in Tyumen with a diagnosis of “generalized pyoderma, acute course, moderate severity.” Upon admission to the inpatient department of the OKVD – complaints of skin rashes, crusts, nail damage, joint pain, an increase in body temperature for 1.5 months. up to 37.5–38 ° C. From the anamnesis of the disease: it is known that he is sick for about 1.5 months.He associates his disease with the intake of large quantities of plums in food. The first rashes appeared on the lower extremities, after intensive scratching they began to become covered with crusts. She was not treated on her own.
Life history: was born and lives permanently in the Kurgan region. In 2009 hepatitis B was diagnosed, at the same time there were multiple fractures of the pelvic bones, hips, legs as a result of a fall from a height. Allergic anamnesis is not burdened.
Gynecological history: regular menstruation, no pregnancies.Single. Has a permanent sexual partner born in 1979, sexual intercourse for 2 years. The last sexual intercourse is 1.5 months. back. Other sexual contacts are not indicated. The sexual partner was summoned to a venereologist at the OKVD. Heredity is not burdened.
Condition at the time of examination: General condition is satisfactory. Temperature 37.6 ° C. Incorrect physique, asthenic constitution. The food is low. The skin is pale, moist, swelling, pasty knee, ankle joints, lower third of the legs.Inguinal lymph nodes are enlarged to the size of a pod, heavy, painful on palpation. NPV – 16 per minute, heart rate – 76 per minute, blood pressure – 110/70 mm Hg. Art.
Local status: the pathological process is widespread with localization on the skin of the red border of the lips, forearms, elbow joints, abdomen, thighs, legs, feet. The red border of the lips is brightly hyperemic, linear ulcers with serous-hemorrhagic crusts are visible in the corners of the mouth. On the mucous membrane of the tongue, a “geographical pattern” and folding are noticeable.On the skin of the forearms, legs, multiple rashes are visible, rounded foci against the background of hyperemic, edematous, infiltrated skin, with a diameter of 1 to 5 cm. On the surface of the skin elements, a layering of thick brown scaly crusts is determined – rupees. On the skin of the thighs, knees, in the pubis, perineum, drainage erythema, edema and layered scaly crusts are localized. On the skin of the periungual ridges, swelling, bright hyperemia with layering of grayish-yellow scales is also revealed. The nail plates on the hands and feet are thickened, exfoliate from the nail bed, and have a yellow-gray color.The interphalangeal joints of the first finger of the right hand are edematous like a “sausage” toe, the interphalangeal joints of the feet are also swollen, stiff and painful when moving. On the skin in the area of ​​the joints, congestive red hyperemia with layering of crusts.
Gynecological examination: The external genitals are formed correctly. The labia majora and labia minora are sharply edematous, the mucous membrane is brightly hyperemic, has a granular relief. The lips of the urethra are edematous, hyperemic. The posterior commissure is torn, bleeding.Vaginal discharge is profuse, purulent-hemorrhagic. Examination in the mirrors is difficult due to the sharp pain and refusal of the patient to be examined in the mirrors.

Laboratory research data

Chest X-ray: lungs without focal and infiltrative shadows, sinuses are free, heart is normal.
Electrocardiogram : sinus tachycardia, heart rate – 103 per minute; signs of load on the right atrium.
Complete blood count: leukocytes – 4.7 × l09 / l; erythrocytes – 3.07 × l012 / l; hemoglobin – 93g / l; hematocrit – 17.9%; platelets – 200 × l09 / l; e-O, n-2, s-79, l-12, mb, ESR – 69 mm / h, anisocytosis, poikilocytosis.
General urine analysis: pH – 6.5, transparent, beats. weight – 1030, protein – 0.3 g / l, sugar – negative, urobilinogen – 17 μmol / l, leukocytes – 25 / μl, ketone – 0.5 mmol / l, nitrates – positive.
Biochemical blood test: total bilirubin – 9 kmol / l, direct – 1 μmol / l, AST – 29 U / l, ALT – 33 U / l, alkaline phosphatase – 124 U, seromucoid – 0.67 U, CRP – 4 mg / l, creatinine – 128 μmol / l, sodium – 133, potassium – 4.1, chlorine – 97, urea – 5.7 – mmol / l, sugar – 5.3 mmol / l.RMP, ELISA for syphilis total – negative result; RIF for chlamydia – positive; PCR for chlamydia – a positive result.
Microflora smear. Urethra: leukocytes 6-8 in the field of view (f / sp), epithelium 2-4 in f / sp. Cervix: leukocytes 40-60 in field of vision, epithelium 6-8 in field of vision. The posterior fornix of the vagina: leukocytes 20-24 in the field of vision, epithelium 2-4 in the field of vision, Trichomonas – found, microflora (gram +) – moderate.
Bacteriological inoculation of skin scales and nail plates: growth of fungi of the genus Candida albicans .Feces for eggs of worms: not found.
RIF for herpes of the 1st and 2nd type: detected.
ELISA on Chl. Trachomatis: IgA not detected, IgG 1: 5 OD, 0.367 / 0.290.
HIV RNA by PCR: detected at a concentration of 2.14 x 105 copies / ml.
Immunogram: CD4 – 252/109 / l, CD8 – 488/109 / l, CD4 / CD 8: 0.52.
Consulted by a specialist from the Center for the Fight against AIDS (CPPS), preliminary diagnosis: HIV infection, stage 4a, phase of progression. After discharge, further observation and treatment was recommended at the Central Pediatric Hospital for antiretroviral therapy.
Based on anamnesis, clinical and laboratory studies, the diagnosis was made: Reactive arthritis, urethrosynovial syndrome, acute course, moderate severity (arthritis, urethritis, vulvitis, widespread blennorrhea keratoderma). Chlamydial infection of the lower urinary tract. Urogenital trichomoniasis. Urogenital herpes, exacerbation. HIV infection, stage 4a, phase of progression. Candidal onychomycosis, paronychia. Hypochromic anemia of mild severity (Fig.1-3).

Treatment : solution (solution) of sodium thiosulfate 30%, 10.0 i / v, No. 10; solution of sodium chloride 0.9%, 400.0 + dexamethasone 8 mg, intravenous drip, No. 5, daily; solution of sodium chloride 0.9%, 200.0 + solution of ascorbic acid 5%, 4.0, intravenous drip, No. 5, daily; doxycycline 0.1, 1 capsule 2 r. / day 21 days; metronidazole solution 100.0 – 2 rubles / day, intravenous drip, No. 6; diclofenac retard 0.1 capsules, 1 r. / day, 10 days; itraconazole 0.1, 2 rubles / day, 21 days; metronidazole 0.25, 2 tab.2 rubles / day, 5 days; acyclovir 200 mg, 3 r. / day, 7 days; fluconazole 150.0, 1 r. / day, after 3 days, No. 3. Topically: tetracycline ointment under the bandage. On the nail plates and periungual rollers 5% iodine solution, clotrimazole cream. It was discharged with improvement: crusts were rejected on the skin of the face and forearms, the appearance of secondary brownish spots was noted on the skin of the trunk, extremities at the site of the former foci, erythema of the periungual ridges persists, the nail plates are yellow. In the area of ​​the external genital organs, there was a complete epithelialization of erosions with persisting secondary erythema.

Observation 2

Patient V., 35 years old, was admitted to the OKVD of Tyumen in June 2015, complaints of skin rashes, soreness in the area of ​​the hands and feet, changes in nails, pain in the joints. The deterioration of the condition is noted about 3 weeks, when weeping appeared on the feet. Sick for a year, when he first noted a rash on the scalp, pain in the joints. He was examined by a rheumatologist, diagnosed with psoriatic arthritis, and therefore receives methotrexate therapy at a dose of 15 mg / week.Has been registered with the Central Clinical Hospital since 2014 with a diagnosis of HIV infection, stage unknown. A history of symptomatic frontal epilepsy, sequelae of closed craniocerebral trauma, brain contusion in 2014
Local status: the pathological process is widespread. On the scalp, a diffuse plaque of bright red color is localized, with infiltration and abundant silvery-white peeling. On the body there are many bright red plaques with peeling.On the skin of the terminal phalanges of the hands and feet, bright hyperemia, peeling, exudation, oozing are revealed. The periungual ridges and nail beds are brightly hyperemic, edematous. The nail plates of the hands and feet are yellow, totally thickened due to subungual hyperkeratosis, crumbling from the free edge, missing on some fingers. When pressing on the nail plates of the feet, purulent discharge is released. PASI index 45.0 points.
Diagnosis : Plaque psoriasis, progressive stage.Acrodermatitis pustular Allopo, purulent form, moderate severity. Psoriatic arthritis. HIV infection (Fig. 4, 5).

After the treatment, he was discharged with clinical improvement of the skin process. Hyperemia and infiltration in the area of ​​plaques decreased, regressed on the scalp, hyperemia of the nail beds and periungual ridges persists. The nail plates are partially torn off, moderate mid-lamellar peeling remains. Limitation of mobility in the interphalangeal joints remains on the hands and feet.PASI index 14.4 points.

Conclusion

From a clinical and pathogenetic point of view, psoriasis is often included in the group of systemic autoimmune diseases, which include RA, systemic lupus erythematosus (SLE) and other connective tissue diseases. The clinical and pathogenetic commonality of these nosological units is the starting point in the strategy of modern therapy for psoriasis with genetically engineered biological drugs, many of which have already proven themselves in rheumatology. Indeed, at the cellular and molecular level in psoriasis, activated keratinocytes, expressing HLA-DR antigens and other activation receptors, detected, in particular, on activated synoviocytes in rheumatoid arthritis, were found inside the papule [4].At the same time, the accumulation of data on the features of the course of autoimmune syndromes against the background of HIV infection made it possible to notice significant differences between the manifestations of connective tissue diseases: as the level of CD4 + cells decreases, the activity of RA and SLE in HIV-infected patients subsides, and the activity of psoriasis in conditions of CD4 + T-cell immunodeficiency, on the contrary, is increasing. The above contradiction can be explained, in particular, by the fact that the pathogenesis of psoriasis and autoimmune rheumatic diseases may be due to the participation of different T-cell populations.If in RA and SLE the main factor provoking autoimmunoaggression is CD4 + T-lymphocytes, then the activity of psoriasis is probably associated with the expansion of other clones – gamma / delta T-lymphocytes, CD8 + CD4– cells, or natural killer cells, the local activity of which was detected in psoriasis [5]. These judgments are not only of theoretical importance – they must be taken into account when drawing up schemes for genetically engineered biological therapy of psoriasis, so as not to aggravate the immunodeficiency state, which is important in the pathogenesis of this nosology.As shown above, psoriasis in the advanced stage of AIDS acquires a persistent, recurrent course, complicated by pustular rashes on the skin and mucous membranes, weight loss, lymphadenopathy and diarrhea. These signs are possibly associated with the activation of the pyogenic flora of the skin, the addition of other concomitant infections [6]. In this regard, patients with severe forms of pustular dermatosis, accompanied by joint damage, should be carefully examined, including for STIs [7]. From a clinical point of view, the manifestation of pustular dermatoses is a marker of the development of severe T-cell immunodeficiency in HIV-infected patients.Their late diagnosis and incorrect treatment tactics can aggravate the patient’s condition and lead to poor outcomes.

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Psoriasis

What is psoriasis?

Psoriasis is a chronic non-infectious disease, dermatosis, which mainly affects the skin. The autoimmune nature of this disease is currently assumed. Psoriasis usually causes overly dry, red, raised patches of the skin.However, some psoriasis sufferers do not have any visible skin lesions. The spots caused by psoriasis are called plaques. These spots are by nature sites of chronic inflammation and excessive proliferation of lymphocytes, macrophages and keratinocytes of the skin, as well as the excessive formation of new small capillaries in the underlying skin layer.

What causes psoriasis?

The causes of psoriasis are currently not yet fully understood. At the moment, there are two main hypotheses regarding the nature of the process that leads to the development of this disease.

According to the first hypothesis, psoriasis is a primary skin disease in which the normal process of maturation and differentiation of skin cells is disrupted, and excessive growth and multiplication of these cells is observed. At the same time, the problem of psoriasis is seen by the supporters of this hypothesis as a violation of the function of the epidermis and its keratinocytes.

Autoimmune aggression of T-lymphocytes and macrophages against skin cells, their invasion into the thickness of the skin and excessive proliferation in the skin are seen as secondary, as a reaction of the body to the excessive multiplication of “wrong”, immature, pathologically altered keratinocytes.This hypothesis is supported by the presence of a positive effect in the treatment of psoriasis with drugs that inhibit the reproduction of keratinocytes and / or cause their accelerated maturation and differentiation and at the same time do not possess or possess insignificant systemic immunomodulatory properties – retinoids (synthetic analogues of vitamin A), vitamin D and in particular its active form, fumaric acid esters.

The second hypothesis suggests that psoriasis is an immune-mediated, immunopathological, or autoimmune disease in which overgrowth and multiplication of skin cells and, above all, keratinocytes are secondary to various inflammatory factors produced by cells of the immune system and / or to, and autoimmune damage skin cells causing a secondary regenerative reaction.

What happens to the skin and how to care for it?

Impaired barrier function of the skin (in particular, mechanical injury or irritation, friction and pressure on the skin, abuse of soap and detergents, contact with solvents, household chemicals, alcohol-containing solutions, the presence of infected skin lesions or skin allergies, deficiency of immunoglobulins, excessive dryness skin) also play a role in the development of psoriasis.

Infection in dry skin causes dry (non-exudative) chronic inflammation, which in turn causes psoriasis-like symptoms such as itching and increased skin cell proliferation.This in turn leads to a further increase in dry skin, both due to inflammation and increased proliferation of skin cells, and due to the fact that the infectious organism consumes moisture, which would otherwise serve to moisturize the skin. To avoid excessive dryness of the skin and reduce the symptoms of psoriasis, it is not recommended for patients with psoriasis to use washcloths and scrubs, especially hard ones, as they not only damage the skin, leaving microscopic scratches, but also scrape off the upper protective stratum corneum and sebum from the skin, which normally protect skin from drying out and from penetration of microbes.It is also recommended to use talcum powder or baby powder after washing or bathing to absorb excess moisture from the skin that would otherwise “get” to the infectious agent. Additionally, it is recommended to use products that moisturize and nourish the skin, and lotions that improve the function of the sebaceous glands. It is not recommended to abuse soap, detergents. You should try to avoid skin contact with solvents, household chemicals.

Is psoriasis inherited?

The hereditary component plays an important role in the development of psoriasis, and many of the genes associated with the development of psoriasis or directly involved in its development are already known, but it remains unclear how these genes interact during the development of the disease.Most of the currently known genes associated with psoriasis, in one way or another, affect the functioning of the immune system.

It is believed that if healthy parents have a child with psoriasis, then the likelihood of the next child getting sick is 17%, and if one of the parents has psoriasis, the possibility of the disease in children increases to 25% (with the disease of both parents – up to 60-70%).

Due to the fact that in most patients with psoriasis it is not possible to establish the hereditary transmission of dermatosis, it is believed that it is not psoriasis itself that is inherited, but a predisposition to it, which in some cases is realized as a result of a complex interaction of hereditary factors and unfavorable environmental influences.

What does psoriasis look like?

Excessive proliferation of keratinocytes (skin cells) in psoriatic plaques and infiltration of the skin with lymphocytes and macrophages quickly leads to thickening of the skin at the lesion sites, its elevation above the surface of healthy skin and the formation of characteristic pale, gray or silvery spots resembling frozen wax or paraffin (“ paraffin lakes “). Psoriatic plaques most often first appear on places subject to friction and pressure – the surfaces of the elbow and knee bends, on the buttocks.However, psoriatic plaques can occur and are located anywhere on the skin, including the scalp (scalp), palmar surface of the hands, plantar surface of the feet, and external genitalia. In contrast to eczema rashes, which often affect the inner flexor surface of the knee and elbow joints, psoriatic plaques are more often located on the outer, extensor surface of the joints.

What do you need to diagnose psoriasis?

This is usually much more difficult in children than in adults: in children, psoriasis often takes on an atypical form, which can lead to diagnostic difficulties.And the earlier the diagnosis is made, the more opportunities to fight the disease.

There are no diagnostic procedures or blood tests specific to psoriasis. Nevertheless, with active, progressive psoriasis or its severe course, abnormalities in blood tests can be detected, confirming the presence of an active inflammatory, autoimmune, rheumatic process (increased titers of rheumatoid factor, acute phase proteins, leukocytosis, increased ESR, etc.) , as well as endocrine and biochemical disorders.Sometimes a skin biopsy is needed to rule out other skin conditions and histologically confirm the diagnosis of psoriasis.

How to treat psoriasis?

It is worth starting to treat children’s psoriasis as early as possible and supervise the child so that he observes all the doctor’s advice. The baby’s immune system is very sensitive. With the right approach, she can cope with psoriasis, and if you let the disease take its course, the skin will be more and more affected.

If a child has symptoms of the disease – plaques on the skin, itching, redness, peeling, you need to immediately start treatment, strictly follow all the doctor’s recommendations, and he will advise you to apply a special cream to the skin.

In a progressive stage and with common forms of the disease, it is best to hospitalize the child. Prescribe desensitizing and sedatives, inside 5% calcium gluconate solution or 10% calcium chloride solution in tea, dessert or tablespoons 3 times a day. Apply a 10% solution of calcium gluconate intramuscularly, 3-5-8 ml (depending on age) every other day, 10-15 injections per course. With severe itching, antihistamines are needed inside in short courses, for 7-10 days.In older children in a progressive stage, with an excited state, poor sleep, small doses of hypnotics and small tranquilizers (tazepam, seduxen, meprotan) sometimes give a good effect.

Apply vitamins: ascorbic acid 0.05-0.1 g 3 times a day; pyridoxine – 2.5-5% solution, 1 ml every other day, 15-20 injections per course of treatment. Vitamin B12 is especially indicated for common exudative forms of psoriasis – 30-100 mcg 2 times a week intramuscularly in combination with folic and ascorbic acids for 172-2 months.Vitamin A is given at 10,000 – 30,000 ME 1 time per day for 1-2 months. Patients with the summer form of psoriasis, especially with severe itching, are shown nicotinic acid inside. With psoriatic erythroderma, it is advisable: riboflavin-mononucleotide intramuscularly, vitamin B15 orally or in suppositories (in double dosage), potassium orotate. Vitamin D2 should be used with some caution in all forms of psoriasis.

In order to stimulate protective and adaptive mechanisms, pyrogenic drugs are prescribed to normalize vascular permeability and inhibit the mitotic activity of the epidermis.Pyrogenal, Prodigiosan. A good therapeutic effect is given by transfusions of blood, plasma, albumin, weekly, several times, depending on the result obtained. In children with persistent (exudative and erythrodermic) forms of psoriasis, sometimes it is not possible to obtain a positive effect from these funds. Then, glucocorticoids are prescribed orally at 0.5-1 mg per 1 kg of body weight per day (based on prednisolone) for 2-3 weeks, followed by a gradual decrease in the dose of the drug until it is canceled. Cytostatic drugs (methotrexate) are not recommended for children of all ages due to their toxicity.In the stationary and regressive stages of the disease, a more active therapy is prescribed – UFO, general baths at a temperature of 35-37 ° C for 10-15 minutes, after 1 day.

External treatment of psoriasis.

Salicylic (1-2%), sulfur-tar (2-3%) ointments; glucocorticoid ointments (0.5% prednisolone, lokacorten, flucinar, fluorocort, lorinden, etc.). These ointments quickly give a direct effect in the form of occlusive dressings in the localization of psoriatic plaques on the palms and soles.For children with a predominant lesion of the scalp, the recently used phosphodiesterase inhibitors in the form of lubricants or occlusive dressings with 5% theophylline or 1% papaverine ointments can be recommended.

It is necessary to emphasize the importance of sanitation of focal infection (diseases of the respiratory tract, ENT organs, helminthic invasions, etc.). Tonsilectomy and adenotomy for children with psoriasis can be performed after the age of 3 years. In 90% of cases, these surgical interventions have a beneficial effect on the course of the process, and in 10% of patients, especially with widespread exudative psoriasis, exacerbations continue.Follow-up examination after 7-10 years showed that 2/3 of patients after tonsillectomy did not have relapses of the disease, but even the remaining 1/3 of children with exacerbations of the rash were scanty and remissions lengthened; in non-operated children with psoriasis and chronic tonsillitis, exacerbations of dermatosis were more frequent.

Our long-term observations of children indicate that in most cases, relapses of psoriasis with age occur less frequently, are less pronounced and there is a clearly noticeable tendency towards the transition of common forms of dermatosis to limited ones.However, in some patients, the process remains generalized, with a severe course.

Is psoriasis a diagnosis for life?

If you start timely and correct treatment, then no. The development of psoriasis in a child does not at all mean that, as an adult, he will also suffer from this ailment. Of course, psoriasis is a chronic disease, it is almost impossible to recover from it 100%. But the quiet period can be maximized. Pediatric psoriasis is treated like an adult, changing from one treatment to another every three months.

The child should be psychologically prepared in advance for the fact that his body has flaws. Unlike adults, in children, psoriasis often affects not the body, but the face (30% of cases). Rashes can appear on the forehead, on the cheeks, and on the eyelids. Psychologically, it is quite difficult to endure. Also, in one third of children with childhood psoriasis, nails are affected. Therefore, it is rather difficult to hide the disease.

In addition to physically unpleasant sensations, psoriasis can be a severe test for a child’s mental state.Parents cannot leave him alone with a problem. Any activity should be encouraged: sports, games. However, it is worth remembering the precautions. For example, the skin on certain areas of the body can be stretched (for example, when cycling for a long time). And this can provoke psoriasis. Despite the outwardly unsightly skin condition, the child can go swimming! And if there are chemicals in the water, remove

Why is there still no cure for psoriasis completely?

This disease is called mysterious for a reason.The essence of this disease is still not clear. Some psoriasis affects the face, others have limbs, some have joints! Why marriage occurs in the cells of our body is not clear. As an oncology, psoriasis cannot be treated with pills. Interesting developments are underway in Russia now. They try to treat children with ointments made from natural raw materials. The forecasts are favorable, but the ointment has not yet entered production. In the meantime, my advice to parents is not to trust charlatans and pseudo-healers, and in case of signs of psoriasis in a child, contact a professional – a pediatric dermatologist.

90,000 Psoriasis: new approaches to the treatment of an incurable disease | Scientific discoveries and technical innovations from Germany | DW

Psoriasis is one of the most common skin diseases: according to various estimates, it affects 2 to 5 percent of the world’s population. This non-infectious ailment manifests itself in the formation of areas of chronic inflammation on the skin in the form of silvery-pink plaques. Usually they are located in the elbows or knees, somewhat less often on the head and other parts of the body.In a severe form of the disease, a significant part of the skin surface is affected. Psoriatic plaques often cause severe itching. In addition, in some cases, psoriasis is accompanied by an inflammatory lesion of the joints – the so-called psoriatic arthritis.

Fortunately, no more than 2 percent of all patients suffer from severe psoriasis. However, even mild forms of this ailment cause significant physical suffering to patients, not to mention psychological trauma. Moreover, the disease, as a rule, develops in waves, periods of remission, that is, improvements, alternate with relapses, that is, exacerbations.In addition, psoriasis usually progresses over time: relapses become more frequent and more severe.

Genetic predisposition – and a lot of treatment methods

The causes of psoriasis are still not known exactly to science, but there is no doubt that the factor of heredity plays an important role here. Jürgen Schauber, a dermatologist at the Munich University Hospital, says: “Patients with psoriasis must have a genetic predisposition to this ailment.This explains the fact that while psoriasis is incurable. All that we can today is to fight the symptoms, with the external manifestations of the disease. We try to suppress the inflammatory process and maintain this state as long as possible. “

What methods are used today to alleviate the condition of patients with psoriasis! There are milk and oil baths, and baths with decoctions of sage and chamomile, and various emollient and moisturizing creams, and salicylic, naphthalan or tar ointments, and preparations based on fumaric acid, and vitamin D, and corticosteroids, and cytostatics, that is, drugs that block cell division and ultraviolet radiation, and interference therapy (one of the types of electrotherapy based on the use of a low-frequency variable pulse current).Of course, the lack of comprehensive knowledge about the mechanism of action of certain drugs does not prevent them from being used in clinical practice if they really help patients, but it makes it difficult to find more effective methods of treatment. In fact, this search is almost random.

Pathology of the immune response – and cytoplasmic DNA

True, doctors firmly assume that psoriasis belongs to the so-called autoimmune diseases, that is, it is caused by an inadequate response of the patient’s own immune system to some factors that it perceives as a threat, although in reality they are not.Disruption of the normal mechanism of the immune response leads to the fact that immunocompetent cells without any reason migrate to the surface layer of the skin, causing inflammatory reactions there and disrupting the normal cycle of division, development and death of epidermal cells. If in a healthy person such a cycle takes from a month to one and a half, then in a patient with psoriasis it proceeds 10 times faster. Chronic inflammation, combined with rapid keratinization of the upper layer of the skin in certain areas of the body, leads to its exfoliation and the formation of scaly plaques.

And now Jurgen Schauber and his colleagues managed to find out some important details of this process. Apparently, the AIM2 protein plays a key role in the development of psoriasis. Actually, the function of this protein in the body is to detect DNA in the cellular cytoplasm and inform the immune system about it. Indeed, in healthy cells, nucleic acids – carriers of hereditary information – are found only in the nucleus and in mitochondria. The presence of nucleic acids in the cytoplasm usually indicates that the cell is infected with a bacterium or virus.

It is to fight this foreign hereditary material that immunocompetent cells rush to the focus of infection. The same mechanism, obviously, takes place in the case of psoriasis – with the only difference that we are talking here not about foreign, but about our own DNA, emphasizes Jurgen Schauber: “Indeed, patients with psoriasis have cytoplasmic DNA in their skin cells, meanwhile as in healthy people, cytoplasmic DNA is absent. ”

Excess protein AIM2 – and the effectiveness of vitamin D

Apparently, DNA is secreted into the cytoplasm from the cell nucleus – either because in patients with psoriasis, the cell nuclei are not stable enough, or because, that due to the disturbed cycle of division, development and death of epidermal cells, nucleic acids in large quantities, so to speak, go to waste.One way or another, a situation arises in the patient’s skin that gives the immune system every reason for alarm. In addition, in the body of patients with psoriasis, the AIM2 protein is present in a significantly greater amount than in the body of healthy people, therefore the skin of such patients has increased sensitivity. If in the cells of a healthy person a certain amount of cytoplasmic DNA could go unnoticed, then in the cells of a patient with psoriasis, an insignificant amount of it immediately triggers an immune response.

According to the prominent Dutch dermatologist Peter van de Kerkhof, the study of Jurgen Schauber, although it did not fully explain the mechanism of psoriasis, revealed important new details: this mysterious mechanism at the molecular level. And from here follow new approaches to therapy. After all, today medicines are increasingly being created on the basis of a true understanding of the nature of the disease. And earlier it was a matter of chance – to find a drug that effectively suppresses the symptoms of psoriasis. “

At least now it has become clear why ointments containing vitamin D help many patients. The fact is that vitamin D stimulates the synthesis of cathelecidin in skin cells, an antimicrobial peptide that is prone to firmly bind to free DNA. That is, this protein can slow down or even completely block the very cascade of reactions that triggers the psoriatic inflammatory response. In this regard, the development of a new drug seems to be very promising, even more effective than vitamin D, which stimulates the synthesis of cathelecidin.

Author: Vladimir Fradkin
Editor: Efim Shuman

90,000 clinical and laboratory assessment, approaches to therapy – the topic of a scientific article on clinical medicine

© Evdokimov E.Yu., Sundukov A.V., 2017

UDC 616.517-06: 616.98: 578.828.6] -092: 612.017.1.064] -085

Evdokimov E.Yu.1, Sundukov A.V. 2

PSORIASIS IN HIV-INFECTED PATIENTS: CLINICAL AND LABORATORY ASSESSMENT, APPROACHES TO THERAPY

1FBUN “Central Research Institute of Epidemiology” Rospotrebnadzor, 111123, Moscow, Russia; 2FGBOU VO “Moscow State University of Medicine and Dentistry. A.I. Evdokimov “Ministry of Health of Russia, 127473, Moscow, Russia

Clinical and laboratory evaluation of the effectiveness of therapy for psoriasis vulgaris in 78 HIV-infected patients using two treatment regimens is presented.The features of the clinical course of psoriasis were found depending on the number of CD4 + lymphocytes in the peripheral blood. A histological and histochemical study of skin biopsies was performed in 15 patients. The dynamics before and after treatment of CD4 + and CD8 + lymphocytes in skin and blood biopsies, their relationship by the psoriasis severity index (PASI) was shown. This study is of theoretical and practical interest for understanding the significance and role of CD4 + and CD8 + lymphocytes in the formation of inflammatory reactions in the skin of patients with psoriasis vulgaris and as a possible treatment option for psoriasis in HIV-infected patients.

Keywords: HIV infection; psoriasis; immune status.

For citation: Evdokimov EY., Sundukov A.V. Psoriasis in HIV-infected patients: clinical and laboratory assessment, approaches to therapy. Russian Journal of Skin and Venereal Diseases. 2017; 20 (4): 227-231. DOI: http://dx.doi.org/10.18821/1560-9588-2017-20-4-227-231

Evdokimov E.Yu.1, Sundukov A.V.2

PSORIASIS IN HIV-INFECTED PATIENTS: CLINICAL AND LABORATORY EVALUATION, APPROACHES TO THERAPY

1 Central Research Institute of Epidemiology, Moscow, 111123, Russian Federation;

2A.I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, 127473, Russian Federation

Clinical and laboratory evaluation of the effectiveness of therapy of psoriasis vulgaris in 78 HIV-infected patients using the two treatment regimens is presented.Peculiarities of clinical course of psoriasis depending on the number ofCD4 + lymphocytes in the peripheral blood are shown. Histological and histochemical studies of biopsy samples from psoriatic skin lesions and apparently healthy skin in 15 people were performed. The dynamics before and after treatment of CD4 + and CD8 + lymphocytes in biopsies of skin and blood, their relationship with the index of severity of psoriasis (PASI) are presented. This study is of theoretical and practical interest in understanding the value and role of CD4 + and CD8 + lymphocytes in the formation of inflammatory reactions in the skin of patients with psoriasis as a possible option for treatment of psoriasis in HIV-infected patients.

Keywords: psoriasis; HIV infection; histochemistry; immune status.

For citation: Evdokimov E. Yu., Sundukov A.V Psoriasis in HIV-infected patients: clinical and laboratory evaluation, approaches to therapy.

Russian Journal of Skin and Venereal Diseases (Rossiyskii Zhurnal Kozhnykh i Venericheskikh Boleznei). 2017; 20 (4): 227-231.(in Russian).

DOI: http://dx.doi.org/10.18821/1560-9588-2017-20-4-227-231

Conflict of interest. The authors declare no conflict of interest.

Acknowledgment. Funding was sponsorship.

Received 12 April 2017

Accepted 26 June 2017

Psoriasis affects more than 150 million people in the world, and it is one of the most common dermatoses [1, 2].The pathogenesis of this disease remains poorly understood. In the development of psoriasis, heredity plays an important role; the probability of transmission of a predisposition is estimated at 60-90%. The manifestation of psoriasis has a bimodal character: with the first

For correspondence:

Evdokimov Evgeny Yurievich, Candidate of Medical Sciences, Researcher, Clinical Department of the Central Research Institute of Epidemiology, Rospotrebnadzor, 111123, St.Moscow, Russia. E-mail: evdokimovevg @ yandex.ru

For correspondence:

Evdokimov Evgeny Yu., MD, PhD, researcher of clinical department Central Research Institute of Epidemiology, Moscow, 111123, Russian Federation. E-mail: [email protected] Information about the authors:

Evdokimov E. Yu., http // orcid.org / 0000-0003-2694-8900; Sundukov A.V., http // orcid.org / 0000-0002-3798-7780.

age peak at 16-40 years old and with the second at 40-60 years old [3, 4]. At the same time, gender differences between patients were not revealed [5].

In recent years, comorbidity has been revealed not only with psoriatic arthritis, but also with diseases such as lipid metabolism disorders, type 2 diabetes, hypertension, lymphoma, melanoma, and non-melanotic skin cancer [6].

The manifestation and exacerbation of psoriasis are most often caused by psychoemotional stress, infectious diseases of the oropharynx, drugs f-blockers, lithium salts, interferon-a2b), alcohol and smoking [7].

An important role in the pathogenesis of psoriasis is attributed to the functional incompetence of the epidermis [8, 9] relative to immune-competent cells in the skin [10]. In the focus of inflammation, there is an increase in the number of macrophages, CD4 + and CD8 + lymphocytes, which are also found in healthy skin, but in small numbers [11].It is important that, in the absence of damage, all of them are not involved in immune processes and are activated only after the start of a cascade of inflammatory reactions [12]. Some

Table 1

Distribution of HIV-infected patients with psoriasis depending on the number of CE4 + lymphocytes

Subgroup of patients 1st group (more than 600 cells / ml) 2nd group (400-599 cells / ml) 3rd group (200-399 cells / ml) 4th group (less than 200 cells / ml)

A 10 10 9 11

B 9 11 8 10

Total… 19 21 17 21

researchers [13] note that in the early stages of the development of psoriatic plaques, skin infiltration by neutrophils, mast and plasma dendritic cells is revealed; during the process of chronicity, these cells in the skin are found less often and mainly CD4 + and CD8 + lymphocytes predominate.

In addition, the failure of the epidermis is associated with a violation of the content and ratio of ceramides in the psoriatic plaque, leading to transdermal water loss [14].

Psoriasis is more common in HIV-infected patients than in the general population. K. Wolff et al. [15] showed that psoriasis occurs in 6% of HIV patients. Against the background of HIV infection, common forms of psoriasis vulgaris, pustular psoriasis, psoriatic erythroderma and psoriatic arthritis are more common [16]. In the late stages of HIV infection in patients with psoriatic disease, there are inflammatory lesions of the eyes and damage to the central and peripheral nervous system, signs of heart and renal failure [17].Psoriasis in HIV-infected patients is more often severe, difficult to respond to standard therapy. Therefore, research in this area is an urgent public health problem [18, 19].

Purpose of the study – clinical and laboratory evaluation of the effectiveness of treatment of psoriasis vulgaris in HIV-infected patients using a natural silicon-containing mineral – zeolite.

Material and methods

We observed 78 HIV-infected patients suffering from psoriasis vulgaris, including 48 (61.5%) men and 30 (38.5%) women aged 18 to 49 years.The average duration of psoriasis was 7.5 ± 2.6 years. Psoriasis before infection was registered in 55 (70.5%) patients,

Fig. 1. The histological picture of psoriasis vulgaris. Elongation of the papillary layer of the dermis, pronounced acanthosis, thinning of the papillary zone of the epidermis. Staining with hematoxylin and eosin. Uv. 200.

in 23 (29.5%) patients arose already against the background of HIV infection.The main reason for the development of psoriasis was a stress factor (loss of work, death of relatives, divorce, etc.) – in 64.4% of patients, in 8.1% – alcohol abuse, in 27.5% of patients the cause of the disease was not established. The history of psoriasis in relatives was revealed in 32 (41.02%) patients, of which 9 (11.5%) had siblings. Psoriatic arthropathy was observed in 11 (14.1%) patients, damage to the nail plates – in 21 (26.9%).

In addition to standard general clinical and instrumental examinations, all patients were assessed for the number of CD4 + and CD8 + lymphocytes and viral load (HIV RNA).

Depending on the number of CD4 + lymphocytes, all patients were divided into four groups: 1st group – more than 600 cells / ml, 2nd group – 400-599 cells / ml, 3rd group – 200-399 cells / ml, 4th – less than 200 cells / ml. Each group was divided into two subgroups. Subgroup A consisted of 40 patients who received, in addition to standard therapy, inside, 2 capsules 3 times a day, the natural mineral zeolite and topically on the foci of a cream based on the same active substance.The duration of the course was 3 months. Subgroup B consisted of 38 people who received only standard therapy (ointment containing flumethasone pivalate 200 μg and salicylic acid 30 mg in 1 g of ointment) once a day, vitamins A and E 300 mg 2 times a day, pentoxifylline 200 mg 3 once a day, 10% dextran solution 400 ml intravenously 1 time per day for 5 days.

Distribution of patients with psoriasis into groups depending on the number of CD4 + lymphocytes is given in table.1. In 38 (48.7%) HIV-infected patients, immunodeficiency was revealed in the form of a decrease in the level of CD4 + lymphocytes below 400 cells / ml, of which 21 (26.9%) – below 200 cells / ml. All patients in groups 3 and 4 received antiretroviral therapy (ART).

Clinical assessment of the course of psoriasis and the effectiveness of the therapy was performed based on the international psoriatic lesion area and severity index (PASI) [20].

PASI was determined before the start of treatment and 6 weeks after the therapy – PASI 75.

The diagnosis of psoriasis vulgaris was histologically confirmed in 15 (19.2%) HIV-infected patients of group 2 (8 patients from subgroup 2A and 7 from subgroup 2B) (Fig. 1, 2). The presented sections show pronounced acanthosis and thinning of the supra-papillary zone of the epidermis, hyperkeratosis with parakeratosis, lymphoid infiltration of the epidermis and dermis, lengthening of the papillary layer of the dermis, perivascular lymphoid infiltration of the capillaries, which is characteristic of the inflammatory process in the psoricum.

In the same 15 patients of the 2nd group, an immunohistochemical study of skin biopsies from psoriatic

Fig. 2. The histological picture of psoriasis vulgaris. Severe acanthosis of the supra-papillary layer of the epidermis, edema of the dermis, intracellular edema of epithelial cells with deformation of the nuclei. Staining with hematoxylin and eosin. Uv. 400.

Table 2

The number of CD4 + lymphocytes in HIV-infected patients before and after treatment

Dynamics of PASI before and after treatment in subgroups

Table 3

Number Number of PASI patients before treatment PASI 75 after treatment

Group of patients subgroup

A B A B A B

1st 19 10 9 11.6 ± 2.9 10.8 ± 3.4 4.2 ± 1.3 * 8.1 ± 2.2

2nd 21 10 11 16.2 ± 3.1 16.3 ± 2.4 6.1 ± 1.4 * 9.7 ± 1.6

3rd 17 9 8 23.4 ± 4.7 22.2 ± 5.3 13.5 ± 2.7 17.8 ± 3.2

4th 21 11 10 30.6 ± 6.6 32.5 ± 7.2 24.5 ± 3.5 26.8 ± 3.8

Note.Here and in table. 3, 4: * – p <0.05 - statistically significant differences between subgroups A and B.

plaques and healthy skin before and after treatment. The number of CD4 + and CD4 + lymphocytes in biopsies was assessed, the study was performed on serial dewaxed sections of skin biopsies using the biotin-streptovidin immunoperoxidase method with monoclonal antibodies to markers of CD4 + lymphocytes at a dilution of 2: 70 human CD4 +, clone 4B12, “Dako”, Denmark) and CD8 + lymphocytes at a dilution of 1: 100, according to the manufacturer’s recommendation (mouse anti-human CD8 +, clone C8 / 144B, “Dako”, Denmark).

Lymphocytic infiltration of the skin was assessed using a histological study, by counting the number of positively stained CD4 + -, CD8 + lymphocytes in at least 10 fields of view with uv. 400 in the epidermis and dermis, areas of the most intense staining.

Statistical analysis of the obtained data was carried out using parametric methods using the statistical data analysis package Statistica 10.0 for Windows (“StatSoft Inc.”, USA). The obtained data were checked for compliance with the law of normal distribution using the coefficients of kurtosis (Es) and skewness (As) and their errors, using the Student’s t-test. Differences in values ​​were considered statistically significant at p <0.05.

Results

The content of CD4 + lymphocytes in the peripheral blood was determined in all 78 HIV patients before and 6 weeks after the start of treatment (Table 1).2).

Distribution of PASI, which was also assessed in all patients included in the study, in the dynamics of the disease before and after treatment in subgroups A and B (Table 3).

Immunohistochemical study was performed in 15 people, the results of the study of biopsies from healthy skin and psoriatic plaques – before and after treatment (Table 4).

Discussion

As a result of the study, it was found that patients of subgroups 1A and 2A had a statistically significant increase in the concentration of CD4 + lymphocytes in the peripheral blood compared with patients who received only standard therapy.Moreover, in the 3rd and 4th groups of patients (concentration of CD4 + lymphocytes

Group Number Number of PASI patients before treatment PASI 75 after treatment

patients subgroup

A B A B A B

1st 19 10 9 11.6 ± 2.9 10.8 ± 3.4 4.2 ± 1.3 * 8.1 ± 2.2

2nd 21 10 11 16.2 ± 3.1 16.3 ± 2.4 6.1 ± 1.4 * 9.7 ± 1.6

3rd 17 9 8 23.4 ± 4.7 22.2 ± 5.3 13.5 ± 2.7 17.8 ± 3.2

4th 21 11 10 30.6 ± 6.6 32.5 ± 7.2 24.5 ± 3.5 26.8 ± 3.8

below 400 cells / ml), there were no statistically significant differences between the subgroups, depending on the therapy.

As the number of CD4 + lymphocytes in the peripheral blood decreased, there was an increase in PASI in the groups, which indicated the aggravation of the manifestations of psoriasis in HIV-infected patients against the background of immunosuppression. As can be seen from the data presented after treatment, PASI 75 decreased in the 1st and 2nd groups of patients, it was lower in subgroups 1A and 2A, who received additional therapy based on zeolite, which slows down autoimmune processes in the skin and contributes to the normalization of skin hydration.At the same time, in patients of the 3rd and 4th groups, no statistically significant differences were revealed depending on the therapy. When performing an immunohistochemical study of skin biopsy samples in HIV-infected patients in a psoriatic plaque during an exacerbation of psoriasis, the ratio of CD4 + / CD8 + lymphocytes was 1: 1. During the period of psoriasis regression in HIV-infected patients, the ratio of CD4 + / CD8 + lymphocytes in the skin was 2: 1.

Patients who received additional therapy based on the natural mineral zeolite showed a statistically significant decrease in the level of CD4 + and CD8 + lymphocytes in the skin compared with patients who received only standard therapy for psoriasis.

Clinical example

Patient E., 48 years old, who was admitted for inpatient examination and treatment to the HIV department of the Infectious Clinical Hospital No. 2 (Moscow), was under our supervision since April 2016.

Main diagnosis: HIV infection, stage III, without antiretroviral therapy.

Concomitant diagnosis: generalized psoriasis vulgaris, progressive stage, winter form, type II; recurrent herpes simplex.

HIV infection first detected in December 2010

The patient has been suffering from psoriasis since February 2012, the hereditary history is not aggravated, the cause of the disease is considered the stress caused by the detection of HIV infection. He was treated out-of-pocket by a dermatologist at the local polyclinic, took medications that are difficult to name, there was a moderate improvement in the condition of the skin, but persistent itching persisted.The last exacerbation was observed in February 2016 after psychoemotional stress.

Local status. Skin changes are localized along the back surface of both shoulders, elbows, buttocks, thighs, anterior

Table 4

Immunohistochemical study of CD4 + and CD8 + lymphocytes in skin biopsies of patients with psoriasis vulgaris before and after treatment

SB4 + – lymphocytes SB8 + – lymphocytes

Term in psoriatic plaque in healthy skin in psoriatic plaque in healthy skin

A B A B A B A B

Before treatment 31.2 ± 3.3 34.4 ± 3.4 12.3 ± 2.5 13.4 ± 5.2 28.3 ± 3.4 29.4 ± 4.2 6.5 ± 1 , 4 7.3 ± 2.2

After treatment 7.3 ± 1.4 * 13.1 ± 2.2 2.2 ± 1.2 * 6.1 ± 1.5 4.0 ± 2.2 * 10.3 ± 2.3 3, 5 ± 1.1 * 6.1 ± 1.3

and lateral surfaces of the legs.The rashes are represented by hyperaemic spots and plaques of various sizes, covered with small-medium-sized “stearic” scales, the psoriatic triad is positive. From subjective complaints – constant, moderately pronounced itching.

Laboratory examination. General analysis of blood and urine – indicators within normal limits. Biochemical blood test: glucose 4.8 μm / l, cholesterol 6.73 mmol / l, alanine aminotransferase (ALT) 11 U / l, aspartate aminotransferase (AST) 26 U / l, alkaline phosphatase (ALP) 72 U / l.

Chest X-ray is normal.

Immune status: CD4 + lymphocytes 453 cells / ml, CD8 + lymphocytes 287 cells / ml, CD4 + / CD8 + 1.59, HIV RNA 47 326 copies / ml.

A diagnostic biopsy of the skin of the posterior surface of the right shoulder region was performed (Fig. 3).

In the presented biopsy, there is a pronounced lymphoid infiltration of the epidermis and dermis, acanthosis with lengthening and expansion downward of epidermal outgrowths and thinning of the suprapillary layer of the epidermis, hyperkeratosis and parakeratosis.The histological conclusion: the morphological picture, taking into account the clinical data, may correspond to psoriasis vulgaris.

In April 2016, for psoriasis, it was prescribed: topically flu-metasone pivalate 200 μg and salicylic acid 30 mg in 1 g of ointment once a day; inside: vitamins A and E 300 mg 2 times a day, pentox-syphillin 200 mg 3 times a day, hydroxyzine 25 mg 1-2 times a day, depending on the severity of itching (after 3 weeks, hydroxyzine was canceled due to a decrease in the intensity of skin itching),

Fig.3. Histological picture of patient E., 48 years old. Acanthosis, lymphoid infiltration of the dermis, thinning of the suprasoculoid zone of the epidermis, lengthening of the papillary layer of the dermis. Staining with hematoxylin and eosin. Uv. 100.

Fig. 4. Patient E., 48 years old. The clinical picture of psoriasis vulgaris (L40.0).

a – before treatment: symmetrically expressed inflammation on the skin of the back surface of the shoulders; the arrow indicates the Kebner phenomenon at the site of scar formation after skin biopsy; b – before treatment: “duty” plaque in the area of ​​the left elbow joint – severe inflammation, mid-lamellar peeling; c – 6 weeks after the start of treatment: a significant decrease in inflammation of both shoulder surfaces of the skin, the arrow indicates the formed scar at the site of the skin biopsy; d – after treatment: in the area of ​​the left elbow joint, the condition of the skin has improved, inflammation has decreased, fine-lamellar peeling of the skin remains.

additionally inside, 2 capsules 3 times a day, cream-containing natural zeolite on the foci.

Fig. 4, a, b shows the condition of the skin before treatment. The arrow indicates the Kebner phenomenon at the site of histological material sampling. After therapy, a significant improvement in the condition of the skin was noted (Fig. 4, c, d).

After 6 weeks from the start of treatment, the patient noted almost complete disappearance of itching, preservation of slight dryness of the skin.There is a pronounced regression of rashes by more than 70%, there are “duty” plaques on the skin of the elbow joints and in the area of ​​the ankle joints. Laboratory indicators of the immune status improved slightly: CE4 + lymphocytes 487 cells / ml, CE8 + lymphocytes 246 cells / ml, CD4 + / CD8 + 1.97, HIV RNA 42 433 copies / ml.

Immunohistochemical study: the number of CD4 + lymphocytes before treatment in psoriatic plaque – 29, in healthy skin – 13, 6 weeks after the therapy – 5 and 7, respectively; the number of CD8 + lymphocytes before treatment in psoriatic plaque – 32 and in healthy skin – 12, after therapy – 6 and 5, respectively.

Conclusions

• Psoriasis in HIV-infected patients worsens with increasing immunodeficiency, as evidenced by PASI, which increases as the level of CD4 + lymphocytes decreases;

• the number of CD4 + / CD8 + lymphocytes in the psoriatic plaque changes depending on the activity of the process, while during the exacerbation the ratio is 1: 1, during the regression period – 2: 1;

• the use of capsules and cream containing the natural mineral zeolite has shown clinical and laboratory effectiveness in the complex therapy of psoriasis in HIV-infected patients.

Acknowledgments. The authors would like to thank the patients included in the study for their patience and compliance. Financing. The study was not sponsored. Conflict of interest. The authors declare that they have no conflicts of interest.

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Received 04/12/17 Accepted 06/26/17

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