Psoriasis

Psoriasis is a common, chronic, relapsing, inflammatory skin disorder. Psoriasis has a genetic basis and can affect the skin the nails and also joints.

Psoriasis has a tendency to wax and wane.

Flares can be related to systemic, environmental factors, or infection.





Psoriasis most commonly manifests itself on the skin of the elbows, knees, scalp, and lumbosacral areas.



Most psoriatic nail disease occurs in people with clinically evident psoriasis.


Psoriatic arthritis is a chronic inflammatory arthritis that is commonly associated with psoriasis.



Frequency

Approximately 2-3% of people are affected by psoriasis

At least 5% of patients with psoriasis develop psoriatic arthritis

Sex

Psoriasis is slightly more common in women than in men


Symptoms of Psoriasis

The surface of psoriatic lesions often has a layer of dead skin cells that appear as silver scales.

Erythematous(Red) scaly area which can have a sudden onset.

Scaling plaques that itch.

Lesions may be vesicular.

Joint Pain.



Joint Findings

Sausage Digits

Enthesopathy- An inflammation of the insertion points of tendon into bone.

Tendonitis


Nail Findings

Oil drop - a translucent, yellow-red discoloration in the nail bed resembling a drop of oil beneath the nail plate.


Pitting- Pitting is a result of the loss of cells from the surface of the nail plate.


Beau lines- These lines are transverse lines in the nails


Leukonychia- Leukonychia is areas of white nail plate.


Onycholysis Onycholysis is a separation of the nail plate from its attachment to the nail bed.



Causes


Psoriatic lesions are caused by an increase in the skin cells turnover rate.

Genetic factors- Approximately 40% of patients with psoriasis or psoriatic arthritis have first-degree relatives who are affected.

Psoriatic nail disease may be due to a combination of genetic, environmental, and immune factors.



Differentials

• Seborrheic dermatitis
• Onychomycosis
• Squamous cell carcinoma
• Nummular eczema
• Lichen planus
• Lichen simplex chronicus
• Pustular eruptions

Arthritic Differentials

• Gout
• Osteoarthritis
• Rheumatoid arthritis
• Septic arthritis

Work Up


Radiographs of affected joints can be help differentiate the type of arthritis.

Psoriatic arthritis- The diagnosis is based primarily on clinical and radiographic findings.

Nail biopsy- A nail biopsy may be obtained to confirm the diagnosis of nail psoriasis



Laboratory studies

Rheumatoid factor (RF)- negative

Erythrocyte sedimentation rate (ESR)- usually normal

Uric acid level- May be elevated in psoriasis





Treatment

Skin Lesions

Topical corticosteroids- Used to reduce plaque formation.


Coal tar- Coal tar is an inexpensive treatment that is available over the counter in shampoos or lotions for use in widespread areas of involvement..

Keratolytic agents- Used to remove scale, to smooth the skin, and to treat hyperkeratosis


Psoriatic arthritis

Nonsteroidal anti-inflammatory drugs- (NSAIDs)

Disease-modifying antirheumatic drugs (DMARDs)

Anti–tumor necrosis factor (TNF)-alpha medications.

Nails
Avulsion therapy -can be used as an alternative therapy for psoriatic nail disease.

Gout

Gout is a common disorder of uric acid metabolism. It is a medical condition that usually presents with recurrent attacks of acute inflammatory arthritis. Gout is caused by cellular reaction to uric acid and can lead to deposits of monosodium urate crystals in soft tissues and joints.



Types

Primary gout - May occur alone. Accounts for about 90% of cases of the disease.

Secondary gout- May be associated with other medical conditions or medications. Accounts for about 10% of cases of the disease.


Frequency
Approximately 1% of the general population have gout.

Sex
Predominance- 90% male


Symptoms

Gout is associated with considerable pain.

Acute episodes of gout may incapacitate a patient.

Involved joints typically have the following symptoms: swelling, warmth, erythema, and tenderness.

The first metatarsal phalangeal joint is most commonly affected, however other joints can be involved such as the ankle or the knee.


A tophus deposit may develop in the ear.


Causes

Conditions that may cause acute changes in the level of uric acid and may precipitate a gout attack:

• Hyperuricemia
• End-stage renal disease
• Alcohol ingestion
• Disorders that cause high cell turnover with release of purines
• Over consumption of foods high in purines
• Underexcretion of uric acid - renal insufficiency

Long Term Effects

Untreated chronic tophaceous gout can lead to severe joint destruction.

Deposition of uric acid crystal in the kidneys may produce renal failure or obstruction.


Differential Diagnosis

Cellulitis- A severe inflammation of dermal and subcutaneous layers of the skin.

Gonococcal Arthritis- Is caused by infection with Neisseria gonorrhoeae.

Calcium Pyrophosphate Deposition Disease- Is a type of arthritis caused by the deposition of calcium pyrophosphate crystals.

Rheumatoid Arthritis- Is a chronic systemic inflammatory disease that affects the peripheral joints.

Psoriatic Arthritis- Is a chronic inflammatory arthritis that is commonly associated with psoriasis.


Laboratory Studies

Synovial fluid- The physician may aspirate the involved joint to rule out an infectious arthritis and to confirm a diagnosis of gout.

Serum uric acid.

Uric acid in 24-hour urine sample.


Imaging

Routine radiographs reveal punched-out erosions or lytic areas with overhanging edges. These finding are not acute.



Treatment

Acute gout

• Indomethacin- is the traditional Nonsteroidal anti-inflammatory drug (NSAID) of choice for acute gout.
• Colchicine.
• Corticosteroids- May be indicated in those patients who do not tolerate NSAID or Colchicine.

Chronic gout

• Probenecid- For patients who are hypoexcreters of uric acid.
• Allopurinol- For patients who are over producers of uric acid. Allopurinol reduces the generation of uric acid in the body.
• Uloric- Prevents uric acid production and lowers elevated serum uric acid levels.

Diet

Patients with gout should avoid beer and hard liquor. These elevate levels of uric acid and may precipitate attacks of gout.

High purine foods should be consumed in moderation:

• Kidney
• Liver
• Meats
• Shellfish

Shoes that are creating their own path in our world: Part 2

Simple Shoes

This shoe company has come along way since opening in 1991. The Simple shoes that we know and love today are not at all the same shoes from the 90’s. For about 13 years Simple was just like every other shoe company out there. But in 2004 Simple Shoes had an epiphany and decided to take on the challenge of providing eco friendly shoes to the public. They started small with 2 different styles in 2005 called their ‘Green Toe’ collection. These shoes where a hit and as soon as the ball was rolling for Simple there was no stopping it. Over the past few years Simple has produced with even more shoes that incorporate natural and sustainable materials into their products. In 2006, Simple set a new goal to become a 100% sustainable company. This was a huge step for any company, and a very exciting one at that. In 2007, they took it one step further (we didn’t think it was possible!). Simple shoes started to use recycled materials as well as products found naturally in our world. So now, old tires can gather dirt on people’s feet instead of in a dump. To learn more about Simple Shoes visit www.simpleshoes.com.

Shoes that are creating their own path in our world: Part 1

Tom’s

Tom’s are extremely colorful with many different patterns, but this is just a bonus. The best thing about these shoes is that you get two for the price of one! Deals are great aren’t they!! What is even better about this deal is that one pair of shoes goes to you and one pair of shoes goes to a child who doesn’t have any shoes to call their own. Tom’s was started in 2006 by Blake Mycoskie. His inspiration came from seeing children without shoes on his visit to Argentina. A little known fact is that many diseases can be picked up from the ground by being absorbed through the skin on the feet. Another concern is puncture wounds especially when medical treatment is not readily available. These things are not acceptable when there is something we can do about them. So, when Blake came back to the states he got very busy. During his first year in business he gave 10,000 shoes to children all around the world. Tom’s have become increasingly popular over the years. Their expansion has been exciting and inspiring. As of April 2010, Tom’s have given approximately 600,000 shoes to children all over the world! To check out Tom’s shoes online please visit www.toms.com.

Tinea Pedis

Is a fungal infection of the skin that causes scaling, flaking, and itch of affected areas. It is also known as Ring Worm or Athlete's foot.

Symptoms
The symptoms of athlete's foot or tinea pedis typically include itching and burning of the feet.

The skin may peel or crack with or without any associated pain.

Commonly the rash is localized to the soles of the feet.

Sometimes the flaking skin may spread to the sides and tops of the feet in a moccasin distribution.


The digital interspases may have some moisture, peeling, redness and flaking as well.



Types of Tinea Pedis


T rubrum is the most common cause for tinea pedis.

Trichophyton mentagrophytes, and Epidermophyton floccosum are other causative organisms.




Vesicular tinea pedis-
Usually caused by T mentagrophytes.
This type is characterized by painful, pruritic vesicles most often on the instep.






Interdigital tinea pedis-
Usually caused by T rubrum seen more in hot/ humid environments
This type is characterized by redness, maceration, fissuring, and scaling between toes. It is also associated with itching





Chronic hyperkeratotic tinea pedis-usually caused by T rubrum.
This type is characterized by chronic redness on the bottom of the foot or sides with scaling.




Risk Factors

• A hot, humid, tropical environment
• Prolonged use of footwear
• Hyperhydrosis- Sweating
• Certain people may have a genetic predisposition to the infection

Work Up

In suspected tinea pedis a KOH (potassium hydroxide) staining may be ordered by the doctor for fungal detection by obtaining a sample of the flaking skin

Fungal culture- may be performed to confirm the diagnosis of tinea pedis. A culture can be used to identify the fungal species.



Treatment

Tinea pedis can be treated with topical or oral antifungals. Some topical medications are over the counter. Topical agents are generally used for 1-6 weeks


Examples of Topical Medication

Topical Imidazoles

• Clotrimazole 1% (Lotrimin)
• Econazole 1% cream (Spectazole)
• Ketoconazole 1% cream (Nizoral)

Topical Pyridones

• Ciclopirox 1% cream (Loprox)

Topical Allylamines

• Naftifine 1% cream (Naftin)
• Terbinafine (Lamisil)

Oral Antifungals

Considered in patients with extensive chronic hyperkeratotic or inflammatory/vesicular tinea pedis

• Terbinafine (Lamisil)
• Itraconazole (Sporanox)

Prevention

• Keeping your feet clean and dry
• Avoiding prolonged moist environments
• Disinfecting old shoes
• Periodic use of anti fungal foot powder in the shoes