unit 4

psorasis
Psoriasis is a long-lasting autoimmune disease characterized by patches of
abnormal skin. These skin patches are typically red, itchy, and scaly.Psoriasis
varies in severity from small, localized patches to complete body coverage. Injury
to the skin can trigger psoriatic skin changes at that spot, which is known as the
Koebner phenomenon.

There are five main types of psoriasis: plaque, guttate, inverse, pustular, and
erythrodermic. Plaque psoriasis, also known as psoriasis vulgaris, makes up
about 90 percent of cases. It typically presents as red patches with white scales
on top.Areas of the body most commonly affected are the back of the forearms,
shins, navel area, and scalp. Guttate psoriasis has drop-shaped lesions. Pustular
psoriasis presents as small non-infectious pus-filled blisters. Inverse psoriasis
forms red patches in skin folds. Erythrodermic psoriasis occurs when the rash
becomes very widespread, and can develop from any of the other types.
Fingernails and toenails are affected in most people with psoriasis at some point
in time. This may include pits in the nails or changes in nail color.

The symptoms of psoriasis include:

Areas of itchy, scaly skin on the scalp, knees, elbows, and upper body; these
deep-pink, raised plaques of skin have white scales.
Psoriasis on fingernails and toenails can make the nails become thick, pitted,
and discolored; nails may separate from underlying nail bed.
Red, scaly, cracked skin with tiny pustules on the palms of the hands and/or
feet; you may have pustular psoriasis.
Stiffness, pain, and tenderness of the joints
Reduced range of motion
Nail changes, such as pitting, which is found in up to 80% of people with
psoriatic arthritis
Causes
genetisc;
Around one-third of people with psoriasis report a family history of the
diseasePsoriasis has a strong hereditary component, and many genes are
associated with it, but it is unclear how those genes work together. Most of the
identified genes relate to the immune system, particularly the major
histocompatibility complex (MHC) and T cells.
Lifestyle

Conditions reported as worsening the disease include chronic infections, stress,

and changes in season and climate. Others that might worsen the condition
include hot water, scratching psoriasis skin lesions, skin dryness, excessive
alcohol consumption, cigarette smoking, and obesity.
HIV

The rate of psoriasis in HIV-positive individuals is comparable to that of HIV-

negative individuals, however, psoriasis tends to be more severe in people
infected with HIV. A much higher rate of psoriatic arthritis occurs in HIV-positive
individuals with psoriasis than in those without the infection. The immune
response in those infected with HIV is typically characterized by cellular signals
from Th2 subset of CD4+ helper T cells,whereas the immune response in
psoriasis vulgaris is characterized by a pattern of cellular signals typical of Th1
subset of CD4+ helper T cells and Th17 helper T cells
Microbes

Psoriasis has been described as occurring after strep throat, and may be
worsened by skin or gut colonization with Staphylococcus aureus, Malassezia,
and Candida albicans
Medications

Drug-induced psoriasis may occur with beta blockers,lithium, antimalarial

medications, non-steroidal anti-inflammatory drugs,terbinafine, calcium channel
blockers, captopril, glyburide, granulocyte colony-stimulating factor,interleukins,
interferons,lipid-lowering drugs, and paradoxically TNF inhibitors such as
infliximab or adalimumab.Withdrawal of corticosteroids (topical steroid cream)
can aggravate psoriasis due to the rebound effect
The 5 Major Types of Psorias

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."

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 often pops up in these areas:

Elbows
Knees
Scalp
Lower back

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

Triggers include:

Upper respiratory infection such as strep throat or tonsillitis

Stress
Skin injury
Certain drugs such as beta-blockers
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 shows up as areas that are bright red, smooth, and shiny, but don't
have scales. It's usually found in these locations:

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

Inverse psoriasis may worsen with sweating and rubbing. A buildup of yeast may
trigger it.
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 immediate medical
attention.

Generalized pustular psoriasis can cause:

Fever
Chills
Nausea
Fast heart rate
Muscle weakness
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 burned. You might also have:

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 develop an infection, pneumonia, or congestive
heart failure.

Triggers include:

Suddenly stopping your systemic psoriasis treatment

An allergic drug reaction
Severe sunburn
Infection
Medications such as lithium, anti-malarial drugs, cortisone, or strong coal tar
products

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

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

Common symptoms include:

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
This is a condition where you have both psoriasis and arthritis (joint
inflammation). In 70% of cases, people have psoriasis for about 10 years before
developing psoriatic arthritis. About 90% of people with it also have nail changes.
The most common symptoms are:

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
Mechanism
Psoriasis is characterized by an abnormally excessive and rapid growth of the
epidermal layer of the skin.[44] Abnormal production of skin cells (especially
during wound repair) and an overabundance of skin cells result from the
sequence of pathological events in psoriasis.[17] Skin cells are replaced every 3–
5 days in psoriasis rather than the usual 28–30 days.[45] These changes are
believed to stem from the premature maturation of keratinocytes induced by an
inflammatory cascade in the dermis involving dendritic cells, macrophages, and T
cells (three subtypes of white blood cells).[11][36] These immune cells move from
the dermis to the epidermis and secrete inflammatory chemical signals
(cytokines) such as interleukin-36γ, tumor necrosis factor-α, interleukin-1β,
interleukin-6, and interleukin-22.[29][46] These secreted inflammatory signals are
believed to stimulate keratinocytes to proliferate.[29] One hypothesis is that
psoriasis involves a defect in regulatory T cells, and in the regulatory cytokine
interleukin-10.[29]

Gene mutations of proteins involved in the skin's ability to function as a barrier

have been identified as markers of susceptibility for the development of psoriasis.
[47][48]

DNA released from dying cells acts as an inflammatory stimulus in psoriasis[49]

and stimulates the receptors on certain dendritic cells, which in turn produce the
cytokine interferon-α.[49] In response to these chemical messages from dendritic
cells and T cells, keratinocytes also secrete cytokines such as interleukin-1,
interleukin-6, and tumor necrosis factor-α, which signal downstream inflammatory
cells to arrive and stimulate additional inflammation.[29]

Dendritic cells bridge the innate immune system and adaptive immune system.
They are increased in psoriatic lesions[44] and induce the proliferation of T cells
and type 1 helper T cells (Th1). Targeted immunotherapy as well as psoralen and
ultraviolet A (PUVA) therapy can reduce the number of dendritic cells and favors
a Th2 cell cytokine secretion pattern over a Th1/Th17 cell cytokine profile.[29][38]
Psoriatic T cells move from the dermis into the epidermis and secrete interferon-γ
and interleukin-17. Interleukin-23 is known to induce the production of interleukin-
17 and interleukin-22
Interleukin-22 works in combination with interleukin-17 to induce keratinocytes to
secrete neutrophil-attracting cytokines
diagnosis

A health care professional can usually diagnose psoriasis by carefully checking

the skin and asking the patient about signs and symptoms. There are no specific
blood tests or diagnostic procedures for psoriasis.
Physical exam and medical history. Your doctor usually can diagnose psoriasis
by taking your medical history and examining your skin, scalp and nails.
Skin biopsy. Rarely, your doctor may take a small sample of skin (biopsy). He or
she will likely first apply a local anesthetic. The sample is examined under a
microscope to determine the exact type of psoriasis and to rule out other
disorders
inflammatory infiltrates can typically be visualized on microscopy when
examining skin tissue or joint tissue affected by psoriasis. Epidermal skin tissue
affected by psoriatic inflammation often has many CD8+ T cells while a
predominance of CD4+ T cells makes up the inflammatory infiltrates of the
dermal layer of skin and the joints
Epidemiology

Psoriasis is estimated to affect 2–4% of the population of the western world.[8]

The rate of psoriasis varies according to age, region and ethnicity; a combination
of environmental and genetic factors is thought to be responsible for these
differences.[8] It can occur at any age, although it most commonly appears for
the first time between the ages of 15 and 25 years. Approximately one third of
people with psoriasis report being diagnosed before age 20.[103] Psoriasis
affects both sexes equally.[55]
Psoriasis affects about 6.7 million Americans and occurs more frequently in
adults
Management

While no cure is available for psoriasis,many treatment options exist. Topical

agents are typically used for mild disease, phototherapy for moderate disease,
and systemic agents for severe disease
Topical agents

Topical corticosteroid preparations are the most effective agents when used
continuously for 8 weeks; retinoids and coal tar were found to be of limited
benefit and may be no better than placebo
Vitamin D analogues such as paricalcitol were found to be superior to placebo.
Combination therapy with vitamin D and a corticosteroid was superior to either
treatment alone and vitamin D was found to be superior to coal tar for chronic
plaque psoriasis
moisturizers and emollients such as mineral oil, petroleum jelly, calcipotriol, and
decubal (an oil-in-water emollient) were found to increase the clearance of
psoriatic plaques. Emollients have been shown to be even more effective at
clearing psoriatic plaques when combined with phototherapy

The emollient salicylic acid is structurally similar to para-aminobenzoic acid

(PABA), commonly found in sunscreen, and is known to interfere with
phototherapy in psoriasis. Coconut oil, when used as an emollient in psoriasis,
has been found to decrease plaque clearance with phototherapy

Ointment and creams containing coal tar, dithranol, corticosteroids (i.e.

desoximetasone), fluocinonide, vitamin D3 analogs (for example, calcipotriol),
and retinoids are routinely used. The use of the finger tip unit may be helpful in
guiding how much topical treatment to use.

Vitamin D analogues may be useful with steroids; however, alone have a higher
rate of side effects.[69] They may allow less steroids to be used.[70]

Another topical therapy used to treat psoriasis is a form of balneotherapy, which

involves daily baths in the Dead Sea.
UV phototherapy

Phototherapy in the form of sunlight has long been used for psoriasis. UVB
Wavelengths of 311–313 nanometers are most effective, and special lamps have
been developed for this application. The exposure time should be controlled to
avoid over exposure and burning of the skin. The UVB lamps should have a timer
that will turn off the lamp when the time ends. The amount of light used is
determined by a person's skin type
Surgery

Limited evidence suggests removal of the tonsils may benefit people with chronic
plaque psoriasis, guttate psoriasis, and palmoplantar pustulosis
Diet

Uncontrolled studies have suggested that individuals with psoriasis or psoriatic

arthritis may benefit from a diet supplemented with fish oil rich in
eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).[87] Diet
recommendations include consumption of cold water fish (preferably wild fish, not
farmed) such as salmon, herring, and mackerel; extra virgin olive oil; legumes;
vegetables; fruits; and whole grains; and avoid consumption of alcohol, red meat,
and dairy products. The effect of consumption of caffeine (including coffee, black
tea, mate, and dark chocolate) remains to be determined .
Treatment
Psoriasis treatments reduce inflammation and clear the skin. Treatments can be
divided into three main types: topical treatments, light therapy and systemic
medications.
Topical treatments

Used alone, creams and ointments that you apply to your skin can effectively
treat mild to moderate psoriasis. When the disease is more severe, creams are
likely to be combined with oral medications or light therapy. Topical psoriasis
treatments include:

Topical corticosteroids. These drugs are the most frequently prescribed

medications for treating mild to moderate psoriasis. They reduce inflammation
and relieve itching and may be used with other treatments.

Mild corticosteroid ointments are usually recommended for sensitive areas,

such as your face or skin folds, and for treating widespread patches of damaged
skin.

Your doctor may prescribe stronger corticosteroid ointment for smaller, less
sensitive or tougher-to-treat areas.

Long-term use or overuse of strong corticosteroids can cause thinning of the

skin. Topical corticosteroids may stop working over time. It's usually best to use
topical corticosteroids as a short-term treatment during flares.
Vitamin D analogues. These synthetic forms of vitamin D slow skin cell growth.
Calcipotriene (Dovonex) is a prescription cream or solution containing a vitamin
D analogue that treats mild to moderate psoriasis along with other treatments.
Calcipotriene might irritate your skin. Calcitriol (Vectical) is expensive but may be
equally effective and possibly less irritating than calcipotriene.
Anthralin. This medication helps slow skin cell growth. Anthralin (Dritho-Scalp)
can also remove scales and make skin smoother. But anthralin can irritate skin,
and it stains almost anything it touches. It's usually applied for a short time and
then washed off.

Topical retinoids. These are vitamin A derivatives that may decrease

inflammation. The most common side effect is skin irritation. These medications
may also increase sensitivity to sunlight, so while using the medication apply
sunscreen before going outdoors.

The risk of birth defects is far lower for topical retinoids than for oral retinoids.
But tazarotene (Tazorac, Avage) isn't recommended when you're pregnant or
breast-feeding or if you intend to become pregnant.

Calcineurin inhibitors. Calcineurin inhibitors — tacrolimus (Prograf) and

pimecrolimus (Elidel) — reduce inflammation and plaque buildup.
 Calcineurin inhibitors are not recommended for long-term or continuous use
because of a potential increased risk of skin cancer and lymphoma. They may be
especially helpful in areas of thin skin, such as around the eyes, where steroid
creams or retinoids are too irritating or may cause harmful effects.
Salicylic acid. Available over-the-counter (nonprescription) and by prescription,
salicylic acid promotes sloughing of dead skin cells and reduces scaling.
Sometimes it's combined with other medications, such as topical corticosteroids
or coal tar, to increase its effectiveness. Salicylic acid is available in medicated
shampoos and scalp solutions to treat scalp psoriasis.

Coal tar. Derived from coal, coal tar reduces scaling, itching and inflammation.
Coal tar can irritate the skin. It's also messy, stains clothing and bedding, and has
a strong odor.

Coal tar is available in over-the-counter shampoos, creams and oils. It's also
available in higher concentrations by prescription. This treatment isn't
recommended for women who are pregnant or breast-feeding.
Moisturizers. Moisturizing creams alone won't heal psoriasis, but they can
reduce itching, scaling and dryness. Moisturizers in an ointment base are usually
more effective than are lighter creams and lotions. Apply immediately after a bath
or shower to lock in moisture.

scabies
Each year, scabies affects millions of people of all races, ages, and socioeconomic
status.

It is highly contagious, being easily spread through close physical contact and by sharing
bedding, clothing, and furniture infested with mites.

Scabies is estimated to infect over 300 million humans worldwide each year, including 1
million people in the United States.

Scabies most frequently occurs in children and young adults, with outbreaks in child care
facilities and schools common.
Signs and symptoms
Commonly involved sites of rashes of scabies

The characteristic symptoms of a scabies infection include intense itching and superficial
burrows.The burrow tracks are often linear, to the point that a neat "line" of four or more
closely placed and equally developed mosquito-like "bites" is almost diagnostic of the
disease.[citation needed] Because the host develops the symptoms as a reaction to the
mites' presence over time, typically a delay of four to six weeks occurs between the
onset of infestation and the onset of itching. Similarly, symptoms often persist for one to
several weeks after successful eradication of the mites. As noted, those re-exposed to
scabies after successful treatment may exhibit symptoms of the new infestation in a
much shorter period—as little as one to four days.
Itching

In the classic scenario, the itch is made worse by warmth, and is usually experienced as
being worse at night, possibly because distractions are fewer.[16] As a symptom, it is
less common in the elderly.
Rash

The superficial burrows of scabies usually occur in the area of the finger webs, feet,
ventral wrists, elbows, back, buttocks, and external genitals.[16] Except in infants and
the immunosuppressed, infection generally does not occur in the skin of the face or
scalp. The burrows are created by excavation of the adult mite in the epidermis.

In most people, the trails of the burrowing mites are linear or S-shaped tracks in the skin
often accompanied by rows of small, pimple-like mosquito or insect bites. These signs
are often found in crevices of the body, such as on the webs of fingers and toes, around
the genital area, in stomach folds of the skin, and under the breasts of women.
he most common site of infestation in adults and older children
include:
·0 in between the fingers
·1 around fingernails
·2 armpits
·3 waistline
·4 inner parts of the wrists
·5 inner elbow
·6 soles of the feet
·7 the breasts, particularly the areas around the nipples
·8 male genitalia
·9 buttocks
·10 knees
·11 shoulder blades

causes
mite causes this common skin condition. Called the human itch mite, this eight-
legged bug is so small that you cannot see it on the skin. People get scabies
when the mite burrows into the top layer of skin to live and feed. When the skin
reacts to the mite, an extremely itchy rash develops.

This mite can travel from the infected person to another person. Most people get
scabies from direct, skin-to-skin contact. Less often, people pick up mites from
infested items such as bedding, clothes, and furniture. The mite can survive for
about 3 to 4 days without being on a human. Worldwide, there are millions of
cases of scabies each year.

Anyone can get scabies. It strikes people of all ages, races, and income levels.
People who are very clean and neat can get scabies. It tends to spread easily in
nursing homes and extended-care facilities. The good news is that a
dermatologist can successfully diagnose and treat scabies. With today’s
treatments, scabies need only cause short-term distress.
Pathophysiology
The symptoms are caused by an allergic reaction of the host's body to mite
proteins, though exactly which proteins remains a topic of study. The mite
proteins are also present from the gut, in mite feces, which are deposited under
the skin. The allergic reaction is both of the delayed (cell-mediated) and
immediate (antibody-mediated) type, and involves IgE (antibodies, it is
presumed, mediate the very rapid symptoms on reinfection).The allergy-type
symptoms (itching) continue for some days, and even several weeks, after all
mites are killed. New lesions may appear for a few days after mites are
eradicated. Nodular lesions from scabies may continue to be symptomatic for
weeks after the mites have been killed.

Rates of scabies are negatively related to temperature and positively related to

humidity
Diagnosis
A photomicrograph of an itch mite (S. scabiei)

Scabies may be diagnosed clinically in geographical areas where it is common when

diffuse itching presents along with either lesions in two typical spots or itchiness is
present in another household member.[11] The classical sign of scabies is the burrow
made by a mite within the skin.[11] To detect the burrow, the suspected area is rubbed
with ink from a fountain pen or a topical tetracycline solution, which glows under a
special light. The skin is then wiped with an alcohol pad. If the person is infected with
scabies, the characteristic zigzag or S pattern of the burrow will appear across the skin;
however, interpreting this test may be difficult, as the burrows are scarce and may be
obscured by scratch marks.[11] A definitive diagnosis is made by finding either the
scabies mites or their eggs and fecal pellets.[11] Searches for these signs involve either
scraping a suspected area, mounting the sample in potassium hydroxide and examining
it under a microscope, or using dermoscopy to examine the skin directly.

treatment
According to the American Academy of Dermatologists (AAD), some common
medicines used to treat scabies include:

5 percent permethrin cream

25 percent benzyl benzoate lotion
10 percent sulfur ointment 1 percent lindane lotion

Your doctor may also prescribe additional medications to help relieve some of the
bothersome symptoms associated with scabies. These medications include:

antihistamines, such as Benadryl (diphenhydramine) or pramoxine lotion to

help control the itching
 antibiotics to kill any infections that develop as a result of constantly scratching
your skin
steroid creams to relieve swelling and itching

More aggressive treatment may be needed for severe or widespread scabies. An

oral tablet called ivermectin (Stromectol) can be given to people who:

don’t see an improvement in symptoms after initial treatment

have crusted scabies
have scabies that covers most of the body

During the first week of treatment, it may seem as if the symptoms are getting
worse. However, after the first week, you’ll notice less itching, and you should be
completely healed by the fourth week of treatment. Skin that hasn’t healed within
a month may still be infested with scabies mites. It’s important to remember that
“post-scabies itch” can last up to one month.Others

Other treatments include lindane, benzyl benzoate, crotamiton, malathion, and

sulfur preparations.[11][16] Lindane is effective, but concerns over potential
neurotoxicity have limited its availability in many countries.[16] It is banned in
California,[39] but may be used in other states as a second-line treatment.[40]
Sulfur ointments or benzyl benzoate are often used in the developing world due
to their low cost;[16] Some 10% sulfur solutions have been shown to be effective,
[41] and sulfur ointments are typically used for at least a week, though many
people find the odor of sulfur products unpleasan

eczema
Dermatitis, also known as eczema, is a group of diseases that results in
inflammation of the skin.[1] These diseases are characterized by itchiness, red
skin, and a rash.[1] In cases of short duration there may be small blisters while in
long-term cases the skin may become thickened.[1] The area of skin involved
can vary from small to the entire body
symptoms

Most people develop atopic dermatitis before the age of 5 years. Half of those
who develop the condition in childhood continue to have symptoms as an adult.

However, these symptoms are often different to those experienced by children.

People with the condition will often experience periods of time where their
symptoms flare up or worsen, followed by periods of time where their symptoms
will improve or clear up.
Symptoms in infants under 2 years old

Rashes commonly appear on the scalp and cheeks.

 Rashes usually bubble up before leaking fluid.
Rashes can cause extreme itchiness. This may interfere with sleeping.
Continuous rubbing and scratching can lead to skin infections.

Symptoms in children aged 2 years until puberty

Rashes commonly appear behind the creases of elbows or knees.

They are also common on the neck, wrists, ankles, and the crease between
buttock and legs.

Over time, the following symptoms can occur:

Rashes can become bumpy.

Rashes can lighten or darken in color.
Rashes can thicken in a process known as lichenification. The rashes can then
develop knots and a permanent itch.

Symptoms in adults

Rashes commonly appear in creases of the elbows or knees or the nape of the neck.
Rashes cover much of the body.
Rashes can be especially prominent on the neck, face, and around the eyes.
Rashes can cause very dry skin.
Rashes can be permanently itchy.
Rashes in adults can be more scaly than those occurring in children.
Rashes can lead to skin infections.

Adults who developed atopic dermatitis as a child but no longer experience the condition may still
have dry or easily-irritated skin, hand eczema, and eye problems.
different types
·12 Atopic dermatitis: This health condition has a genetic basis and produces
a common type of eczema. Atopic dermatitis tends to begin early in life in
those with a predisposition to inhalant allergies, but it probably does not
have an allergic basis. Characteristically, rashes occur on the cheeks,
neck, elbow and knee creases, and ankles.
·13
·14 Irritant dermatitis: This occurs when the skin is repeatedly exposed to
excessive washing or toxic substances.
·15
·16 Allergic contact dermatitis: After repeated exposures to the same
substance, an allergen, the body's immune recognition system becomes
activated at the site of the next exposure and produces a dermatitis. An
example of this would be poison ivy allergy.
·17
·18 Stasis dermatitis: It commonly occurs on the swollen lower legs of people
who have poor circulation in the veins of the legs.
·19
·20 Fungal infections: This can produce a pattern identical to many other
 types of eczema, but the fungus can be visualized with a scraping under
the microscope or grown in culture.
·21
·22 Scabies: It's caused by an infestation by the human itch mite and may
produce a rash very similar to other forms of eczema.
·23
·24 Pompholyx (dyshidrotic eczema): This is a common but poorly understood
health condition which classically affects the hands and occasionally the
feet by producing an itchy rash composed of tiny blisters (vesicles) on the
sides of the fingers or toes and palms or soles
·25 .
·26 Lichen simplex chronicus: It produces thickened plaques of skin
commonly found on the shins and neck.
·27
·28 Nummular eczema: This is a nonspecific term for coin-shaped plaques of
scaling skin most often on the lower legs of older individuals.
·29
·30 Xerotic (dry skin) eczema: The skin will crack and ooze if dryness
becomes excessive.
·31
·32 Seborrheic dermatitis: It produces a rash on the scalp, face, ears, and
occasionally the mid-chest in adults. In infants, in can produce a weepy,
oozy rash behind the ears and can be quite extensive, involving the entire
body.

Risk factors
The primary risk factor for atopic dermatitis is having a personal or family history of
eczema, allergies, hay fever or asthma.
Complications

·33 Asthma and hay fever. Eczema sometimes precedes these conditions. More
than half of young children with atopic dermatitis develop asthma and hay fever
by age 13.
·34
·35 Chronic itchy, scaly skin. A skin condition called neurodermatitis (lichen
simplex chronicus) starts with a patch of itchy skin. You scratch the area, which
makes it even itchier. Eventually, you may scratch simply out of habit. This
condition can cause the affected skin to become discolored, thick and leathery.
·36
·37 Skin infections. Repeated scratching that breaks the skin can cause open
sores and cracks. These increase the risk of infection from bacteria and viruses,
including the herpes simplex virus.
·38
·39 Irritant hand dermatitis. This especially affects people whose work requires
that their hands are often wet and exposed to harsh soaps, detergents and
disinfectants.
·40
·41 Allergic contact dermatitis. This condition is common in people with atopic
dermatitis.
·42
·43 Sleep problems. The itch-scratch cycle can cause poor sleep quality.
diagnosis
An accurate diagnosis requires an examination of the entire skin surface and a careful
health history. It is important for a doctor to rule out curable conditions caused by
infectious organisms. Occasionally, a sample of skin (biopsy) may be sent for
examination in a laboratory.

Home care

There are numerous things that people with eczema can do to support skin health and
alleviate symptoms, such as:

·44 taking lukewarm baths

·45 applying moisturizer within 3 minutes of bathing to "lock in" moisture
·46 moisturizing every day
·47 wearing cotton and soft fabrics, and avoiding rough, scratchy fibers and tight-
fitting clothing
·48 using a mild soap or a non-soap cleanser when washing
·49 air drying or gently patting skin dry with a towel, rather than rubbing the skin
dry after bathing
·50 where possible, avoiding rapid changes of temperature and activities that
make you sweat
·51 learning and avoiding individual eczema triggers
·52 using a humidifier in dry or cold weather
·53 keeping fingernails short to prevent scratching from breaking the skin
Prevention
The following tips may help prevent bouts of dermatitis (flares) and minimize the drying
effects of bathing:

Moisturize your skin at least twice a day. Creams, ointments and lotions seal in
moisture. Choose a product or products that work well for you. Using petroleum jelly on
your baby's skin may help prevent development of atopic dermatitis.

Try to identify and avoid triggers that worsen the condition. Things that can worsen the
skin reaction include sweat, stress, obesity, soaps, detergents, dust and pollen. Reduce
your exposure to your triggers.

Infants and children may experience flares from eating certain foods, including eggs,
milk, soy and wheat. Talk with your child's doctor about identifying potential food
allergies.
Take shorter baths or showers. Limit your baths and showers to 10 to 15 minutes. And
use warm, rather than hot, water.
 Take a bleach bath. The American Academy of Dermatology recommends considering
a bleach bath to help prevent flares. A diluted-bleach bath decreases bacteria on the
skin and related infections. Add 1/2 cup (118 milliliters) of household bleach, not
concentrated bleach, to a 40-gallon (151-liter) bathtub filled with warm water. Measures
are for a U.S.-standard-sized tub filled to the overflow drainage holes.

Soak from the neck down or just the affected areas of skin for about 10 minutes. Do
not submerge the head. Take a bleach bath no more than twice a week.
Use only gentle soaps. Choose mild soaps. Deodorant soaps and antibacterial soaps
can remove more natural oils and dry your skin.
Dry yourself carefully. After bathing gently pat your skin dry with a soft towel and apply
moisturizer while your skin is still damp.
Medications
There is little evidence for antihistamine; they are thus not generally recommended.[4]
Sedative antihistamines, such as diphenhydramine, may be tried in those who are
unable to sleep due to eczema.[4]
Colloidal oatmeal

Oatmeal contains avenanthramide (anthranilic acid amides), which can have an anti-
inflammatory effect.[46]
Corticosteroids

If symptoms are well controlled with moisturizers, steroids may only be required when
flares occur.[4] Corticosteroids are effective in controlling and suppressing symptoms in
most cases.[47] Once daily use is generally enough.[4] For mild-moderate eczema a
weak steroid may be used (e.g., hydrocortisone), while in more severe cases a higher-
potency steroid (e.g., clobetasol propionate) may be used. In severe cases, oral or
injectable corticosteroids may be used. While these usually bring about rapid
improvements, they have greater side effects.
immunosuppressants

Topical immunosuppressants like pimecrolimus and tacrolimus may be better in the short
term and appear equal to steroids after a year of use
When eczema is severe and does not respond to other forms of treatment, systemic
immunosuppressants are sometimes used. Immunosuppressants can cause significant
side effects and some require regular blood tests. The most commonly used are
ciclosporin, azathioprine, and methotrexate
Light therapy

Light therapy using ultraviolet light has tentative support but the quality of the evidence is
not very good.[54] A number of different types of light may be used including UVA and
UVB;[55] in some forms of treatment, light sensitive chemicals such as psoralen are also
used. Overexposure to ultraviolet light carries its own risks, particularly that of skin
cancer
·54 Antihistamines such as diphenhydramine (Benadryl) can control the itch.
·55
·56 Corticosteroid cream or ointment can reduce the itch. For a more severe
reaction, you can take steroids like prednisone (Rayos) by mouth to control
swelling.
·57
·58 Calcineurin inhibitors such as tacrolimus (Protopic) and pimecrolimus (Elidel)
reduce the immune response that causes red, itchy skin.
·59
·60 Antibiotics treat skin infections.
·61
·62 Light therapy exposes your skin to ultraviolet light to heal your rash.
·63
·64 Cool compresses applied before you rub on the corticosteroid cream can help
the medicine get into your skin more easily.
Alternative medicine
Limited evidence suggests that acupuncture may reduce itching in those affected by
atopic dermatitis
Neither evening primrose oil nor borage seed oil taken orally have been shown to be
effective
pset.
Probiotics do not appear to be effective.There is insufficient evidence to support the use
of zinc, selenium, vitamin D, vitamin E, pyridoxine (vitamin B6), sea buckthorn oil,
hempseed oil, sunflower oil, or fish oil as dietary supplements.

Chiropractic spinal manipulation lacks evidence to support its use for dermatitis. There is
little evidence supporting the use of psychological treatments.While dilute bleach baths
have been used for infected dermatitis there is little evidence for this practice.

impetigo
impetigo (im-puh-TIE-go) is a common and highly contagious skin infection that mainly
affects infants and children. Impetigo usually appears as red sores on the face,
especially around a child's nose and mouth, and on hands and feet. The sores burst and
develop honey-colored crusts .
Signs and symptoms
Contagious impetigo
This most common form of impetigo, also called nonbullous impetigo, most often begins
as a red sore near the nose or mouth which soon breaks, leaking pus or fluid, and forms
a honey-colored scab,[8] followed by a red mark which heals without leaving a scar.
Sores are not painful, but they may be itchy. Lymph nodes in the affected area may be
swollen, but fever is rare. Touching or scratching the sores may easily spread the
infection to other parts of the body.[9]

Skin ulcers with redness and scarring also may result from scratching or abrading the
skin.
Drawing of impetigo all over the face.
Impetigo on the back of the neck.
A severe case of facial impetigo.
Bullous impetigo
Bullous impetigo after the bulla have broken
Bullous impetigo, mainly seen in children younger than 2 years, involves painless, fluid-
filled blisters, mostly on the arms, legs, and trunk, surrounded by red and itchy (but not
sore) skin. The blisters may be large or small. After they break, they form yellow scabs.
[9]
Ecthyma
Ecthyma, the nonbullous form of impetigo, produces painful fluid- or pus-filled sores with
redness of skin, usually on the arms and legs, become ulcers that penetrate deeper into
the dermis. After they break open, they form hard, thick, gray-yellow scabs, which
sometimes leave scars. Ecthyma may be accompanied by swollen lymph nodes in the
affected area
Causes
Impetigo is primarily caused by Staphylococcus aureus, and sometimes by
Streptococcus pyogenes.[10] Both bullous and nonbullous are primarily caused by S.
aureus, with Streptococcus also commonly being involved in the nonbullous form.[11]

Predisposing factors
Impetigo is more likely to infect children ages 2–5, especially those that attend school or
day care.[3][12][1] 70% of cases are the nonbullous form and 30% are the bullous form.
[3] Other factors can increase the risk of contracting impetigo such as diabetes mellitus,
dermatitis, immunodeficiency disorders, and other irritable skin disorders.[13] Impetigo
occurs more frequently among people who live in warm climates.[

Transmission
The infection is spread by direct contact with lesions or with nasal carriers. The
incubation period is 1–3 days after exposure to Streptococcus and 4–10 days for
Staphylococcus.[15] Dried streptococci in the air are not infectious to intact skin.
Scratching may spread the lesions.

Diagnosis
Impetigo is usually diagnosed based on its appearance. It generally appears as honey-
colored scabs formed from dried serum, and is often found on the arms, legs, or face.
[10] If a visual diagnosis is unclear a culture may be done to test for resistant bacteria

Prevention
To prevent spread of impetigo to other people the skin and any open wounds should be
kept clean. Care should be taken to keep fluids from an infected person away from the
skin of a non-infected person. Washing hands, linens, and affected areas will lower the
likelihood of contact with infected fluids. Sores should be covered with a bandage.
Scratching can spread the sores; keeping nails short will reduce the chances of
spreading. Infected people should avoid contact with others and eliminate sharing of
clothing or linens.[17]

Keeping skin clean is the best way to keep it healthy. It's important to wash cuts,
scrapes, insect bites and other wounds right away.

To help prevent impetigo from spreading to others:

·65 Gently wash the affected areas with mild soap and running water and then
cover lightly with gauze.
·66 Wash an infected person's clothes, linens and towels every day and don't
share them with anyone else in your family.
·67 Wear gloves when applying antibiotic ointment and wash your hands
thoroughly afterward.
·68 Cut an infected child's nails short to prevent damage from scratching.
·69 Wash hands frequently.
·70 Keep your child home until your doctor says he or she isn't contagious.

Treatment
For generations, the disease was treated with an application of the antiseptic gentian
violet.[18] Today, topical or oral antibiotics are usually prescribed. Mild cases may be
treated with bactericidal ointment, such as mupirocin. In 95% of cases, a single antibiotic
course results in resolution in children.[19] It has been advocated that topical antiseptics
are not nearly as efficient as antibiotics, and therefore should be avoided.[3]

More severe cases require oral antibiotics, such as dicloxacillin, flucloxacillin, or

erythromycin. Alternatively, amoxicillin combined with clavulanate potassium,
cephalosporins (first-generation) and many others may also be used as an antibiotic
treatment. Alternatives for people who are seriously allergic to penicillin or infections with
MRSA include doxycycline, clindamycin, and SMX-TMP. When streptococci alone are
the cause, penicillin is the drug of choice.

When the condition presents with ulcers, valacyclovir, an antiviral, may be given in case
a viral infection is causing the ulcer
What is the treatment for impetigo?
The following steps are used to treat impetigo.

Cleanse the wound; use moist soaks to gently remove crusts

Apply antiseptic (povidone iodine, hydrogen peroxide cream, chlorhexidine,
superoxidised solution and others) or antibiotic ointment (fusidic acid, mupirocin or
retapamulin) as prescribed
Cover the affected areas.
If impetigo is extensive, oral antibiotics are recommended, often flucloxacillin.

unit
2

Rheumatoid
arthritis (RA)
is an autoimmune disease that can cause joint pain and damage throughout your
body. The joint damage that RA causes usually happens on both sides of your
body. So if a joint is affected in one of your arms or legs, the same joint in the
other arm or leg will probably be affected, too. This is one way that doctors
distinguish RA from other forms of arthritis, such as osteoarthritis (OA).

Rheumatoid arthritis symptoms

RA is a long-term or chronic disease marked by symptoms of inflammation and

pain in the joints. These symptoms and signs occur during periods known as
flares. Other times are known as periods of remission — this is when symptoms
dissipate completely.:

·71 joint pain

·72 joint swelli
·73 joint stiffness
·74 loss of joint function
Rheumatoid arthritis can affect many nonjoint structures, including:

·75 Skin
·76 Eyes
·77 Lungs
·78 Heart
·79 Kidneys
·80 Salivary glands
·81 Nerve tissue
·82 Bone marrow
·83 Blood vessels
Rheumatoid arthritis diagnosis
Diagnosing RA can take time and may require multiple lab tests to confirm
clinical examination findings. Your doctor will use several tools to diagnose RA.

First your doctor will ask about your symptoms and medical history. They’ll also
perform a physical exam of your joints. This will include looking for swelling and
redness, and testing your reflexes and muscle strength. Your doctor will also
touch the affected joints to check for warmth and tenderness. If they suspect RA,
they’ll most likely refer you to a specialist called a rheumatologist.

Since no single test can confirm a diagnosis of RA, your doctor or rheumatologist
may use several different types of tests. They may test your blood for certain
substances like antibodies, or check the level of certain substances like acute
phase reactants that are elevated during inflammatory conditions. These can be
a sign of RA and help support the diagnosis.

They may also request certain imaging tests. Tests such as ultrasonography, x-
ray exams, and magnetic resonance imaging (MRI) not only show if damage
from RA has been done to your joints but also how severe the damage is. A
complete evaluation and monitoring of other organ systems might be in order for
some people with RA
Blood test for rheumatoid arthritis
There are several types of blood tests that help your doctor or rheumatologist
determine whether you have RA. These tests include:

·84 Rheumatoid factor test: This blood test checks for a protein called
rheumatoid factor. High levels of rheumatoid factor are associated with
autoimmune diseases, especially RA.
·85
·86 Anticitrullinated protein antibody test (anti-CCP):This test looks for an
antibody that’s associated with RA. People who have this antibody usually
have the disease. However, not everyone with RA tests positive for this
antibody.
·87
·88 Antinuclear antibody test: This tests your immune system to see if it’s
producing antibodies. Your body may make antibodies as a response to
many different types of conditions, including RA.
·89
·90 Erythrocyte sedimentation rate: This test helps determine the degree of
inflammation in your body. The result tells your doctor whether
inflammation is present. However, it doesn’t indicate the cause of the
inflammation.
·91 C-reactive protein test: A severe infection or significant inflammation
anywhere in your body can trigger your liver to make C-reactive protein.
High levels of this inflammatory marker are associated with RA.
Causes
Rheumatoid arthritis vs. osteoarthritis

Rheumatoid arthritis occurs when your immune system attacks the synovium —
the lining of the membranes that surround your joints.

The resulting inflammation thickens the synovium, which can eventually destroy
the cartilage and bone within the joint.

The tendons and ligaments that hold the joint together weaken and stretch.
Gradually, the joint loses its shape and alignment.
Doctors don't know what starts this process, although a genetic component
appears likely. While your genes don't actually cause rheumatoid arthritis, they
can make you more susceptible to environmental factors — such as infection
with certain viruses and bacteria — that may trigger the disease.

Risk factors

Factors that may increase your risk of rheumatoid

arthritis include:

·92 Your sex. Women are more likely than men to develop rheumatoid
arthritis.
·93
·94 Age. Rheumatoid arthritis can occur at any age, but it most commonly
begins between the ages of 40 and 60.
·95
·96 Family history. If a member of your family has rheumatoid arthritis, you
may have an increased risk of the disease.
·97
·98 Smoking. Cigarette smoking increases your risk of developing
rheumatoid arthritis, particularly if you have a genetic predisposition for
developing the disease. Smoking also appears to be associated with
greater disease severity.
·99
·100 Environmental exposures. Although uncertain and poorly understood,
some exposures such as asbestos or silica may increase the risk for
developing rheumatoid arthritis.
·101
·102 Emergency workers exposed to dust from the collapse of the World Trade
Center are at higher risk of autoimmune diseases such as rheumatoid
arthritis.
·103
·104 Obesity. People who are overweight or obese appear to be at
somewhat higher risk of developing rheumatoid arthritis, especially in
women diagnosed with the disease when they were 55 or younger.
·105
Complications
Rheumatoid arthritis increases your risk of developing:

·106 Osteoporosis. Rheumatoid arthritis itself, along with some medications

used for treating rheumatoid arthritis, can increase your risk of
osteoporosis — a condition that weakens your bones and makes them
more prone to fracture.
·107
·108 Rheumatoid nodules. These firm bumps of tissue most commonly form
around pressure points, such as the elbows. However, these nodules can
form anywhere in the body, including the lungs.
·109
·110 Dry eyes and mouth. People who have rheumatoid arthritis are much
more likely to experience Sjogren's syndrome, a disorder that decreases
the amount of moisture in your eyes and mouth.
·111
·112 Infections. The disease itself and many of the medications used to
combat rheumatoid arthritis can impair the immune system, leading to
increased infections.
·113 Abnormal body composition. The proportion of fat compared to lean
mass is often higher in people who have rheumatoid arthritis, even in
people who have a normal body mass index (BMI).
·114
·115 Carpal tunnel syndrome. If rheumatoid arthritis affects your wrists, the
inflammation can compress the nerve that serves most of your hand and
fingers.
·116
·117 Heart problems. Rheumatoid arthritis can increase your risk of
hardened and blocked arteries, as well as inflammation of the sac that
encloses your heart.
·118
·119 Lung disease. People with rheumatoid arthritis have an increased risk
of inflammation and scarring of the lung tissues, which can lead to
progressive shortness of breath.
·120
·121 Lymphoma. Rheumatoid arthritis increases the risk of lymphoma, a
group of blood cancers that develop in the lymph system.

The goals of rheumatoid arthritis (RA) treatment are to:

·122 Stop inflammation (put disease in remission)

·123 Relieve symptoms
·124 Prevent joint and organ damage
·125 Improve physical function and overall well-being
·126 Reduce long-term complications
·127
To meet these goals, the doctor will follow these strategies:

Early, aggressive treatment. The first strategy is to reduce or stop inflammation

as quickly as possible – the earlier, the better.

Targeting remission. Doctors refer to inflammation in RA as disease activity.

The ultimate goal is to stop it and achieve remission, meaning minimal or no
signs or symptoms of active inflammation. One strategy to achieve this goal is
called “treat to target.”

Tight control. Getting disease activity to a low level and keeping it there is what
is called having “tight control of RA.” Research shows that tight control can
prevent or slow the pace of joint damage.
medications of RA
There are different drugs used in the treatment of rheumatoid arthritis. Some are
used primarily to ease the symptoms of RA; others are used to slow or stop the
course of the disease and to inhibit structural damage.
Drugs That Ease Symptoms

Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over-the-counter

and by prescription. They are used to help ease arthritis pain and inflammation.
NSAIDs include such drugs as ibuprofen, ketoprofen and naproxen sodium,
among others. For people who have had or are at risk of stomach ulcers, the
doctor may prescribe celecoxib, a type of NSAID called a COX-2 inhibitor, which
is designed to be safer for the stomach. These medicines can be taken by mouth
or applied to the skin (as a patch or cream) directly to a swollen joint.
Drugs That Slow Disease Activity

Corticosteroids. Corticosteroid medications, including prednisone, prednisolone

and methyprednisolone, are potent and quick-acting anti-inflammatory
medications. They may be used in RA to get potentially damaging inflammation
under control, while waiting for NSAIDs and DMARDs (below) to take effect.
Because of the risk of side effects with these drugs, doctors prefer to use them
for as short a time as possible and in doses as low as possible.

DMARDs. An acronym for disease-modifying antirheumatic drugs, DMARDs are

drugs that work to modify the course of the disease. Traditional DMARDs include
methotrexate, hydroxycholorquine, sulfasalazine, leflunomide, cyclophosphamide
and azathioprine. These medicines can be taken by mouth, be self-injected or
given as an infusion in a doctor’s office.

Biologics. These drugs are a subset of DMARDs. Biologics may work more
quickly than traditional DMARDs, and are injected or given by infusion in a
doctor’s office. Because they target specific steps in theinflammatory process,
they don’t wipe out the entire immune response as some other RA treatments do.
In many people with RA, a biologic can slow, modify or stop the disease – even
when other treatments haven’t helped much.

JAK inhibitors. A new subcategory of DMARDs known as “JAK inhibitors” block

the Janus kinase, or JAK, pathways, which are involved in the body’s immune
response. Tofacitinib belongs to this class. Unlike biologics, it can be taken by
mouth.
Surgery

Surgery for RA may never be needed, but it can be an important option for
people with permanent damage that limits daily function, mobility and
independence. Joint replacement surgery can relieve pain and restore function in
joints badly damaged by RA. The procedure involves replacing damaged parts of
a joint with metal and plastic parts. Hip and knee replacements are most
common. However, ankles, shoulders, wrists, elbows, and other joints may be
considered for replacement.
Rheumatoid arthritis surgery may involve one or more of the following
procedures:

Synovectomy. Surgery to remove the inflamed synovium (lining of the joint).

Synovectomy can be performed on knees, elbows, wrists, fingers and hips.

Tendon repair. Inflammation and joint damage may cause tendons around
your joint to loosen or rupture. Your surgeon may be able to repair the tendons
around your joint
.
Joint fusion. Surgically fusing a joint may be recommended to stabilize or
realign a joint and for pain relief when a joint replacement isn't an option
.
Total joint replacement. During joint replacement surgery, your surgeon
removes the damaged parts of your joint and inserts a prosthesis made of metal
and plastic.

Dietary supplements

FATTY ACIDS
Gamma-linolenic acid, an omega-6 fatty acid, may reduce pain, tender joint
count and stiffness, and is generally safe. For omega-3 polyunsaturated fatty
acids (found in fish oil), a meta-analysis reported a favorable effect on pain,
although confidence in the effect was considered moderate. The same review
reported less inflammation but no difference in joint function. A review examined
the effect of marine oil omega-3 fatty acids on pro-inflammatory eicosanoid
concentrations; leukotriene4 (LTB4) was lowered in people with rheumatoid
arthritis but not in those with non-autoimmune chronic diseases. (LTB4)
increases vascular permeabiltity and stimulates other inflammatory substances.A
third meta-analysis looked at fish consumption. The result was a weak, non-
statistically significant inverse association between fish consumption and RA

Pregnancy

More than 75% of women with rheumatoid arthritis have symptoms improve
during pregnancy but might have symptoms worsen after delivery.[18]
Methotrexate and leflunomide are teratogenic (harmful to foetus) and not used in
pregnancy. It is recommended women of childbearing age should use
contraceptives to avoid pregnancy and to discontinue its use if pregnancy is
planned.[68][74] Low dose of prednisolone, hydroxychloroquine and
sulfasalazine are considered safe in pregnant persons with rheumatoid arthritis.

Vaccinations

People with RA have an increased risk of infections and mortality and

recommended vaccinations can reduce these risks. The inactivated influenza
vaccine should be received annually.The pneumococcal vaccine should be
administered twice for people under the age 65 and once for those over 65
Lastly, the live-attenuated zoster vaccine should be administered once after the
age 60, but is not recommended in people on a tumor necrosis factor alpha
blocker.