Scally Skin Lesion?Psoriasis

Definition – A chronic non-inflammatory dermatosis characterized by well demarcated erythematous plaques topped with silvery scales. 

Do any of your parents have Psoriasis? Then can you get it too?

There is a well known genetic predisposition to psoriasis. So, if you have psoriasis, yes, you can get it too. If your mother or father has psoriasis, then there is a 25% chance for you to get it too. Studies have been done all over the world and they have found that there is 73% concordance of the disease among identical twins. It means that there is a strong genetic predisposition. 

What happens in Psoriasis?

In psoriasis, there is abnormal proliferation of the cells of the skin. Not only that, the keratinization is also defective. These results in abnormal skin lesions.

How to identify psoriasis

Psoriasis can be identified by the characteristics of the lesions and their distribution. The lesions can range from chronic plaques on the elbows to the acute generalized pustular form. But still it can be confused with several other diseases because they show the same lesion pattern.

·         Psoriasiform drug eruptions

·         Hyperkeratotic eczema

·         Reiter’s disease

·         Seborrhoeic dermatitis (scalp)

·         Pityriasis rosea

·         Candidiasis of flexures (on flexures)

·         Fungal infections of the nails (nails)

The usual presentation patterns of Psoriasis

·         Plaque –red plaques (ranging up to several centimeters) covered by waxy whitish scales on knees and elbows. If you remove these scales, it can bleed. These lesions sometimes can be pruritic.

·         Guttate – In this form there are symmetrical, drops like lesions over the trunk and the limbs. These lesions usually occur in adolescents and young adults following streptococcal throat infections.

·         Flexural – These lesions are found in axillae, submamary areas and natal clefts of elderly people.

·         Localized forms – yellow to brown colour sterile pustules on the palms or soles. Commonly seen in middle aged females. Or it could present in nails, scalp or nappy areas. Psoriasis in the scalp can be confused with dandruff, but can be differentiated by its well demarked and more thickly scaled nature.

·         Generalized pustular – small sterile yellowish pustules are seen all over the body. This is very rare but can be life threatening. The disease starts rapidly and the patient will have fever and malaise. This form requires hospital admission.

·         Nail involvement – thimble pitting, onycholysis (separation of the distal edge of the nail from the nail bed), oily or salmon pink discoloration of the nail and building up of keratin under the distal nail edge..

·         erythroderma

The Psoriatic condition may be complicated by arthropathy, erythroderma and Koebner phenomenon.

Treatment

Psoriasis is a condition which needs long term treatment. Treatment of psoriasis includes tropical therapy, systemic therapy..

·         Tropical therapy

o   Vitamin D analogues – These inhibit cell proliferation and stimulate keratinocyte differentiation.These preparations are well tolerated by patients as they do not have any bad smell or stain. In comparision to steroids, they do not cause skin atrophy, but they may cause some skin irritation.  E.g:  Dovonex, Curatoderm

o   Topical corticosteroids – These are non irritative compared to vitamin D analogues.

o   Coal tar preparations

o   Dithranol

o   Retinoids

o   Keratolytics and scalp preparations

·         Systemic Therapy

o   Methotrexate

o   Retinoids

o   Ciclosporins

Systemic Lupus Erythematosus

SLE is a multi-organ, multi-systemic autoimmune disease predominant among females. There is high prevalence among black Americans, but its prevalence is low among black Africans.

As it is a multi systemic disease condition, its manifestation can be seen in many organ systems of the body. The symptoms can be categorized as follows.

Mucocutaneous lesions

The characteristic skin rashes are the commonest manifestation of the disease.  They will have the typical malar rash over the butterfly distribution of the face. Apart from that they will presents with,

•  discoid rash
•  urticarial and purpuric rashes
• levido reticularis
• Alopecia (loss of hair) - they may have reversible loss of hair or scaring alopecia in which the hair does not regrow.
• They may have nasal, oral, pharyngeal and laryngeal ulcers
• Raynaud phenomenon and shincter haemorrages are seen on the hands.

 Musculoskeletal diseases

The joints are usually affected and they present with migratory assymmetrical arthralgia. They may have reducible non erosiv ejoint difformity, avascular necrosis and myalgia.

Neuropsychiatric Disease

They may develop headache, fits, psychosis, strokes, aseptic meningitis, peripheral or cranial neuropathies or movement disorders. 

Renal Disease 


The disease can affect the interstitiam, glomeruli or the tubules. It can vary from mild (mild hematuria and proteinuria)  to severe disease (nephrotic syndrome). 

Cardiovascular Disease

Pericardium, myocardium or the endocardium can get affected giving rise to,

1. pericarditis, cardiac tamponade
2. myocardial ischemia (rare)
3. endocarditis
4. congenital heart block in neonatal lupus
5. hypertension

Hematological Disorders 

Alterations of most of the blood consituents occurs giving rise to,

1. neutripenia
2. lymphopenia
3. thrombocytopenia
4. hemolytic anemia
5. thrombotic tendencies
6. bleeding tendencies
7. non tender lymphadenopathy
8. splenomegally

Pulmonary Disease

The pleura, interstitium or the  vasculature can get affected, giving rise to, 

1. pleuricy
2. acute pneumonitis
3. chronic pneumonitis
4. shrinking lung

Gastrointestinal Disorders

 Involvement of the gastrointestinal tract is uncommon, but they may get affected leading to,

1. dyspepsia
2. peptic ulcer disease
3. pancreatitis
4. chronic active hepatitis
5. peritonitis
6. mesenteric vasculitis 

Investigations

• The WBC/DC could be normal or low. 
• High ESR and low C reactive protein ca be used to differentiate SLE from other disorders, but this is also hard as SLE patients are immunosupprsed and more prone to infections, which causes elevated CRP levels.
• High immunoglobulin levels and low complement C4 levels are also seen.
• There could be also Antinucleic antibodies and anti double strant DNA antibodies

Treatment

• Mild SLE is usually traeted with tropical steroids and hydroxychloroquine. They should be also advised to avoid exposure to sunlight.
• Moderate SLE is traeted with systemic steroids - prednisilone or methyl prednisilone or steroidsparing other cytotoxic drugs.
• Cyclophosphamide pulse therapy, azathioprine, methyl prednisilone are given for other organ involvemint.

References:

Kumar and Clark’s Clinical Medicine 7^th Edition

Do you have Headache? What Might be the Cause?

Headache is a common symptom of most of the neurological diseases involving the brain. Some of these caonditions can be fatal and accurate identification of the cause of headache is essential.

So if you have headache, first you should see what kind of a headache that is, because the nature of the headache differs with the type of underlying pathology.

Are you having headache for a long period (from months to years)? Does it reccurs occasionally?

 Then it could be due to following causes.

 The most common cause for this kind of headache is migraine. Migraine is not a serious condition and nowadays there are more successful treatments for this condition.

 Glaucoma and sinusitis can also cause recurrent attacks of headache.


Does your headache aggravates when you cough, strain, sneeze, walk or lie down?

 Then you could be having any of the following conditions.

Brain tumour - in this type of headache you may also have vomiting as an associated feature.

Headache which gradually rises within days to weeks

Brain Tumour
Encephalitis
Meningitis

Headache with tenderness (pain when touching) of the scalp

giant cell arteritis

Pain after injury to the head

Most of the times these kinds of headache does not indicate any serious pathological condition, but subdural haematoma should always be considered.

Single attack of severe headache

Subarachnoid haemorrhage
migraine
meningitis

Joint Pain and Swelling? Rheumatoid Arthritis?

Today I met a patient who has had and still having multiple joint pain and swelling for more than 20 years duration. She was 44 years now and is suffering from sero positive rheumatoid arthritis since childhood. Despite her present day condition with all the pains, aches and disabilities, she was surprisingly quite happy and active.

She has first started experiencing right knee pain which was very mild initially. Then  the pain has gradually increased in severity. The mild pain has been there for nearly an year, and she had not look for medical advice since it was not unbearable.

But the things began to get worse after about one year. By that time, both her knees were swollen and painful and the same kind of symptoms has started to appear in all joints in her body.

For the past 25 years the arthritis condition relapses and recurses. Her X-Ray revealed severely reduces bone densities. Her condition was kept under control by medication for about 15 years, but unfortunately her condition has started worsening recently.

Recently, her mobility has reduced due to severe hip, knee and back pain. As a result she has started to develope joint deformoties, due to lack of exercise. Therefore her doctors had decided to  do a hip replacement and knee replacement. Both the surgeries were successful and now she says that she is not experiencing any pain in those replaced joints.  This is good news for people who are awaiting joint replacement as a treatment method for rheumatoid arthritis.

This is a more severe form of rheumatoid arthritis. Not all the rheumatoid arthritis patients develop same kind of illness. Some people may experience only one episode of joint pain and the illness never occurs gain in their lives again.

Have you got joint pain and swelling? How to know whether it is actually rheumatoid arthritis.

People with following properties are more likely to have Rheumatoid arthritis.

• Female gender
• Age 30-50 years
• The following pattern of joint involvement

Gradually rising moderate joint pain. If the disease has taken several months to years, to reach its maximum condition, you are more likely to have rheumatoid arthritis.  

• Symmetrical joint involvement – This means the bilateral involvement of the joint.

The peripheral joints are commonly involved (peripheral poly-arthritis)
 

• Stiffness of the joints - Commonly this is referred to as morning stiffness. It is the inability to move the joints after a period of rest. The small joints of the hands and feet are commonly affected.

 Morning stiffness occurs because the joint stays imobile throughout the night while you are slleeping. People who stay awake and active during night, like watchmen, may complain of evening stiffness instaed of morning stiffness.

• People with a family history of arthritic condition.

These symptoms are not highly specific for rheumatoid arthritis. The same kinds of symptoms also appear in following diseases, too.
 

• Postviral Arthritis
• Seronegative spondyloarthropathies
• Polymyalgia Rheumatica
• Acute Nodal Osteoarthritis

Therefore specific investigations are required to confirm th diagnosis. So, if you are suspected to have rheumatoid arthritis, your doctor will initially do the following tests.

• ESR
• CRP

Rheumatoid arthritis is a inflammatory disease of the joints. Therefore, the inflamatory markers of the body such as ESR and CRP should be elevated.

But these two tests alone are not diagnostic for rheumatoid arthritis. So if they are elevated the doctor will order a test for rheumatoid factor. This is positive in 80% of the patients with rheumatoid arthritis. A negative result does not entirely rule out rheumatoid arthritis, because they might be having sero negative rheumatoid arthritis.


Treatment available for rheumatoid arthritis

Early visit to rheumatologist is essential for the better management of the disease. Even though rheumatoid arthritis is a very concerning illness, the patient should understand that it can be managed and the patient can live a almost normal life if he/she follows the treatment schedule tightly.

25% of the patients have a chance of recovering entirely, which gives every rheumatoid arthritic patient a hope.

The management involves drug therapy and physiotherapy.

Does Acupuncture helps to relieve rheumatoid arthritis?

There are evidence that patients with rheumatoid arthritis seemed to be relieved by other intervention methods like acupuncture, and ayuruvedic methods . If you are interested, you should check on that too, but don't forget your routine medications and physiotherapy.
 

References:

Kumar and Clark's clinical Medicine Seventh Edition

Hutchison's Clinical Methods 22nd Edition

Bailey and Love's Short Practice of Surgery 25th Edition

Hip Joint Replacement

Replace your hip, and you'll be able walk just like before. This is one of the miracles achieved by the advancement of the medical and surgical practices.

Hip replacement (joint replacement) surgeries are done in increasing numbers throughout the world. This indicates the high positive outcome rates of the surgery. A total of 50 000 total hip replacements are been done in United Kingdom every year.

The prognosis of the surgery is very good and 95% of the patients are found to have a almost normal joint movements without any pain. The replaced joined may function really well even for more than 20 years. 

As a result of high number of people getting their joints replaced, the number of people with failure is also increasing, but this is a relative increase, not an absolute one.

I have met with several patients who had to get their hip joints replaced due to advanced stages of rheumatoid arthritis  and osteoarthritis. One of them had a her both knee and hip joints replaced and now her condition has really improved. She says that now she can walk with no pain at all.

References:

Bailey and Love's Short Practice of Surgery 25th Edition