No Improvement of Dandruff, after using every single anti-dandruff product available? It could be due to Psoriasis

Some people experience alopecia and dandruff. Most of the time this is due to dandruff, but some times it could be due to Psoriasis. If you have psoriatic lesions all over the body, it is not very hard to diagnose it. But if there are not any other significant lesions in other places of the body, the diagnosis becomes a little harder.

These people may go on trying various commercially available anti-dandruff agents, but still get no improvement. A dermatologist can easily differentiate such situations as psoriasis, only by looking at the lesion. How do they do that?

They do it by careful examination of the lesion. The psoriatic lesions are described as erythematous patches topped with large silvery scales. The key feature in differentiating these two is “large scales and patchy distribution”. Dandruff is usually distributed throughout the skull and psoriatic lesions presents as patched.  The psoriatic scales are large and dandruff scales are very small.

The dermatologist will do a thorough examination in other places too, and may find several such lesions in other parts of the body too. 

New Research Findings: Combined Oral Contraceptive Pills Can Reduce Acne

A study done in United States of America by Koltun. W et. al.(2011) has found that a low dose combined oral contraceptive can reduce acne, and in some they were able to cure acne totally.  The study was done using 893 healthy women with acne who took ethinylestradiol 20μg/drospirenone 3mg combined oral contraceptive. They were compared with 442 healthy women with acne who were given only a placebo. The Combined oral contraceptives (COC) and placebo pills were given for 6 cycles. The  COC group had three times better acne reduction.


References:

Koltun W, Maloney JM, Marr J, and Kunz M. (2011). Treatment of moderate acne vulgaris using a combined oral contraceptive containing ethinylestradiol 20 μg plus drospirenone 3mg administered in a 24/4 regimen: a pooled analysis. Pubmed. [online] Available at: <http://www.ncbi.nlm.nih.gov/pubmed/21288628>[Accessed 9 February 2011]

Research Findings: Most effective treatment for acne rosacea

Acne rosacea causes popular pustular lesions on the skin. This can be successfully treated with tropical metronidazole or azelaic acid. Most patients find it easy to tolerate Metronidazole than azelaic acid.  Other drugs which are also effective against acne are,

·        Oral doxycycline

·        Tetracycline

It is still to find out which one is the best among these drugs.

Treatment for Acne

Acne is caused by a bacterium called Propinobacterium acne. Usually most people with acne have already tried over the counter creams. Most people with mild acne improve with this treatment and people with more severe condition are treated with systemic drugs. Benzoyl peroxide (Panoxyl, Acnecide, Brevoxyl) cream or gel are given for mild cases. They are given for local appliance twice a day. They can cause irritation and contact dermatitis in some people. These creams act by reducing the number of Propianobacterium acnes.

If you have more comedons(black heads) tretinoin is used. This is available as cream or gel. It also produces irritation as a side effect. Antibiotics like clindamycine and erythromycin is also given along or with zink or benzoyl peroxide for mild to moderate acne.

  

Psoriasis Treatment- Side Effects of Cyclosporine

Are you a psoriasis patient? Are you given psoriasis? Then you should know about the side effects of cyclosporine. This is a very effective drug in severe psoriasis, but it should be given under specialist care.

Side effects of long term treatment include,

• Hypertension
• Kidney damage
• Viral warts with risk of skin cancer
• Hypertriglyceridaemia
• Hersutism

Therefore the doctor will do the following tests before starting treatments.

• Blood pressure
• Serum creatinine

 

He will check serum creatinine 2 or three times before starting the treatment. Serum creatinine is a good indicator of renal function. Values more than the normal levels, indicate kidney damage.  This is to establish a baseline value for serum creatinine so subsequent values (every other week) after starting the treatments can be used to assess any kidney damage.

Fifty percent of patients who are on cyclosporine can develop systolic blood pressure >160mmHg and diastolic blood pressure >95mmHg. Such patients are given calcium channel blockers like Nifedipine or angiotensin converting enzyme inhibitors if not tolerated. 

A lipid profile will also be done to see any development of Hypertriglyceridaemia.

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

Purple Discoloration around the Eyes? Is it Dermatomyositis?

Dermatomyositis is a rare condition in which there is purple discoloration and edema around the eyes. They also have purple raised vasculitic patches on the fingers. They may also have Raynaud phenomenon.

 But, these are not the only main symptoms in dermatomyositis. People who have dermatomyositis also have fatigue, weight loss, fever and malaise and the cardinal feature, progressive, symmetrical proximal muscle weakness. Their pelvic and shoulder muscles become wasted and movements like squatting and climbing stairs become difficult. Usually the face muscles and distal limb muscles are not affected. 

This is a disease common among females. These patients are in a higher risk of developing pulmonary interstitial fibrosis, Raynaud phenomenon, arthritis and hardening and fissuring of skin over the purple surface of the fingers. 

This can be a part of paraneoplastic syndrome, so the patient should be checked for breast, lung ovarian and stomach cancers.  

The disease is treated with physiotherapy, steroids and immunosuppressive therapy.

Related Topics:

Causes of 'Black Eye' 

More in:

The Official Patient's Sourcebook on Dermatomyositis: A Revised and Updated Directory for the Internet Age

Myositis and You: A Guide to Juvenile Dermatomyositis for Patients, Families, and Healthcare Providers

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