Psoriasis
Psoriasis
is a diverse skin disease that appears in many forms.
Each form has distinct characteristics. Typically, people have only
one type of psoriasis at a time, but occasionally two or more different
types of psoriasis can occur at the same time. Psoriasis can also
occasionally change from one form to another. Trigger factors may
"convert" some forms of psoriasis, such as plaque, to
another form, such as pustular. Generally, one type of psoriasis
will clear and then another form of psoriasis will appear later.
Plaque psoriasis is the most prevalent form of the disease. About
80 percent of all those who have psoriasis have this form. Its
scientific name is psoriasis vulgaris (vulgaris means common).
It is characterized by raised, inflamed, red lesions covered by
a silvery white scale. It is typically found on the elbows, knees,
scalp and lower back. For further information please visit psoriasis.org
Treating Psoriasis
Systemic Medications
Systemic medications are prescription medications that affect
the entire body, and are usually reserved for patients with moderate
to severe psoriasis who are not responsive to or eligible for
conventional topical medications or ultraviolet (UV) light treatments.
Biologics
Biologic medications are developed from living sources, such
as cells, rather than combinations of chemicals like traditional
drugs. As of January 2007, Amevive, Enbrel, Raptiva and Remicade
are approved by the U.S. Food and Drug Administration (FDA) for
treating psoriasis. Enbrel, Humira and Remicade are FDA-approved
for the treatment psoriatic arthritis.
Other biologics are being developed for treating psoriasis and
psoriatic arthritis.
Biologics are fairly new treatments for psoriasis and psoriatic
arthritis. Their overall safety is still being evaluated; long-term
side effects are not fully known.
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Diseases of the Skin, Lupus
OVERVIEW
Lupus is a Latin word meaning wolf. In medicine, Lupus is an autoimmune disease that can affect various parts of the body, including the skin, joints, heart, lungs, blood, kidneys and brain. The most common organ to be impacted is the skin. Normally the body's immune system makes antibodies to protect the body against viruses, bacteria, and other foreign invaders. These foreign materials are called antigens. In an autoimmune disorder like lupus, the immune system cannot tell the difference between foreign antigens and its own cells and tissues. The immune system then makes antibodies directed against itself. These antibodies -- called "auto-antibodies" (auto means 'self') -- cause inflammation, pain and damage in various parts of the body.
Lupus can be divided into several types:
- Discoid (DLE) - skin rash is the main symptom, although some evidence of lupus can be seen in blood tests
- Sub Acute Cutaneous Lupus Erythematosus (SCLE) - more generalized skin rashes, some systemic symptoms
- Systemic or Acute Cutaneous Lupus Erythematosus (LE) - skin rash may be less significant than internal symptoms
- Neonatal Lupus Erythematosus (Neonatal LE) - skin rash, heart and other problems may be present at birth, the mother usually has lupus but may not be diagnosed.
The cardinal feature of lupus is inflammation which is characterized by pain, heat, redness, swelling and loss of function, either on the inside or on the outside of the body (or both). In the skin inflammation may be seen as a red or purplish rash with a sharp edge, with or without scale, hair loss either diffuse or in patches, swollen tender nail folds, and the well-known butterfly rash on the cheeks (rosacea may mimic this buttrfly pattern). On healing, lupus can leave light or dark marks on the skin.
For most people, lupus is a relatively mild disease affecting only a few organs, usually the skin. For others, it may cause serious and even life-threatening problems. Although epidemiological data on lupus is limited, studies suggest that more than 16,000 Americans develop lupus each year. For some people lupus can be caused by drugs, particularly heart medicines hydralazine, procainamide and occasionally minocycline which is used to treat acne. Discontinuing these medications can sometimes eliminate the lupus symptoms. In some patients there is a family history of lupus or other autoimmune diseases such as rheumatoid arthritis, thyroiditis ulcerative colitis, Crohn's disease, Addison's disease, dermatomyositis, scleroderma, alopecia areata, vitiligo, psoriasis, lichen planus, etc. Some patients will have overlap of lupus with another autoimmune disease. Women are affected more often than men and men tend to have a milder, skin only form called discoid lupus however when men have systemic lupus it can be more aggressive.The Lupus Foundation estimates between 1.5 - 2 million Americans have a form of lupus, but the actual number may be higher.
DIAGNOSING LUPUS
The Eleven Criteria Used for the Diagnosis of Lupus Not All Are Present or Required
Criterion or Symptom |
Definition |
Malar Rash |
Rash over the cheeks |
Discoid Rash |
Red raised patches |
Photosensitivity |
Reaction to sunlight, resulting in the development of or increase in skin rash |
Oral Ulcers |
Ulcers in the nose or mouth, usually painless |
Arthritis |
Nonerosive arthritis involving two or more peripheral joints (arthritis in which the bones around the joints do not become destroyed) |
Serositis |
Pleuritis or pericarditis (inflammation of the lining of the lung or heart) |
Renal Disorder |
Excessive protein in the urine (greater than 0.5 gm/day or 3+ on test sticks) and/or cellular casts (abnormal elements the urine, derived from red and/or white cells and/or kidney tubule cells) |
Neurologic
Disorder |
Seizures (convulsions) and/or psychosis in the absence of drugs or metabolic disturbances which are known to cause such effects |
Hematologic
Disorder |
Hemolytic anemia or leukopenia (white blood count below 4,000 cells per cubic millimeter) or lymphopenia (less than 1,500 lymphocytes per cubic millimeter) or thrombocytopenia (less than 100,000 platelets per cubic millimeter). The leukopenia and lymphopenia must be detected on two or more occasions. The thrombocytopenia must be detected in the absence of drugs known to induce it. |
Antinuclear
Antibody |
Positive test for antinuclear antibodies (ANA) in the absence of drugs known to induce it. |
Immunologic
Disorder |
Positive anti-double stranded anti-DNA test, positive anti-Sm test, positive antiphospholipid antibody such as anticardiolipin, or false positive syphilis test (VDRL). |
Adapted from: Tan, E.M., et. al. The 1982 Revised Criteria for the Classification of SLE. Arth Rheum 25: 1271-1277.
Other Criteria Used for the Diagnosis of Lupus and other Autoimmune Diseases
Skin
Disorder |
Hair loss, with and without rash or scarring; bright red or dark brown patches or bumps on face, scalp, chest, extremities; |
Vascular
Disorder |
Intolerance to cold, fingers turn purple then white, know as Raynaud's phenomenon; erythema and tenderness around fingernails; ulcers and scarring on finger tips |
Other Blood Tests |
A positive antinuclear antibodies, ANA, is often seen in lupus and other autoimmune diseases (+ANA should be in the absence of drugs known to induce it); Sjogren's antibodies (SS-A & SS-B antibodies), Centromere antibodies (often seen in CREST syndrome;, Anti-dsDNA (anti-double stranded DNA); Anti-ssDNA (anti-single stranded DNA), anti-ENA (anti-Smith and RNP antibodies); antiphospholipid antibody (anticardiolipin and lupus anticoagulant); anti-Histone antibodies (may be positive in drug induced lupus; Anti-SCL70 (more often seen in progressive systemic sclerosis also called scleroderma); Anti-JO (more often seen in polymyositis/dermatomyositis), elevated erythrocyte sedimentation rate, ESR; elevated C-reactive protein, CRP; elevated Rheumatoid Factor, RF
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HLA-B27 test is associated with the presence of one of a group of diseases called seronegative spondyloarthropathies. This includes diseases such as ankylosing spondylitis (AS), psoriatic arthritis, and Reiter's syndrome. HLA-B27 is present in about 90% of people with AS, but the gene can also be seen in people with no sign of arthritis or inflammation.
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ANCA are antibodies found in the blood in most people with Wegener's granulomatosis, a rare disease that affects the upper respiratory tract, lungs, and kidneys. ANCA are uncommon in other diseases, which makes them useful in diagnosing Wegener's.
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The complement system is a complicated network of proteins that influence the immune system and inflammation. Decreased levels of various components of complement -- C3, C4, or CH50 -- can be seen in lupus. Other diseases that involve inflammation of the blood vessels -- called vasculitis -- also often have decreased levels of complement in the blood. In systemic lupus, complement levels are used to follow the illness because they go up with worsening and down with improvement of lupus disease activity.
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Cryoglobulins are antibodies that may be high in a variety of different diseases, including rheumatoid arthritis, lupus, Sjögren's syndrome, Waldenstrom's macroglobulinemia, multiple myeloma, lymphoproliferative disorders, hepatitis B and C, and other infections.
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TREATING LUPUS
While currently there is no cure for lupus, early diagnosis and proper medical treatment can significantly help control the disease. Dr. Sekula Gibbs will take into account the seriousness and severity of your symptoms and organs involved, your response to treatment as well as your age, health, and lifestyle, and the types and risks of potential side effects from the drugs. Dr. Sekula Gibbs believes in working with your primary care physician and consulting other specialists such as a rheumatologist, cardiologist, nephrologist or neurologist as necessary. Although lupus is a chronic disease, regular follow up, close monitoring and appropriate treatment can reduce inflammation and pain, minimize scarring, help maintain a relatively normal lifestyle and stop the development of serious complications.
Just as the symptoms of lupus vary from one individual to another, your treatment will be tailored to your specific problems. All medicines can have side effects and patients should report problems immediately.
Principal drugs used in the management of lupus
I. Non Major Organ Involvement
(fever, arthritis, pleurisy/pericarditis, rash)
Non-Steroidal Anti-inflammatory
Drugs (NSAIDs)
diclofenac (Cataflam, Voltaren)
etodolac (Lodine)
fenprofen (Nalfon)
flurbiprofen (Ansaid)
ibuprofen (Motrin, Advil, Nuprin)
ketoprofen (Orudis, Actron)
meclofamate (Meclomen)
meloxicam (Mobic)
nabumetone (Relafen)
naproxen (Naprosyn, Anaprox, Aleve)
oxaprozin (Daypro)
piroxicam (Feldene)
salicylates (Aspirin, Arthopan)
sulindac (Clinoril)
tolmetin (Tolectin)
Side effects - abdominal pain, heartburn, gastric ulcers and bleeding, fluid retention, rashes, sores in mouth, kidney or liver damage, dizziness or confusion, headache
Anti-Malarials
hydroxychloroquine (Plaquenil)
chloroquine (Aralen)
quinicrine (Atabrine)
Side effects - nausea, abdominal pain/cramps, rash, skin pigmentation, weakness, blurred vision, headache, eye damage, anemia, hepatitis.
Corticosteriods
Topical Creams/Ointments/Intralesional Injections (for skin rashes, nodules hair loss)
clobetasol (Temovate)
halobetasol (Ultravate)
hydrocortisone (Cortef, Cortaid, Westcort)
triamcinolone (Aristocort, Kenalog)
betamethasone (Valisone, Diprosone)
flurandrenolide (Cordran)
fluocinolone (Synalar)
fluocinonide (Lidex)
Side effects - skin thinning and pigment changes, superficial blood vessel formation
Tablets
prednisone (Deltasone)
prednisolone (Prelone)
methylprednisolone (Medrol)
Side effects - weight gain, round or moon shaped face, mood changes, thin/fragile skin, acne, diabetes, facial hair, cataracts, osteoporosis, osteonecrosis, muscle weakness, hypertension, gastric ulcers, infections
Intravenous
methylprednisolone (Solu-Medrol)
hydrocortisone (Solu-Cortef)
Side effects - metallic taste, infections, nervousness
Intramuscular
triamcinolone (Kenalog)
Side effects - as with all steroids plus temporary depression or dimpling at the site of injection.
Cytotoxics & Immunosuppressives
methotrexate (Rheumatrex)
Side effects - nausea, abdominal pain, mouth ulcers, rashes, cough, shortness of breath, lung or bone marrow damage, liver damage including hepatitis and cirrhosis, birth defects, miscarriage
azathioprine (Imuran)
Side effects - Nausea or vomiting, pancreatitis, infection, liver disease, cancer
Retinoids and Thalidomide
isotretinoin (Accutane)
acitretin (Soriatane)
Side effects - birth defects, miscarriage, dryness, hair loss, muscle aches, liver and bone marrow damage,
thalidomide
Side effects - birth defects, nerve damage, sedation, mood change
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II. Major Organ Involvement
(nephritis, neurologic disease, etc.)
Corticosteroids See above; typically used in higher doses or as intravenous infusion
Cytotoxics & Immunosuppressives
azathioprine (Imuran)
See above
cyclophosphamide (Cytoxan)
Side effects - nausea or vomiting, rash, infection, hair loss, bladder damage, infertility, cancer
chlorambucil (Leukeran)
Side effects - Nausea or vomiting, rash,infection, hair loss, infertility, cancer
cyclosporine (Sandimmune, Neoral)
Side effects - hypertension, hair growth, tremors, nerve damage, tender or enlarged gums, kidney damage
mycophenolate mofetil (Cellcept)
Side effects - diarrhea, nausea
modified by Shelley Sekula Gibbs, M.D. 2008
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Diseases of the Skin
Warts and Molluscum Contagiosum
OVERVIEW
Disclaimer: Information posted on this web site is for general education and general information about products and services available from Dr. Shelley Sekula Gibbs and Bay Oaks Dermatology Skin, Laser and Vein Center. This information is not medical advice. It should not be taken as medical advice. Information should not be used to diagnose or treat a health problem or disease and is in no way meant to be a substitute for professional medical care. Visitors to the web site are advised to schedule an appointment or consult their own physician if they suspect they have a health condition or serious medical problem. Every patient has a unique response to treatment. The results depicted in the photographs on this site are not necessarily representative of the results you will receive. No guarantees or warrantees are implied or given.
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