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For lesions in extra-genital regions, superpotent topical corticosteroids are effective, with or without occlusion, when used twice daily for several weeks In some patients, flurandrenolide (Cordran) tape may be more effective, since it prevents scratching and rubbing of the lesion The injection of triamcinolone acetonide suspension (5 10 mg/mL) into the lesions may occasionally be curative Continuous occlusion with a flexible hydrocolloid dressing for 7 days at a time for 1 2 months may also be helpful The area should be protected and
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Atopic dermatitis runs a chronic or intermittent course Affected adults may have only hand dermatitis Poor prognostic factors for persistence into adulthood in atopic dermatitis include onset early in childhood, early generalized disease, and asthma Only 40 60% of these patients have lasting remissions
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the patient encouraged to become aware of when he or she is scratching For genital lesions, see the section Pruritus Ani
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The disease tends to remit during treatment but may recur or develop at another site
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extensor surfaces in contrast to atopic dermatitis, with poorly demarcated plaques in flexural distribution In body folds, scraping and culture for candida and examination of scalp and nails will distinguish psoriasis from intertrigo and candidiasis Dystrophic changes in nails may simulate onychomycosis, but again, the general examination combined with a potassium hydroxide (KOH) or fungal culture will be valuable in diagnosis The cutaneous features of reactive arthritis (Reiter s syndrome) mimic psoriasis
ESSENTIALS OF DIAGNOSIS
Silvery scales on bright red, well-demarcated plaques, usually on the knees, elbows, and scalp (Plate 4) Nail findings including pitting and onycholysis (separation of the nail plate from the bed) Mild itching (usually) May be associated with psoriatic arthritis Histopathology is not often useful and can be confusing
Treatment
There are many therapeutic options in psoriasis to be chosen according to the extent and severity of disease Certain drugs, such as -blockers, antimalarials, statins, and lithium, may flare or worsen psoriasis
A Limited Disease
For many patients, the easiest regimen is to use a highpotency to ultra-high-potency topical corticosteroid cream or ointment It is best to restrict the ultra-high-potency corticosteroids to 2 3 weeks of twice-daily use and then use them in a pulse fashion three or four times on weekends or switch to a midpotency corticosteroid Topical corticosteroids rarely induce a lasting remission They may induce tachyphylaxis or cause psoriasis to become unstable Additional measures are therefore commonly added to topical corticosteroid therapy Calcipotriene ointment 0005%, a vitamin D analog, is used twice daily for plaque psoriasis Initially, patients are treated with twice-daily corticosteroids plus calcipotriene twice daily This rapidly clears the lesions Calcipotriene is then used alone once daily and with the corticosteroid once daily for several weeks Eventually, the topical corticosteroids are stopped, and once- or twice-daily calcipotriene is continued longterm Calcipotriene usually cannot be applied to the groin or on the face because of irritation Treatment of extensive psoriasis with calcipotriene may result in hypercalcemia Calcipotriene is incompatible with many topical corticosteroids (but not halobetasol), so if used concurrently it must be applied at a different time Tar preparations such as Fototar cream, LCD (liquor carbonis detergens) 10% in Nutraderm lotion, alone or mixed directly with triamcinolone 01%, are useful adjuncts when applied twice daily Occlusion alone has been shown to clear isolated plaques in 30 40% of patients Occlusive hydrocolloid dressings such as thin DuoDerm are placed on the lesions and left undisturbed for as long as possible (a minimum of 5 days, up to 7 days) and then replaced Responses may be seen within several weeks For the scalp, start with a tar shampoo, used daily if possible For thick scales, use 6% salicylic acid gel (eg, Keralyt), P & S solution (phenol, mineral oil, and glycerin), or fluocinolone acetonide 001% in oil (Derma-Smoothe/ FS) under a shower cap at night, and shampoo in the morning In order of increasing potency, triamcinolone 01%, or fluocinolone, betamethasone dipropionate, fluocinonide or amcinonide, and clobetasol are available in solution form for use on the scalp twice daily For psoriasis in the body folds, treatment is difficult, since potent
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