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We report the case history of a patient with a known history of psoriasis, who developed an exacerbation of the treated skin area after radiotherapy for carcinoma of the breast. This illustrates the Koebner phenomenon, with the replication of a dermatosis at the site of skin trauma.
Following publication of treatment guidelines for patients with psoriasis, a six-centre audit was undertaken to assess current therapeutic practice for two second-line treatments, PUVA and methotrexate. The audit consisted of random sampling of casenotes by external auditors from a paired dermatology department, and assessment by questionnaire. One hundred and eight PUVA and 118 methotrexate casenotes were audited. The commonest indications for treatment were: (a) failure of tropical therapy--PUVA (mean 81% of casenotes), methotrexate (84%); (b) repeated hospital admissions--PUVA (16%), methotrexate (25%). For both PUVA and methotrexate, some aspects of treatment were well documented: PUVA--psoralen dosage (91%), response to PUVA (89%), cumulative lifetime UVA dosage (81%); methotrexate--pretreatment assessment of full blood count (91%), urea and electrolytes (85%), liver function tests (84%). For other aspects documentation was less complete: PUVA--no documentation of presence/absence of skin cancer history (66%), note of photoactive drugs (32%); methotrexate--concurrent medication (69%), history of presence/absence of liver disease (36%). Another aspect which was poorly documented in both PUVA and methotrexate notes was whether advice on contraception/fertility had been given. There was no indication in 29 of 32 casenotes of females of child-bearing age receiving PUVA, and 52 of 63 case notes of relevant patients on methotrexate. This project has demonstrated that formal, multicentre audit based on published guidelines is a practical proposition.
In a randomized, double-blind, placebo-controlled study, patients received 10 fish or olive oil capsules three times daily for the whole study in addition to applying betamethasone diproprionate to their psoriatic plaques for the first 3 weeks. Most patients gradually worsened upon discontinuation of corticosteroids. Using survival analysis methods, no significant difference was found between the fish and olive oil groups. The authors attempt to put the role of fish oil in the therapy of psoriasis into perspective and discuss the efficacy of fish oil when used alone versus in combination therapy.
In an open multicenter study, cyclosporin (CsA) at low doses (3 mg/kg/day adjusted during the course of treatment on the basis of clinical response and tolerability up to a maximum of 5 mg/kg/day) was given to 293 evaluable patients with severe plaque-form psoriasis (M/F 215/78, aged 19-80 years, 2-53 years from diagnosis) in order to evaluate its safety and efficacy over a median follow-up of 7 months of treatment and 3 months after treatment. All patients were unsatisfactory responders to conventional topical therapy and had indications for systemic treatment. Patients entered the study only if they were within the normal range for renal and hepatic function and blood pressure, and were free of any clinically obvious immunodeficiencies, malignancies or blood dyscrasia. All gave their informed consent. After remission (defined as reduction > or = 75% of the body area involved and an improvement of at least 2 points on a 4-point scale for desquamation, erythema and infiltration) CsA was slowly tapered off (0.5 mg/kg/day every 2 weeks) until total discontinuation or the reappearance of signs of the disease; the dose of CsA was also varied in the case of any important modification in renal and hepatic function of blood pressure. As concomitant treatment, white petrolatum was allowed, as well as specific local therapy after CsA discontinuation. Considerable improvement (> 50% reduction in the skin area affected) was observed in 98%, and only 2% (5 patients) did not respond. Clinical remission was achieved in 225 patients (77%): of these, 73% after a median of 2 months at CsA doses of 2.5-3.49 mg/kg/day, 8% after 4 months at doses < or = 2.49 mg/kg/day and 19% after 3 months at doses > or = 3.5 mg/kg/day. After remission, the gradual withdrawal of the drug over a period of 3 months (0.5 mg/kg/day every 2 weeks) allowed control over the disease (the absence of relapse) to be maintained for a median of 8 months in 133 patients (59%). The topical therapies permitted after remission and during the maintenance phase (steroids, inert topical agents and exposure to UVB radiation) were used in less than 50% of cases. Disease relapse (the reappearance of skin involvement over more than 50% of the area affected at baseline) occurred in 92 of the 225 patients achieving remission, 24 of whom relapsed a median of 6 months after remission, when CsA had been completely withdrawn; the remaining relapses occurred about 4 months after remission, during the gradual withdrawal of the drug.(ABSTRACT TRUNCATED AT 400 WORDS)
Thirty-three patients (M/F 25/8, aged 19-71 years) with severe erythrodermic psoriasis entered an open multicenter study to evaluate the efficacy (induction and maintenance of clinical remission) and toleratility of long-term treatment with cyclosporin. It was given at a maximum initial dose of 5 mg/kg/day (initial mean dose 4.2 mg/kg/day), subsequently adjusted during the course of treatment according to clinical response, patient tolerability and any modification in laboratory parameters or blood pressure, carefully monitored each month. All of the patients were unsatisfactory responders to conventional systemic therapy (PUVA therapy, retinoids, corticosteroids), free of any clinically obvious immunodeficiencies, malignancies or blood dyscrasia and within the normal range for renal and hepatic function and blood pressure. At remission (defined as complete resolution of erythema in the body area involved), cyclosporin was slowly tapered off (0.5 mg/kg every 2 weeks) until total discontinuation or the reappearance of signs of disease. As concomitant therapy, white petrolatum in association with cyclosporin as well as specific local therapy between cyclosporin cycles was allowed. After 6.3 +/- 3.4 months (mean +/- SD), cyclosporin doses of 3-5 mg/kg/day had led to complete remission in 67% of patients (22/33) in a median time of 2-4 months; in a further 27% of cases, considerable improvement in skin involvement was observed, with a reduction of more than 70% in comparison with baseline.(ABSTRACT TRUNCATED AT 250 WORDS)
Report about the effect of the therapy of psoriasis with topical application of Meladinine and blacklight as inaugurated by Mortazawi and Oberste-Lehn as well as Tronier. In a high percentage of patients treated a regression of the lesions could be observed. As this therapy is possible for ambulatory patients the number of cases in need of stationary treatment may be reduced.
In the epidermal cells of patients suffering from psoriasis we found a significant prolongation of DNA-synthesis time (ts) in uninvolved skin, very early lesions, and fully developed plaques. In uninvolved psoriatic skin ts in addition increased significantly within 6 hours after stripping of the horny layer. In normal epidermis and in other states of epidermal inflammation and hyperproliferation (akanthosis by petrolatum, toxic dermatitis, chronic allergic ekzema, neurodermitis, allergic patch test reaction) a comparable prolongation of ts was not ascertainable. This prolongation is most distinct in the early lesions and proceeds the development of hyperproliferation and akanthosis. A dermal infiltrate with increased proliferative activity seems to be a stimulus, in the sense of a Koebner-phenomenon. The abnormal psoriatic epidermis, with disturbed DNA-synthesis, reacts to this infiltrate as well as to other irritants not with a limited hyperproliferation but with the development of psoriatic plaque.
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