A new study provides “the best data to date” for transplantation in scleroderma, experts say, showing it substantially improves skin and pulmonary function in patients with systemic sclerosis.

Published in the Lancet, the findings were so strong in the transplant group that most patients in the control group arm switched therapy, trading cyclophosphamide for haemopoietic stem-cell transplantation  (HSCT) at around 14 months after study enrolment.

All 10 patients initially randomised to the non-myeloablative autologous transplant experienced disease improvements by 12 months’ follow-up, defined as at least a 25 per cent decrease in mRSS (skin score) for patients with an initial score of more than 14, or a greater than 10 per cent increase in forced vital capacity.

By contrast, none of the nine patients in the control group experienced an improvement in their condition — at least, not until after they had switched therapies. Overall, data from 11 patients followed up for as long as two years after transplant suggested that improvements in mRSS and forced vital capacity persisted.

The study authors noted that unlike previous studies, theirs did not have a high initial mortality rate. This was most likely due to their cautious approach, they said, which included using a relatively low dose of initial intravenous rabbit anti-thymocyte globulin and undertaking complete pretransplantation cardiac assessment.

They concluded: “If undertaken early in disease course with careful precardiac assessment, HSCT has little morbidity and improves lung function, whereas delaying transplantation through treatment with standard of care (cyclophosphamide) allows disease progression, increases transplantation risk, and might contraindicate HSCT.”

Lancet 2011; doi:10.1016/S0140-6736(11)60982-3

Chronic plaque psoriasis has red, raised and heavily-scaled plaques on the skin

Dr Helen Richards and Dr Dónal Fortune look at the psychological impact of having psoriasis and how medical professionals can help alleviate associated distress and depression in patients

“I am silvery, scaly. Patterns of flakes form wherever I rest my flesh. We psoriatics live a long time and are ironically healthy in other respects. Lusty, though we are loathsome to love. Keen-sighted, though we hate to look upon ourselves. The name of the disease, spiritually speaking, is Humiliation. I should have been smashed at birth. Strategies of self-concealment ramify and self examination is endless.”

John Updike, ‘At War With My Skin’, The New Yorker, Sept 2, 1985, Pages 39-57.

Psoriasis is a chronic, inflammatory, currently incurable dermatological disease estimated to affect between 0.5 per cent and 4.6 per cent of the population, varying according to race and geographical location. It has an equal sex distribution and its onset may occur at any age, although 75 per cent of cases occur before the age of 40 years.

Chronic plaque psoriasis — the most common form — has a number of characteristic features which include red, raised and heavily scaled plaques on elbows, knees and scalp, although any skin surface may be affected. Psoriasis is viewed in most classifications as being due primarily to an interaction between genetic and environmental factors, with the course of the disease influenced by a number of co-morbidities, including psychological stress.

In common with many skin conditions, psoriasis may be viewed in the clinical setting as a relatively minor complaint. Indeed, the adjustment of patients with psoriasis and the psychological impact of the condition has only relatively recently been afforded serious consideration. Burgeoning empirical evidence suggests that psoriasis has the potential for significant psychological and social morbidity.

This article will overview the psychological burden of psoriasis, the impact of distress on the management of the condition and will suggest that a bio-psychosocial conceptualisation of psoriasis that adequately recognises the reciprocal interaction between biological, psychological and social processes would appear to be the most helpful means to consider and manage the condition.

Psychological impact

Patients’ accounts of the impact of psoriasis have highlighted the extent of psychological distress experienced. These studies suggest that at least 25 per cent of patients living with psoriasis will experience significant psychological distress as a result of the condition. Patients report considerable difficulties in: social and interpersonal relationships (between 27 per cent and 40 per cent of patients describe difficulties with sexual activities due to the condition); every-day activities; quality of life; anxiety; depression; excessive worrying; and perceptions of being stigmatised.

The extent of patients’ distress can be clearly seen from work which has identified active suicidal ideation in 5.5 per cent of patients with psoriasis, with approximately 10 per cent of patients reporting a wish to be dead.

There is evidence that individuals with psoriasis will avoid social encounters to prevent humiliation, or alternatively, engage in behaviour in an effort to hide both the physical and psychological aspects from others. This anticipatory/avoidant behaviour has also been demonstrated by our research team to have neurocognitive effects as assessed by fMRI. Moreover, in terms of quality of life (QoL), research has suggested that psoriasis can contribute to as much disability as other major medical conditions such as heart disease and cancer. Patients with psoriasis achieve significantly lower scores on QoL and disability assessments than healthy controls and are willing to incur considerable costs for a cure.

The physical and emotional effects of psoriasis have also been illustrated to have a significantly negative impact on patients’ occupational function, with one study reporting around 25 per cent of patients with psoriasis have missed work or school due to their condition. More recent studies have also highlighted the wider impact of the condition on partners or other key family members.

Differences between patients and their partners in beliefs about the emotional impact of psoriasis and beliefs about how long the condition would last were associated with elevated worry in patients and depression in their partners. It has been suggested that such differences are likely to affect patient/family involvement in their care, as well as adherence to medication.

The suggestion that such psychological stress affects the course of the condition tends to be commensurate with the experience of patients, with studies demonstrating that between 37 per cent and 88 per cent of patients report that their psoriasis gets worse or started at times of increased stress.

Indeed, longitudinal studies also suggest a possible reciprocal relationship between stress, distress or disability and the effectiveness of conventional treatments, with evidence suggesting that both clinical and psychological outcomes are optimised when patients’ emotional concerns are addressed.

One of the most interesting and reproducible findings across the past 10 years or so is that clinical severity of psoriasis is not a reliable predictor of the severity of stress, distress or disability experienced by patients – a few small plaques can be as socially and psychologically disabling as a substantial area of involvement.

Moreover, it has been shown that improvement in the clinical severity of psoriasis due to successful treatment and as rated by dermatologists does not necessarily improve the psychological distress experienced by patients.

Factors demonstrated to mediate the relationship between psychological outcome and disease severity include the beliefs patients hold about their psoriasis, including its consequences and perceived control of psoriasis.

Despite the well-established difficulties highlighted above, it is perhaps surprising that studies demonstrate up to 50 per cent of individuals with psoriasis do not adhere to the medical regimen suggested to them. A plethora of studies have suggested a number of sociodemographic, treatment related, psoriasis related and consultation factors to influence this process. Included among these are satisfaction with the consultation and psychological distress, which further highlight the importance of addressing these factors for optimal disease management.

The studies outlined above highlight the importance of routine enquiry about the psychosocial impact of psoriasis for patients, rather than relying on clinical severity indicators as a reflection of potential psychological distress. Moreover, given that the therapeutic power of conventional treatments can be affected by psychological distress, simply treating the signs and symptoms of disease is unlikely to be the most effective approach. Research strongly suggests that adjunctive psychological interventions augment the effectiveness of standard treatments.

Management of psychological factors

Attending to the psychological aspects of the condition when managing patients is strongly recommended in the recent European S3 guidelines on the systemic treatment of psoriasis vulgaris. However, while biopsychosocial conceptualisations of psoriasis for its assessment and management are often strongly recommended, there is unfortunately little evidence that this translates into everyday clinical practice. Commensurate with this are the difficulties associated with identifying such psychological distress in routine clinical consultations, with one study indicating only one-third of patients with clinically significant distress being appropriately recognised.

Research has shown that adjunctive psychological interventions enhance the effectiveness of standard treatments in psoriasis. The most promising adjunctive treatment, cognitive behavioural therapy (CBT) specifically targets patterns of unhelpful thoughts and beliefs held by patients, and aims to change the effects of such thoughts and beliefs on how people feel and what people do.

Beneficial effects

A number of studies have shown beneficial effects of CBT on psoriasis patients’ levels of distress. Published studies of CBT approaches for people diagnosed with psoriasis have usually entailed attending for six-to-12 weekly sessions with a clinical psychologist, and results have shown some early promise.

For example, patients who opted for a psoriasis-specific group psychological intervention, in addition to standard treatment, showed significantly greater reductions in unhelpful beliefs about the condition, anxiety and depression, disability, stress and physician-rated clinical severity of psoriasis, compared with patients receiving standard care.

Furthermore, almost three times as many patients in the adjunctive psychological treatment group as those on standard treatment achieved 75 per cent clearance of their psoriasis over six weeks. Such interventions can be considered time intensive for both patient and clinician.

‘A number of studies have shown beneficial effects of CBT on psoriasis patients’ levels of distress’

More recent work at both the University of Nijmegen, Netherlands and the University of Manchester, UK are developing internet-based cognitive-behavioural approaches (ETIPs – Electronic Targeted Intervention for Psoriasis) for managing psychological symptoms associated with the condition.

While such studies are in their early stages, internet-based approaches in conditions such as depression are promising and are recommended by NICE in the UK. Therefore, results of such studies will be awaited with interest by clinicians and patients alike.

Psoriasis presents healthcare professions and patients with a number of significant challenges in the optimal management of the condition. In the Republic of Ireland, access to appropriate psychological services is limited. Moreover, regardless of the positive benefits of appropriate psychological interventions, it is important to note that not all patients are willing to participate in such interventions. Factors such as elevated worry, anxiety and feelings of stigmatisation can all impede attendance.

Patients can, however, be offered a stepped-care approach, which may use support from medical or nursing staff to scaffold patients into a more comprehensive management approach. Dermatologists and GPs can also inform and encourage patients to seek support from local psoriasis patient associations.

Patient associations can offer information about many aspects of living with psoriasis that the patient can share with key individuals around them, e.g. work colleagues and family members. This, in turn, may help to increase understanding about the condition and may in some cases help to reduce stigma.

At the simplest level, the physician can employ an empathic approach, which takes appropriate account of both the physical aspects of the disease and psychosocial issues impacting on the patient and the condition. In doing so, a more collaborative management approach can be fostered, which is commensurate with the implicit principle of effective medicine: to treat the whole person within the context of their disease, rather than the signs and symptoms of disease.

Key points:

• Living with psoriasis is associated with significant psychological distress;
• Clinical severity of psoriasis is a poor predictor of psychological outcome;
• About one-in-four psoriasis patients experience clinically significant psychological distress;
• Up to 50 per cent of patients with psoriasis do not adhere to treatment;
• A bio-psychosocial model, taking into account the interaction between biological, psychological and social elements, seems most appropriate for effective clinical management.

References on request

• Dr Helen Richards is a Senior Clinical Psychologist, Department of Clinical Health Psychology, Mercy University Hospital, Cork.
• Dr Dónal Fortune is a Senior Clinical Neuropsychologist, Acquired Brain Injury Ireland.

Dr John Loughnane looks at the recent guidelines, issued by the UK’s National Institute for Health and Clinical Excellence, on the treatment of atopic eczema in children

Atopic eczema (AE) is a chronic, relapsing, pruritic dermatosis, with a tendency to favour flexural areas. It is most likely caused by a mixture of genetic predisposition, host immune responses, skin barrier dysfunction, infectious agents and environmental factors. It usually presents as a red, scaly rash that is especially prominent on the forehead and cheeks of babies from the age of about six weeks. The skin is dry and the main symptom is itch.
With time, the rash spreads to the body and limbs. Lesions favour the flexures, especially the antecubital and popliteal fossae, and the creases of the buttocks and thighs. Constant scratching and rubbing produces redness, scaling, excoriations and skin thickening.
Atopy is an inherited ability to develop an Immunoglobulin E-mediated (IgE-mediated) response to certain allergens. Some 80 per cent of eczema patients have raised levels of IgE, leaving 20 per cent who do not and are by definition not atopic, suggesting that there is more to eczema than allergy.
Eczema is predominantly an inherited condition, although the exact genetic pattern of inheritance is not clear. If one parent is affected, there is a 60 per cent chance of an offspring having the condition. The risk rises to 90 per cent when both parents are affected.
In recent years, it is increasingly recognised that a defective skin-barrier function is the primary underlying problem in eczema. The damaged skin barrier allows water loss, leading to drying and shrinking of surface skin cells. Irritants, allergens and bacteria are thus allowed penetrate the skin barrier.
Irritants further damage the lipid layer. Allergens stimulate IgE production, producing inflammation. Bacteria release toxins that provoke an exaggerated allergy response (so-called superantigens).
It is obvious that restoration and preservation of an effective skin barrier is vital to effective management of eczema.
Food allergens
Dietary allergy is often incriminated in eczema. In most cases, dietary manipulation will already have been tried by patients. Suspect a food allergy in eczema patients only in certain, specific instances, such as where there is:
l Severe disease that is refractory to optimum management;
l History of immediate reaction to food, especially in the area of contact around the mouth;
l Gastro-intestinal problems – colic, vomiting, altered bowel habit, failure to thrive.
There is no really reliable test for food allergy in eczema. Skin-prick testing is not good at detection. Radioallergosorbent (RAST) blood testing for specific allergens is often undertaken. There is, however, a high false-positive and false-negative rate for these tests.
Dietary manipulation
The National Institute for Health and Clinical Excellence (NICE) has issued guidance on dietary manipulation. Soya formula should not be tried before six months of age, as it has a higher risk of allergic reaction than has cows’ milk protein. There is some evidence that an eight-week trial of extensively hydrolysed protein formula or amino acid formula, in place of cows’ milk formula, may help.
Always refer to a dietician if considering their use beyond six weeks. Goats’ milk protein is similar to cows’ milk protein and is therefore not recommended.
Suspected foods should be reintroduced to the diet after the age of three years, when most patients should have no further problems with it. They have usually grown out of their food allergy by then. Allergies to nuts or shellfish tend to persist into adult life, however.
Emollients
As outlined above, a defective skin barrier is the most important feature needing attention in the treatment of eczema. Emollients are greasy substances that form an artificial barrier on the skin. Water is trapped and retained in the skin. With water retention, the skin is more flexible and medications penetrate more effectively. Penetration of bacteria, irritants and allergens is reduced.
Emollients are best applied as part of a moisturising bath regime. Soak for 20 minutes in a tepid bath, to which nothing has been added but an emollient. Soaking for this length of time is necessary to rehydrate the surface skin cells. On getting out of the bath, the skin is rapidly covered in as greasy an emollient as the patient finds tolerable.
This layer of emollient traps water in the superficial skin layers. A good choice for most patients is emulsifying ointment, which is generally acceptable on skin saturated with water in this way.
Moisturisers
Moisturisers need to be applied several times daily, in addition to the above. Once eczema has been controlled with topical steroids, it is essential that a regime of regular moisturiser use be put in place to maintain remission and reduce the frequency of acute flare-ups.
If patients find ointments unacceptable during the day, a possible compromise might be to use an ointment at night with a more acceptable cream moisturiser used during the day.
Moisturisers come as lotions, creams and ointments, depending on their lipid content. Lotions have the lowest lipid content and creams have intermediate content, with ointments having the highest.
Generally, the greasier the emollient, the more effective it is. However, very greasy preparations may not be acceptable to all patients. Creams are more acceptable than ointments, but need to be applied more generously and more often. As most eczema presents in the chronic, dry stage, moisturising ointments are better than creams.
Staphylococcal infection
In eczema patients who suffer recurrent staphylococcal infection, antiseptic bath emollients are sometimes suggested. The antiseptic benzalkonium is contained in Oilatum Plus (6 per cent) and Emulsiderm (0.5 per cent). There is, however, no firm evidence base to support their use.
Urea is added to some moisturisers. Urea penetrates the skin and attracts water. It is contained in Itch Relief Cream from E45, Calmurid and Eucerin. Urea-containing moisturisers are particularly useful in thick, hyperkeratotic eczema, which is more often found on the limbs.
Areas around the eyes and eyelids are sensitive and a combination of soft paraffin and liquid paraffin mixed 50/50 (paraffin gel) may be better tolerated. Epaderm has recently become available in Ireland and is acceptable to many patients, but is a little expensive and not available on the GMS.
Aqueous cream gives a stinging sensation in over 50 per cent of children with eczema. It should not be used as a leave-on emollient, although it is an acceptable soap substitute.
Topical steroids
Topical steroids are the mainstay of treating atopic eczema. They are not curative and suppress the eczema only as long as their use is continued. They are classified according to potency. One should become familiar with one preparation from each potency group.
The classification of topical steroids is as follows:
l Mild – hydrocortisone, 1 per cent;
l Moderate – clobetasone butyrate (Eumovate); alclometasone dipropionate (Modrasone);
l Potent – betametasone valerate (Betnovate); betametasone dipropionate (Diprosone), hydrocortisone butyrate (Locoid); mometasone furoate (Elocon).
l Very potent – clobetasol propionate (Dermovate).
The main side-effect to worry about is skin thinning. Infants and children have thin skin that is more susceptible. At all ages, skin on the face (especially around the eyes), on the genitalia and in the axilla and groin is thin and only mild- or moderate-potency steroids should be used in these areas.
When treating an acute flare of eczema, hydrocortisone is safe to use on the face in babies and children, with a moderately potent steroid on the body. The recent NICE guidelines suggest potent topical steroids could be used in children, provided the child is over the age of one year. Treatment is limited to seven days and not applied to the face.
In adults, a moderately potent steroid may be used on the face while a more potent preparation is used, for short periods, on the body. Once the disease is well under control, the potency of the steroid may be reduced as soon as possible – the step-down approach. Emollients at full dosage should be continued at all times.
Twice-daily application of steroid is no longer advised, as it is no more effective than once daily. The patient should be advised to apply one generous layer daily. Directions included in packaging tend to emphasise a thin layer of steroid only.
Cream formulations of topical steroids should be used if eczema is oozing. They help dry the eczema. However, the majority of eczema that we see is chronic and dry. Ointment formulations, with their good moisturising effect, are more suitable.
Indeed, steroid ointments may be a very acceptable moisturiser and patients should be advised to avoid using a topical steroid as an emollient. When treating a disease flare, a steroid is applied to the inflamed skin, with emollient applied to non-inflamed areas.
Infection in atopic eczema
About 90 per cent of patients with eczema are colonised with Staphylococcus aureus (SA), which rarely colonises non-eczematous skin. The degree of SA colonisation correlates with the level of disease activity. Signs suggesting that infection is exacerbating eczema should be looked for.
Clinically, SA leads to the development of sore, fissured and weeping skin. The best way to avoid infection is good disease control, leading to maintenance of a good skin-barrier.
SA produces toxins that act as superantigens, which greatly promote the eczematous response.
The features of infected eczema are: worsening of eczema, getting redder and sore; weeping; yellow crusting; fissuring – especially if painful; and pustules. Diagnosis of infection is based on clinical appearance, as swabbing the skin of a patient with active eczema almost invariably spreads SA.
Fucidic acid/antibiotic combinations (Fucibet, Fucidin HC) are popular and effective. Fucidic acid should not be continued for longer than 10 to 14 days at a time, to reduce the risk of resistance developing.
If fucidic acid resistance is a problem, consider steroid-antiseptic combinations such as vioform hydrocortisone or chlorquinaldol (Locoid C). Bacteria do not develop resistance to antiseptics. These antiseptic combinations may leave a yellow stain on the skin.
Milton baths
For severe infections, an oral antibiotic should be used – flucloxacillin 250 mg TID for 10 to 14 days. The branded product floxapen syrup is better tolerated by children. If infection is recurring, one might use Milton baths. Add 125ml of Milton to a bath half-full with water. This can be alternated every second night with a moisturising bath.
Many acute flares of eczema presenting in general practice are secondary to infection. The key to getting a good response is to use an antibiotic plus a topical steroid contemporaneously.
The best way to prevent future infection is to get the eczema under good control and keep it that way with an effective maintenance regime. The intact skin-barrier prevents future penetration and infection by SA.
Antihistamines
Histamine does not have an obvious role in the pathogenesis of eczema. Non-sedating antihistamine drugs have not been advised to treat eczema. If sleep is disturbed, a sedating antihistamine may be advised at night, e.g. trimeprazine (Vallergan) or hydroxyzine (Ucerax). It should be limited to seven to 10 days at a time, as there is a risk of tachyphylaxis, i.e. less and less response, with prolonged use.
The latest NICE guidelines suggest a one-month trial of a non-sedating antihistamine (Neoclarityn, Xyzal) if eczema is severe and accompanied by marked itch, hay fever, asthma or urticaria. If thought to be of benefit, they may be continued. Tachyphylaxis does not seem to be a problem with non-sedating antihistamines.
Topical immunomodulators
The most significant advance in treating eczema since the introduction of topical steroids has been the development of topical immunomodulators. There is only one available in Ireland – tacrolimus (Protopic). It is a calcineurin inhibitor. It is licensed for patients over two years of age.
The 0.03 per cent formulation is indicated for those under 16 years. For those aged over 16, the 0.1 per cent preparation may be used.
Points to remember when using tacrolimus:
l It is indicated for moderate to severe eczema that is unresponsive or intolerant of conventional therapy not adequately responsive to topical steroids plus emollients;
l It is as effective as a potent topical steroid;
l It is especially useful on the face, around the eyes and on the neck, i.e. areas at high risk of skin thinning from steroid use;
l It has been licensed for short term and intermittent use and, more recently, for twice weekly, long-term maintenance use;
l Some 20 per cent of patients experience a stinging sensation – this usually resolves in six days. Stinging tends to recur on future reintroduction;
l Thick, very lichenified eczemas tend not to respond very well;
l Skin infection must be cleared prior to use, especially herpes simplex and staphylococcus;
l Sun protection should be advised. Sun protection cream may be applied 20 minutes after tacrolimus application;
l Avoid in pregnancy.
In the US, the Food and Drugs Administration issued an alert to healthcare professionals regarding the potential link between topical tacrolimus and skin cancer and lymphoma.
An expert consensus concluded that this alert was unjustified and caused unnecessary anxiety and confusion. The alert does emphasise the importance of prescribing tacrolimus appropriately.
NICE guidelines recommend consideration of paste bandaging and wet wraps, which cannot be elaborated upon in this article as space prohibits.
Eczema that frequently recurs (despite good moisturiser use) and infection control may still be a problem. Twice weekly long-term maintenance use of either a topical steroid or tacrolimus, applied to the areas prone to flares, may help. Tacrolimus now has a product licence for such use.

Leading Dutch dermatologists have urged colleagues and health services to devise strategies to treat skin cancer as a chronic disease.
“To manage the future costs and quality of care for patients with skin cancer, a revised health strategy is needed,” according to Dr Simone van der Geer, of Erasmus University Medical Center, Rotterdam, and colleagues. “These new strategies should be combined into a disease management system that organises healthcare for one well-documented healthcare problem using a systematic approach.”

The doctors added that the application of disease management systems can assist in the prevention of, education about and treatment of skin cancer. “The disease management system is embedded within a supportive overall organisation structure, which is based on firm financial support that must be available for all aspects of the system, including prevention-based efforts,” they said.
“Skin cancer needs to be regarded as a chronic disease and should not be considered a solitary event requiring the treatment of one tumour,” the doctors concluded.
“Combining these strategies in a disease management system will lead to efficient, evidence-based, high-quality care to help dermatologists deal proactively with chronic diseases such as skin cancer.”
Archives of Dermatology 2010;146:332-336

Survivors of one melanoma appear approximately nine times as likely as the general population to develop a second melanoma, a new American study has found.
Doctors based at the National Cancer Institute used nine cancer registries to identify 89,515 patients who survived at least two months after an initial melanoma diagnosis between 1973 and 2006.

Of these, 10,857 patients, or 12.1 per cent, developed one or more additional primary cancers, such that their overall risk of another cancer increased by 28 per cent. One-fourth of these subsequent cancers were primary melanomas. Women with head and neck melanoma and patients younger than 30 had additionally increased risks of a subsequent melanoma.
“The risk remains elevated more than 20 years after the initial melanoma diagnosis,” the doctors reported. “This increased risk may be owing to behavioural factors, genetic susceptibility or medical surveillance.”
In light of their findings, the doctors concluded that survivors of melanoma ‘should remain under surveillance not only for recurrence, but also for future primary melanomas and other cancers’.
Archives of Dermatology
2010;146:265-272

New diagnoses and a history of non-melanoma skin cancer have become increasingly common, and the disease affects more individuals than all other cancers combined, according to new US reports.
The first report followed a study in which doctors developed a mathematical model to estimate the prevalence of non-melanoma skin cancer in 2007.

“This model used age-specific incidence data adjusted to reflect changes in incidence from 1957 to 2006, the age distribution of the population from 1957 to 2006 and the likelihood that an incident tumour was the first ever for that person.
The researchers estimated that approximately 13 million white, non-Hispanic Americans had had at least one non-melanoma skin cancer by 2007. “The prevalence of a history of skin cancer is far higher than that of any other cancer,” the lead researcher concluded.
In the second study, doctors analysed data from US databases and surveys to estimate the incidence and treatment rates of non-melanoma skin cancer in 2006.
The total number of procedures to treat skin cancer in the study population increased 76.9 per cent from an estimated approximately 1.6 million procedures in 1992 to approximately two million procedures in 2006.
Between 2002 and 2006, procedures to treat non-melanoma skin cancer increased 16 per cent and the number of individuals undergoing at least one procedure increased by 14.3 per cent.
Archives of Dermatology
2010;146:279-282, 283-287

Augmenting the lips with grafts of muscle and connective tissue from the neck appears to result in improved appearance for at least two years, according to a new report.
The report followed a study in which plastic surgeons treated 25 consecutive patients who underwent lip augmentation with segments of their own sternocleidomastoid muscle and fascia.

All patients had a minimum follow-up of one year. After an average of two years, the amount of vermilion showing increased by an average of 20 per cent to 24 per cent for the upper and lower lip. In addition, the average projection of the upper and lower lip increased by an average of 0.9 to 0.99 millimeters. The patients were subjectively pleased with the results, although one requested additional lip augmentation with an injectable gel.
The muscle and fascia can be removed during a concurrent face lift with few complications, the authors note, and are readily incorporated by the lip. There were no deformities in lip contour, limitations in head movement, neck pain or nerve injuries associated with the grafts.
“The postoperative recovery after sternocleidomastoid fascia and muscle grafts to the lips is straightforward,” the authors write. “After the first month of lip swelling, the patient should expect that the lips will still be slightly swollen.”
The senior author’s experience has been that approximately 75 per cent of the immediate intraoperative lip fullness is maintained at one month post-operatively, while approximately 50 per cent of the immediate intraoperative lip fullness is maintained at one year postoperatively.” The surgeon must account for this decrease in the size of grafts initially implanted, they note.
“With careful patient selection and surgical technique, sternocleidomastoid muscle and fascia implantation is a valuable tool when treating the ageing lip,” the authors concluded.
Archives of Facial Plastic Surgery 2010;12:97-102

Dr Dmitri Wall and Prof Sarah Rogers look at the different clinical types of psoriasis and examine the many treatment options, including topical treatments, phototherapy, systemic therapy and biologic agents

Psoriasis is a chronic dermatosis characterised by red scaly patches which classically occur on extensor aspects of the limbs. Psoriasis is most prevalent in the northern hemisphere, where it affects 1-3 per cent of the population, with males and females affected equally. It can begin at any age group from infancy to old age.
The basic lesion is an inflammatory papule, which becomes scaly, and so the disease is referred to as a papulosquamous eruption. Although it is described as a non-itchy dermatosis, many patients will say otherwise.
It is a T-cell mediated disease in which the epidermis renews itself up to six times faster than normal, resulting in thickened, abnormal keratin called parakeratosis. The rash may appear in healing wounds — the so-called Koebner phenomenon, and small bleeding points appear when scale is removed (the Auspitz sign).
The nails are affected in 60 per cent of cases. Psoriatic arthritis (PsA) occurs in up to 20 per cent of patients with psoriasis.
Pathogenesis
As 50 per cent of patients give a family history of psoriasis at presentation, it has long been recognised as an inherited disorder. The major genes for psoriasis are located on chromosome 6p, in particular, Cw62. In those predisposed, psoriasis may be triggered by a number of factors including hormonal, infective, drugs, alcohol and stress.
These are believed to activate a cascade of inflammatory mediators culminating in the influx of T cells into the epidermis, and resulting in the chronic inflammation and excessive proliferation of keratinocytes that give rise to the characteristic plaques seen in psoriasis.
That hormonal factors are important is evidenced by the peak onset of psoriasis in teenage and young adult life with a smaller peak at the menopause; psoriasis usually clears in pregnancy. The most common precipitating infection is streptococcal, as a sore throat. Many teenagers with guttate psoriasis have enlarged tonsils. Acute viral infections may also exacerbate psoriasis.
Of the drugs that precipitate or aggravate psoriasis, lithium has the most dramatic effect. Beta-blockers and antimalarials may exacerbate the disease.
High alcohol intake, in particular, may trigger psoriasis. Stress has long been held to aggravate psoriasis. This has now been backed up in recent work.
Comorbidities
With the exception of its link to PsA, psoriasis had been considered a standalone disease. It was first observed that patients with psoriasis had an increased risk of cardiovascular disease in the 1970s and increased rates of peripheral artery disease and stroke have since been recognised. Psoriatics have a higher incidence of hypertension, dyslipidaemia, central obesity and type 2 diabetes. This is referred to as the metabolic syndrome.
Psoriatics with severe disease and an increased body mass index are prone to fatty liver disease. Excess alcohol consumption in psoriatics not only increases cardiovascular morbidity, but also is associated with greater than threefold increase in fatty liver disease and cirrhosis.
Clinical types
Chronic plaque psoriasis (psoriasis vulgaris) is characterised by red scaly plaques on the extensor aspect of the limbs (fig. 1). It may be localised or generalised. Psoriasis frequently presents in the scalp (fig. 2) where it may be misdiagnosed as seborrhoeic dermatitis or tinea capitis (ringworm).
Guttate psoriasis is eruptive and may cover all areas of the body within the space of a week (fig. 3). It may be mistaken for an exanthem in its early stages and is associated with young age and with streptococcal infection. Its natural history is for spontaneous clearance within eight weeks although it may develop into chronic plaque psoriasis.
Flexural psoriasis (psoriasis inversus) occurs in crease areas of the body, e.g. groin, inframammary region and perineum. Because these areas are warm and can be moist, the rash, while red, will not be scaly and so may be mistaken for intertrigo.
Erythrodermic psoriasis is characterised by generalised redness, exfoliative scaling, swinging temperatures, hypervolaemia and low urinary output (fig. 4).
It constitutes a medical emergency. It may be precipitated by overuse of both oral and potent topical steroids. The patient is admitted for intensive nursing care, temperature control and fluid balance. Though the disease itself is associated with hyperpyrexia, this may be due to septicaemia due to broken areas of skin. Patients with erythrodermic psoriasis are likely to require systemic treatment.
Generalised pustular psoriasis (von Zumbusch) is characterised by widespread, sterile pustules ranging from 2mm up to 1cm in diameter. It may be triggered, as with erythrodermic psoriasis, by withdrawal of steroids, by pregnancy or infection.
The patient is ill with a fever and will require admission for intensive nursing care. This form of psoriasis is also likely to require systemic treatment.
Palmoplantar pustulosis (PPPs) is characterised by flat lakes of pustules on palms and soles that dry up to form a brown papule (fig. 5). It may occur in association with plaque psoriasis or in isolation. It is frequently mistaken for tinea pedis.
In nails, pitting and onycholysis, or distal separation of the nail, are the most common changes. Separation in the centre of the nail gives an oil-drop appearance. The nails may be thickened and discoloured.
Topical treatment
The treatment of psoriasis depends on a number of factors including the type of rash and the site involved. For mild-to-moderate chronic plaque psoriasis topical treatment will suffice.
The majority of patients have mild disease and manage their psoriasis with over-the-counter medication or by consultation with their GP.
Topical treatment is used in all types of psoriasis either alone, or as an adjunct to phototherapy and systemic treatment. It includes dithranol, coal tar, vitamin D analogues, topical steroids, salicylic acid and, of course, emollients.
l Dithranol and coal tar are traditional in-patient treatments. The mechanism of action of both treatments is not fully understood, but both have an anti-inflammatory and anti-proliferative effects. Dithranol was the mainstay of in-patient treatment in Ireland and the UK in days when there were dermatology beds, whereas coal tar was favoured in the USA.
Compounds of dithranol and coal tar suitable for home use contain low concentrations of the active ingredient and are more likely to help than clear. Because dithranol can burn the skin it should be prescribed with caution, particularly in those not experienced in its use.
It may be applied for home use in the short-contact method as Dithrocream, building up the concentration from 0.1 per cent to 2.0 per cent. Crude coal tar ointment and pastes, though effective, are too messy for home use. Tar pomade BP and tar creams contain an aqueous solution of coal tar and are easy to use but tend to help rather than clear.
l Calcipotriol (Dovonex) is a vitamin D analogue that inhibits keratinocyte proliferation and blocks numerous inflammatory mediators. It is now only available in a cream base, which is less effective than the ointment preparation, but more cosmetically acceptable. Dovonex may cause irritation. It is applied BD and may take to to three weeks to become effective. It is also available as a scalp lotion.
l Potent topical steroids (Der-movate, Elocon, Betnovate, Diprosone) are powerful anti-inflammatory and anti-proliferative agents that should not be used in widespread plaque psoriasis. If they are prescribed, it should be for a very limited period only. This is because systemic absorption — which can be significant from inflamed skin — can lead to adrenal suppression, and because psoriasis flares on their withdrawal, becoming unstable (rebound flare). These preparations are suitable for palms and soles where the keratin layer is thick, in an ointment base, and on the scalp as a lotion. One per cent hydrocortisone cream or ointment is suitable for the face. Care should be taken not to overuse around the eye because of the risk of raised intraocular pressure. For flexural involvement, anti-yeast agents are traditionally combined with 1 per cent hydrocortisone, e.g. Daktacort.
l Salicylic acid may be used as a compound in combination with dithranol or tar or on its own as a keratolytic in an ointment base at varying concentrations from 0.5 – 20 per cent. It is used in scalp preparations, often with tar, and alone for thick scaling on palms and soles.
Phototherapy
When psoriasis is widespread, topical treatment becomes impractical and phototherapy is the treatment of choice. The beneficial effect of natural sunlight in psoriasis was known for many years and artificial sources of ultraviolet radiation (UVR) have been used by dermatologists for decades.
Phototherapy is carried out in a hospital unit that is run by nurses, regulated by medical physicists and supervised by consultant dermatologists. Psoralen-UVA (PUVA) requires two visits a week and TLO1 three.
The average number of treatments required to clear psoriasis is 25 and remission, which occurs in greater than 80 per cent, can be expected to last for up to six months.
l Broadband UVB (BB-UVB) formed part of Goerkerman’s coal tar and Ingram’s dithranol regimens, but as a monotherapy it causes significant burning in fair skin and is rarely used as such.
l UVA, by contrast, causes little burning but tans. To enhance its effect, UVA is combined with a psoralen, a photosensitising compound. The combination is called photochemotherapy or PUVA.
l PUVA has been in use since the 1970s but its use is restricted because high cumulative doses lead to the development of squamous cell carcinoma (SCC).
l Narrowband 311nm UVB (NB-UVB/TLO1) has a wavelength close to UVA and causes little burning. It is as effective as PUVA but is considered to be less carcinogenic. It is now the standard form of phototherapy for psoriasis. In order to reduce the development of SCC, no more than 200 exposures of either form of phototherapy are given in a lifetime.
Systemic therapy
Systemic therapy is indicated in psoriasis when phototherapy fails, or when the lifetime number of exposures has been reached. It is also given for erythrodermic psoriasis, general pustular psoriasis, unstable psoriasis and in severe localised disease such as palmoplantar psoriasis when day-to-day function is restricted.
Systemic treatment includes:
l methotrexate (MTX); hydro-xyurea;
l fumaric acid esters (FAE, Fumaderm);
l acitretin (Neotigason);
l ciclosporin (CSA; Neoral);
l biologic therapy.
Because of the close association between psoriasis and comorbidities, the patient’s general health status is assessed prior to systemic treatment. This includes weight, blood pressure, liver function tests (LFT) and glucose as well as their routine bloods and nutritional status.
l Methotrexate (MTX) was first used as an anti-cancer drug and has been used for psoriasis since the 1960s. Although its mechanism of action in psoriasis is not fully known, it is believed to act by reducing the proliferation of T lymphocytes and also by inhibiting their migration once activated.
MTX is hepatotoxic and so should not be prescribed unless the patient undertakes to abstain from alcohol. It is combined with 5mg a day of folic acid to reduce morbidity from the drug. MTX is effective for PsA.
Dose: A test dose to rule out idiosyncratic hypersensitivity is followed by a starting dose of 10mg, increased to a maximum of 30mg a week depending on response. The average maintenance dose is between 7.5 and 15mg weekly.
Side effects: Nausea, hepatotoxicity, bone marrow suppression and teratogenicity. Women of childbearing age must take effective contraception while taking MTX and men should not father children because it interferes with DNA synthesis.
Monitoring: Baseline full blood count (FBC), urea and electrolytes (U&E) and LFT should be carried out. Tests are repeated fortnightly for a month and then three-monthly. Type III procollagen peptide (PIIINP), a marker of hepatic fibrosis, is checked three-monthly.
lHydroxyurea is another anticancer drug used for many years for psoriasis that prevents DNA synthesis and repair by inhibiting ribonucleotide reductase.
It is used less frequently than MTX as it is less effective, but it works well in a small cohort of patients. Hydroxyurea is not effective for PsA.
Dose: Ranges from 500mg daily to TID.
Side effects: The main side effects are marrow suppression and teratogenicity and so it is contraindicated in females of childbearing age. The mean corpuscular volume is high (>100).
Monitoring: Baseline FBC, U&E and LFT. Repeated after weeks one, two and four and three-monthly thereafter. U&E and LFT are monitored less frequently as renal and hepatic side effects are rare.
l Fumaric acid esters (FAE; Fumaderm) have been used in Germany for over 30 years but were only recently introduced here. It is thought that FAE interfere with the cellular metabolic pathways that regulate inflammation and alter the ratio of T cell subtypes in the epidermis. FAE are not effective in PsA.
Dose: FAE are given according to the manufacturers protocol starting with 30mg (Fumaderm Initial), and increased to a maximum dose of 240mg TID (Fumaderm). The reason for the slow build up is to minimise side effects.
Side effects: Flushing, abdominal cramps and diarrhoea; tolerance usually develops with time. Lymphopenia occurs in most patients; the drug is discontinued if it falls below 0.5 ×109/L. Nephrotoxicity is rare and reversible.
Monitoring: Baseline FBC, U&E and LFT. Repeated at weeks two and four and at three-monthly intervals thereafter. Dipstick urinalysis for proteinurea at each visit should be carried out.
l Acitretin (Neotigason) is a vitamin A derivative (retinoid), modulates immune response and increases epidermal cell proliferation. It is infrequently used as a monotherapy because of its unpleasant side effects.
More commonly, it is combined with PUVA (retinoid PUVA; Re-PUVA) as it decreases both the length of treatment and dose of UVA. Acitretin is not effective for PsA.
Dose: Between 0.25 and 1mg/kg daily with the maintenance dose between 10mg and 50mg daily.
Side effects: Cheilitis, pruritus, skin fragility and hair fall. It is not given to women of childbearing age as it is teratogenic and is held in body fat for up to three years. Hypertriglyeridaemia (in 50 per cent) and hepatotoxicity may occur. Calcification of ligaments and diffuse idiopathic skeletal hyperostosis (DISH) may occur.
Monitoring: Baseline FBC, U&E, LFT and fasting lipids. Repeated after weeks one, two and four and at three-monthly intervals thereafter. Twice-yearly X-ray of the thoracic spine or ankle should be carried out.
l Ciclosporin (CSA) inhibits Il-2 and reduces the number of cytotoxic T cells in the epidermis. It is highly effective for psoriasis but its use is restricted because of nephrotoxicity which may be permanent.
Because of nephrotoxicity, CSA is now most often used as a rescue treatment in order to bring severe psoriasis under control quickly. Once the patient’s psoriasis has been stabilised, CSA is replaced with another systemic agent. It is safe in pregnancy. CSA is not effective in PsA.
Dose: Starting at 2.5mg/kg in a BD dose and increased to a maximum of 5mg/kg. The average maintenance dose is 3mg/kg taken as a BD dose.
Side effects: Hypertrichosis, tremor, gum hypertrophy and headache are some common side effects. Nephrotoxicity, hypertension, which increases with dose and time, hyperlipidaemia and hypomagnesaemia.
Monitoring: Baseline BP reading, FBC, U&E, LFT, magnesium and lipids. Repeated after weeks one, two and four and then at each visit. Fasting lipids every six months. If serum creatinine rises by 30 per cent, glomerular filtration rate is measured.
Biologic agents
These powerful new immunosuppressive drugs are used to treat severe psoriasis recalcitrant to other treatments as well as Crohn’s disease and psoriatic arthritis. They are either fusion proteins or monoclonal antibodies that block TNF-α or other cytokines.
By blocking T-cell activation and migration and, subsequently, the inflammatory cascade that leads to keratinocyte proliferation, biologics inhibit plaque formation.
Infliximab is the fastest working and most effective of the biologic agents. It is given by IV infusion. The other biologics are given by sub-cutaneous injection at varying intervals from twice weekly to three monthly.
The real concern with biologics is the unmasking of latent TB, and so patients must be screened before treatment5. If latent TB is suspected, the patient is given a nine-month course of isoniazid and pyrazinamide, with at least two months of treatment prior to commencing biologic treatment.
With active TB, triple therapy with Rifater (containing isoniazid, pyrazinamide and rifampicin) is given for six to nine months. Patient well being, night sweats and weight loss are enquired about at each clinic visit.
Infliximab, etanercept and adalimumab are licensed for both while, at present, ustekinumab is licensed for use in psoriasis but not as yet for PsA.
Side effects: Injection site reactions occur with subcutaneous agents and anaphylaxis may occur with infliximab. They lead to an increased rate of infections such as respiratory tract infections including TB as mentioned above.
Lupus may be precipitated by biologic agents and they are contraindicated in demyelinating diseases and congestive heart failure.
Monitoring: Baseline FBC, U&E, LFT, hepatitis screen and ANA repeated at clinics.
References on request.
l Dr Dmitri Wall
and Professor Sarah Rogers, Department of Dermatology, St Vincent’s University Hospital, Elm Park,
Dublin 4.

Irish people living with psoriasis have indicated that the condition has a ‘very large effect’ on their lives, according to a new international survey. Erica Mills reports on the study’s findings and the latest medical advice

Psoriasis can have a detrimental effect on the relationships, careers and emotional well-being of those with the condition, according to a worldwide survey conducted by Abbott Laboratories and the Psoriasis Association of Ireland. The study, which included 325 Irish people, was conducted in Ireland through the website www.psoriasisuncovered.ie.
The survey also collected responses from 16 other countries attracting over 10,800 responses. Abbott, which employs 3,800 people in Ireland, conducted the research to uncover some of the emotional and mental effects psoriasis can have on individuals and to assess how the condition can impact on the social aspects of their lives, in particular the impact it can have on their career.
The survey is being released in Ireland to mark World Psoriasis Day 2009 on 29 October. According to www.psoriasisuncovered.ie: “For the most part, people with psoriasis function normally. Sometimes people experience low self-esteem because of their psoriasis. Psoriasis is often misunderstood by the public, which can make social interactions difficult. This may lead to emotional reactions such as anxiety, anger, embarrassment and depression.”
Caroline Irwin, Chairperson of the Psoriasis Association of Ireland, hopes that the survey results will help draw attention to the problems faced by people with psoriasis in Ireland. “These results highlight the huge impact that psoriasis, perceived by many to be a simple skin complaint, can have on a person’s quality of life,” she said.
“For the 100,000 people in Ireland, there is often a stigma attached to the condition, which impacts on many facets of daily life. We hope that this research will go some way towards uncovering the, often hidden, impact of psoriasis and that by understanding the social and psychological effects of psoriasis in Ireland and around the world, we can begin to address them.”
People with psoriasis were asked to rate how having psoriasis had affected various aspects of their life, including their social life, their ability to work and to study and how it affected their mood and behaviour.
These responses were also measured using Dermatology Life Quality Index (DLQI) scores. The DLQI is commonly used by dermatologists to understand the impact a dermatological condition has on a patient’s life. The responses are scored between 0-30 points, with 0-1 indicating no impact on a person’s life and 21-30 indicating an extremely large effect.
Of the total survey respondents worldwide, the average DLQI score was 9, indicating a ‘moderate effect’ on the respondent’s life. However, the score was found to be higher in Ireland with an average score of 11, indicating a ‘very large effect’ on the respondent’s life.
Impact on work
Irish respondents also scored more negatively when asked to assess the impact of the condition on various aspects of their life. The results show that many feel that psoriasis has hampered their ability to work normally as 31.8 per cent felt that psoriasis has prevented them from pursuing their desired career path or field, compared to 25.3 per cent worldwide; while 39.8 per cent felt that their behaviour in work was affected by psoriasis compared to 32.2 per cent worldwide. Almost 17 per cent of respondents reported having to quit a job because of their psoriasis with 3.4 per cent reporting that they are currently unemployed because of their psoriasis.
However, the condition was perceived by Irish respondents to be better accepted by their colleagues as only 15.8 per cent of respondents reported that they were treated differently than their colleagues who did not have psoriasis, compared with 18.4 per cent worldwide.
They also felt less discriminated against in the workplace with 13.1 per cent reporting that they have been discriminated against as opposed to the worldwide average of 23.8 per cent.
A vast majority of Irish respondents reported feeling embarrassed about their psoriasis and reported a negative impact on their personal life. Some 82.5 per cent reported feeling embarrassed or self conscious while a total of 88.3 per cent said that it had affected their confidence.
Of the respondents, 83.2 per cent said it had impacted on their mood or mental health and 85.8 per cent reported that it affected their ability to enjoy life.
Professor Sarah Rogers, Department of Dermatology, St Vincent’s University Hospital, Dublin, agrees with the findings of the research.
“I often see the serious impact psoriasis can have on the quality of life of my patients, particularly those living with moderate to severe psoriasis. Newer treatment options are now available which can make significant improvements on the condition long-term with positive benefits on overall quality of life. Early diagnosis and treatment is critical in ensuring optimum results,” she said.
According to www.psoria sisuncovered.ie, 100,000 Irish people have psoriasis. It is an inflammatory skin disorder that is non-contagious and can cause great discomfort and embarrassment for the person affected, according to the survey results. It varies in severity but affects men and women equally. It usually begins between the ages of 15 and 35 but can develop at any time.
The cause of psoriasis is unknown and there is no cure, but treatments can greatly alleviate the symptoms. In cases of psoriasis, the normal rate of skin replacement is accelerated.
Normal skin cells mature every 21 to 28 days, according to www.psoriasisuncov ered.ie, and are invisibly shed. Psoriatic skin cells, however, turn over every two to three days and both dead cells and live cells remain at the surface of the skin, forming lesions that may be painful or itchy.
Psoriasis lesions can develop anywhere on the skin and most commonly appear on the scalp, knees, elbows, torso, hands and feet. They may even occur in the fingernails and toenails.
Treatment will vary from person to person based on factors such as the type of psoriasis, the location on the body and the severity of the condition.
Effective treatment
Effective treatment of psoriasis is important, not only because of the reported social and psychological impact on those with the condition but also because of the potential physical complications associated with it. The ‘psoriasis uncoverered’ website advises of the risk of psoriatic arthritis, which can occur in up to 30 per cent of those with psoriasis, manifesting similar abnormalities as found in rheumatoid arthritis.
“Psoriatic arthritis can affect the fingers and toes and may involve the neck, lower back, knees and ankles. The joints and the soft tissue around them become swollen and stiff. In severe cases, it can be disabling and cause irreversible damage to joints,” according to the website.
Psoriasis may be more problematic than previously thought, according to the ‘psoriasis uncovered’ research, as it may be indicative of other health problems. While psoriasis was once considered to be a simple skin condition, evidence suggests that cardiovascular disease markers are in increased in psoriatic patients; people with psoriasis were found to have greater incidences of diabetes, obesity, high blood pressure and high cholesterol.
The effects of psoriasis on the social and work lives of those with the condition, and on their mental health as shown in the psoriasis uncovered survey, should not be underestimated. The association between cardiovascular markers such as obesity and psoriasis is born out by the replies of respondents in the study.
Some 44.8 per cent of Irish respondents and 40.3 per cent of worldwide respondents indicated that their psoriasis had made participating in sports difficult in the week before they took the study.
A total of 60.9 per cent of Irish respondents and 40.5 per cent of worldwide respondents reported that their social or leisure activities had been affected by their psoriasis in the week before they took the study. The survey found that 36.9 per cent of Irish participants and 36.1 per cent of those worldwide also reported that their sexual activity had been affected — such factors may lead to increased BMI, low self esteem and depression, a fact which is recognised by the American Academy of Dermatology.
According to its guideline: “Increased rates of depression in patients with psoriasis may be another factor leading to increased risk of cardiovascular disease. Although there is some suggestive evidence that treatment of depression with selective serotonin reuptake inhibitors may reduce cardiovascular events, conclusive evidence is lacking.”
In combination with dermatological treatments, the Psoriasis Association of Ireland recommends secondary measures that patients with psoriasis should be advised to follow. Patients with psoriasis who smoke should be advised to stop immediately because of the damage it causes to the immune system; smokers are at increased risk of developing chronic plaque psoriasis and developing pustular psoriasis on their soles and feet.
Doctors should also be advised that there is a link between increased alcohol intake and psoriasis in men, according to the Association. They also note that this link is not seen with other skin conditions.
Practical advice
The website www.psoriasisun covered.ie also offers practical advice to people with psoriasis. It advises patientes to:
l Acknowledge their feelings as it is normal to feel sad, angry and frustrated when they are dealing with psoriasis.
l Manage stress as stress is often the trigger for developing psoriasis for the first time or can irritate existing psoriasis.
l Stay informed about the condition through reading, talking to others, through the internet and in discussions with their doctor.
l Change the way they live — this is stressed as one of the most important steps a person with psoriasis can take. Along with remembering to take any prescribed medication, a good skin care routine with daily moisturising or emollients can make a substantial difference to the condition.
l Not to give up even when psoriasis feels uncontrollable — they stress that it can be managed.
l Seek the support of family and friends.
For further support, people with psoriasis can contact the Psoriasis Association of Ireland or search through its website at www.psoriasisireland.ie.
The Psoriasis Association of Ireland is a patient group for those living with the condition. Set up in 2003, the Association provides a range of services including public information seminars, self-help groups, an advice line, a website, e-newsletters and information leaflets. People with psoriasis can visit www.psoriasisuncovered.ie to find more information.
The results of the survey, ‘Psoriasis Uncovered’, are available to download at www.psoriasisuncovered.ie or you can order free copies for your patients from Psoriasis Uncovered, 15 Fitzwilliam Quay, Dublin 4.Email: psoriasis uncovered@fleishmaneurope.com Tel: (01) 618 8408.

About one-quarter of patients with superficial vein thrombosis also may have deep vein thrombosis (DVT), according to a new report.
The report followed a study in which doctors in Austria followed 46 consecutive patients with superficial vein thrombosis between November 2006 and June 2007.

All patients underwent colour-coded duplex sonography, an imaging test, to confirm superficial vein thrombosis and exclude or detect DVT.
Participants also reported their history of clotting events, use of oral contraceptives and compression stockings, any recent immobilisation and active malignant disease.
Laboratory tests included D-dimer levels, a measure of protein fragments that tends to be elevated in patients with deep vein thrombosis. DVT was detected in 24 per cent of patients with superficial vein thrombosis and was usually asymptomatic.
Deep vein thrombosis occurred in the same leg as superficial vein thrombosis in 73 per cent of the patients, in the other leg in 9 per cent and in both legs in 18 per cent.
“Generally, superficial vein thrombosis is regarded as a condition with an uncomplicated course and usually is not considered to be a severe or life-threatening disease,” the doctors commented.
“However, the occurrence of concomitant deep vein thrombosis and/or pulmonary embolism may lead to severe complications.
The results of this study indicate that concurrent deep vein thrombosis is more likely when superficial vein thrombosis affects the lower leg. In these cases, the deep veins should be assessed by colour-coded duplex sonography to exclude or confirm acute deep vein thrombosis.”
Archives of Dermatology 2009;145:753-757