diagnosis of psoriasis

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Diagnosis : Physicians usually diagnose psoriasis by examining the affected skin. Less often, a small piece of skin affected by the psoriasis is cut out and examined under a microscope. A microscopic examination of tissue taken from the affected skin patch is required to make a definitive diagnosis of psoriasis and to distinguish it from other skin disorders. Usually in psoriasis, the examination will show proliferation of dry skin cells but without many signs of inflammation or infection. Changes in the nails typical of psoriasis are often strong indicators of psoriasis

Psoriasis is characterized by dysfunction of keratopoesis .the major pathological features are parakeratosis . munnro abscesses and an increased number of mitoses. Acantosis and spongiosis are often seen . the dermal-epidermal border is well marked. The upper derma shows papillomatosis and dilation of capillaries with excess of perivascular neutrophilic infilteration . the nerve fibers are Dystrophic, with enalarged neurolema and central cylinder. It’ s also reported that the stratum granulosum is thinned or absent .

It can be difficult for the doctor to diagnose psoriasis in the early stages, when the disease may be limited to rough patches on the elbows. Certain symptoms, such as a dandruff-like scalp condition or what looks like a fungal infection, may be hard to recognize as psoriasis. Nail pits may be a sign of early psoriasis, but they may also be a sign of other conditions. The diagnosis is straightforward if the doctor examines the skin and sees thick, red, flaky patches-the plaques characteristic of psoriasis.

In people with psoriatic arthritis, the arthritis usually follows the appearance of psoriasis. Typically, psoriatic arthritis first appears in the finger and toe joints closest to the nail. Other forms of psoriatic arthritis may be more difficult to diagnose. The joints may be affected in no recognizable pattern. Unlike , psoriatic arthritis cannot be diagnosed by a blood test and also x-ray may taken for diagnosis
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1-" THE HISTOPATHOLOGY OF PSORIASIS ", G. DE ROSA, C. MIGNOGNA, Department of Biomorphological and Functional Sciences, Pathology Section, “Federico II” University of Naples, Italy

2-" Rook’sTextbook of Dermatology ", Tony Burns, Stephen Breathnach, Neil Cox, Christopher Griffi ths, This edition fi rst published 2010, © 1968, 1972, 1979, 1986, 1992, 1998, 2004, 2010 by Blackwell Publishing Ltd, ISBN: 978-1-4051-6169-5

3-" ROBBINS AND COTRAN PATHOLOGIC BASIS OF DISEASE, 8/E",ISBN: 978-1-4160-3121-5, Copyright © 2010 by Saunders, an imprint of Elsevier Inc.

nail psoriasis treatment

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Nail psoriasis is common in psoriatic patients, particularly in patients with joint involvement. It has a significant impact on their quality of life, affecting physical activities as well as causing emotional and social impairement. The disease is often refractory to treatment, and available therapeutic agents affect the matrix or the nail-bed features with variable success. The recent design of the Nail Psoriasis Severity Index allows a more standarized approach regarding outcome assessment.

Nail Psoriasis Severity Index (NAPSI). The nail is divided into quadrants, each of which is rated with a 0 or 1, based on the absence or presence of pathological signs resulting from involvement of both the nail matrix and the nail bed. NAPSI has significantly helped in a more standardized approach to outcome assessment of therapeutic studies.

Nail involvement is common in psoriatic patients, affecting up to 80% of patients at some point in their lives. It has been suggested that nail disease is more common in psoriatic arthritis (PsA) than cutaneous psoriasis. This link highlights the importance of diagnosis of PsA through initial nail manifestations in the absence of cutaneous involvement, since if left untreated, PsA can lead to destructive permanent changes. Nail involvement without cutaneous disease affects 5-10% of patients.

Nail psoriasis has significant adverse influence on the quality of life of many patients. psoriatic patients with nail disease considered their condition a significant cosmetic handicap, interfered with their job and described pain as a symptom.

Typical complaints concerned the ability to grab small objects, tie shoe laces and button clothes; an altered sense of touch was also reported. Despite significant impairment on daily activities, nail disease remains occasionally untreated. Patients are often fatigued, as a result of poor efficacy of various treatment modalities and failure to comply to long-term treatments with topical agents. Owing to great difficulty in drug delivery to the site of action and significant toxicities of most conventional systemic therapies, treatment of nail psoriasis remains a challenge.

In a small number of patients, the diagnosis may be unclear because nail features might be inconclusive. In such situations, onychomycosis should be excluded through direct microscopy and culture of nail clippings and subungual debris. Presence of fungus does not exclude psoriasis as onychomycosis has been reported to have a higher prevalence in psoriatics. Nail-plate histology might be helpful in differential diagnosis, but it might cause permanent dystrophy if nail matrix tissue is included. When the patient presents with pustular nail psoriasis, it is important to rule out both bacterial and fungal infection. Negative results help to establish the diagnosis.

For patients :

Patients should protect their hands and nails by wearing gloves when in contact with water and irritants. This is of particular importance in patients presenting with onycholysis and paronychia. Application of emollient cream in the dry psoriatic skin of the hands and nail folds could also be helpful. The need for injury avoidance, which could aggravate the nail disease, should be stressed. Nails should be cut short to avoid increased risk of injury and onycholysis. Patients who are obsessed with removing debris from beneath the nail with various manicure instruments should be discouraged, since this will only exacerbate onycholysis. Colored nail lacquer is safe to use and can hide discoloration and partially fill surface irregularities. The result is good enough to prevent proper assessment by a dermatologist, consequently it should be removed by the patient before follow-up visits. Prosthetic nails can make onycholysis worse.

Treatment options :

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Onychomycosis (if present) requires antifungal therapy for improvement. The treatment options for nail psoriasis include topical corticosteroids, intralesional corticosteroids, psoralen plus ultraviolet light A (PUVA), topical fluorouracil, topical calcipotriol, topical anthralin, topical tazarotene, topical cyclosporin, avulsion therapy, and systemic therapy for severe cases.

Topical Corticosteroids. Potent and very potent topical steroids have been attempted once or twice daily for 3-9 months under occlusion with cellophane wrap at bedtime can improve nail psoriasis.. Patients should be advised to clip the detached nail plate and apply topical steroids to the nail bed, hyponychium and paronychial area. Improvement has been reported on both the nail bed and the nail matrix features. Side effects of topical steroids after long-term use include telangiectasias and atrophy of the paronychial area . he only study utilizing NAPSI, by Rigopoulos et al., reports an effectiveness for clobetasol propionate 0.05% cream comparable to tazarotene after 12 weeks. New formulations, such as the clobetasol 8% nail lacquer, allow for intermittent application and have demonstrated encouraging results . Avoid long, continuous therapy with corticosteroids to avoid tachyphylaxis. Also, avoid prolonged occlusion. A topical preparation of a combination of high-potency corticosteroid and calcipotriol may benefit some patients .

Intralesional Steroids. Triamcinolone acetonide 10 mg/ml is the mainstay intralesional agent used bimonthly. The procedure should be preceded by ring block or distal block anesthesia if the injection ( injection is given with a 30-gauge needle ) is likely to enter the matrix as this is a very sensitive site. Use of dermojet can offer an alternative application technique with considerably decreased pain. However, even with dermojet, adverse events such as inclusion cysts have been reported. Injection sites should be the proximal paronychial area for nail matrix features treatment and the lateral paronychial area for nail-bed feature treatment. The dose should be 0.05-0.1 ml of triamcinolone acetonide 2.5-10 mg/ml at up to four injection sites, depending on the lesions, used bimonthly for 5-6 months. Side effects include Beau's lines nail atrophy and subungual hemorrhage. Efficacy is high, mainly for nail matrix lesions, but available studies were published before NAPSI design and utilize different doses and outcome assessments, lacking therefore sufficient power to extrapolate a standardized therapeutic regimen. In these studies, 70-90% of psoriatic patients with both nail matrix and nail-bed lesions responded to intralesional steroids. However, onycholysis proved more difficult to treat than the remaining psoriatic lesions, with only 20-55% of patients responding.

Vitamin D Analogues. Calcipotriol twice daily for 3-6 months has been evaluated in the treatment of nail psoriasis in several studies. It presents significant efficacy regarding hyperkeratosis resolution. Tosti et al. reported a 49% reduction of subungual hyperkeratosis after 5 months application in a randomized double-blind study. An open-label study by Rigopoulos et al. reported a decrease of hyperkeratosis up to 70% after 6 months of application for both fingernails and toenails. There are no studies utilizing NAPSI. Side effects were minimal and self-limiting.

Tazarotene. Tazarotene 0.1% gel or cream applied once daily for 12-24 weeks has been documented to improve psoriatic nail features resulting from both nail matrix and nail-bed involvement. Scher et al. reported significant improvement, mainly of onycholysis with tazarotene 0.1% gel in a randomized, vehicle-controlled, double-blind study. Results were visible from week 4 for patients using the agent under occlusion, compared with week 24 for those using it without occlusion. Subsequent studies reported improvement for onycholysis, hyperkeratosis, pitting and salmon patches on both fingernails and toenails Tazarotene application may cause mild skin irritation and a sense of burning or desquamation of the paronychial area.

5-fluorouracil. 5-fluorouracil (5-FU) has been used in the treatment of nail psoriasis in several studies with mixed results. Fredriksson reported improvement in onycholysis and pittings in 17 out of 20 patients after 4 months of 5-FU application once daily. Fritz reported improvement of oil spots and subungual hyperkeratosis in 59 patients applying 5-FU cream and urea 20% twice daily and poor results on a group applying a monotherapy of 5-FU solution.

Anthralin. Anthralin 0.4-2% in petrolatum applied once daily for 5 months has been evaluated by Yamamoto et al. in the treatment of nail psoriasis. Improvement was seen in 60% of the patients regarding pachyonychia, pitting and onycholysis. Despite the use of triethanolamine 10% cream, patients exhibited undesired but reversible pigmentation of the nail plate .

Topical Ciclosporin Solution. Application of ciclosporin maize oil-dissolved oral solution with a final 70% ciclosporin concentration twice daily for 3-4 months has been reported to improve subungual hyperkeratosis and onycholysis in a randomized, placebo-controlled study of 16 patients. Three out of eight patients in the ciclosporin group presented complete resolution, with the remaining five exhibiting improvement. There were no reported adverse events.

Systemic therapies have been used in patients with severe cutaneous psoriasis. Few studies have shown significant improvement in nail psoriasis with long-term results. At present, 3 systemic medications are most commonly used for psoriasis and nail psoriasis: methotrexate, retinoids and cyclosporin. All 3 agents have potential serious adverse effects and toxicities. Carefully weigh the risk-to-benefit ratio in the treatment of nail psoriasis. Systemic therapies are seldom a first-line therapy for nail psoriasis. Topical treatment with calcipotriol can be used as adjunctive therapy and maintenance therapy with systemic treatment. Biological therapy for psoriasis and psoriatic arthritis may have a significant benefit for some patients with psoriatic nail disease .

Retinoids. Etretinate and acitretin have been evaluated for pustular nail psoriasis and nail lesions in patients with extensive cutaneous and/or joint involvement. Mahrle et al. reported improvement of nail lesions in 47 out of 60 patients receiving etretinate for cutaneous psoriasis in a multicenter study. Piraccini et al. reviewed treatment outcomes in 46 patients with pustular psoriasis. Patients with severe disease received oral retinoids and six out of 12 patients had improvement of their nail lesions. Mild-severity patients received calcipotriol, topical steroids or oral nimesulide with only calcipotriol presenting efficacy comparable to retinoids. Acitretin in a dose of 0.25-0.5 mg/kg/day for 3 months exhibits satisfactory efficacy in the management of pustular psoriasis, dystrophy, pittings and subungual hyperkeratosis. Acitretin may cause leukonychia, pseudopyogenic granuloma, brittle nails and lesions, such as paronychia. In addition, even though retinoid dose for nail psoriasis is considerably lower than the dose administered for the treatment of cutaneous lesions, liver function should be regularly monitored.

Ciclosporin. Data regarding the efficacy of ciclosporin in the treatment of nail psoriasis are conflicting. Mahrle et al. reported mild improvement of 17.5%, using a four-point scale score, in the nail lesions of 90 out of 137 patients receiving ciclosporin 2.5-5.0 mg/kg for 10 weeks in a multicenter study. Feliciani et al. reported improvement in 47% of 21 patients treated with ciclosporin 3.5 mg/kg for 3 months compared with an improvement of 79% of 33 patients similarly matched treated with the same ciclosporin dosage plus topical calcipotriol. Patients treated with ciclosporin should be monitored for renal function and blood pressure since prolonged treatment duration may result in well-documented adverse events. systemic ciclosporin should be considered a second-line treatment for nail psoriasis.

Photochemotherapy & Psoralen & UVA Bath. Psoralen and UVA (PUVA) has been reported to improve onycholysis, salmon patches, subungual hyperkeratosis, proximal paronychia and onychorrhexis in a small series of patients with nail psoriasis. It has no effect on pitting. Both oral and topical PUVA therapies have improved nail psoriasis in 3-6 months. A possible adverse effect of PUVA may be nail discoloration.

Superficial X-ray Therapy. Superficial x-rays are still being in use in Germany and Switzerland for the treatment of psoriatic nails. Yu et al. used superficial radiotherapy (SRT) for psoriatic fingernails as three fractionated doses of 150 cGy (90 kV, 5 mA, 1.00 mm aluminium filter). The treated nails demonstrated a significant fall in scoring on a clinical rating scale at 10 and 15 weeks after therapy (mean scores = 4.4 and 4.6, respectively) when compared with a mean pretreatment score of 5.5 at week 0 (p < 0.0001 and p < 0.05, respectively); the treated nails also showed significant clinical improvement when compared with the sham-treated nails at weeks 10 and 15 (p < 0.05). Mean nail thickness in treated nails 15 weeks after therapy was significantly thinner (mean thickness = 0.75 mm) than that of sham-treated nails (0.88 mm; p = 0.005), but the difference was not significant at week 20. The rate of linear nail growth was unaffected. The authors concluded that SRT appears to confer a definite albeit temporary benefit on psoriasis of the nails at this dosage.

Biologicals. There are presently few available studies on biological therapy for nail psoriasis, but there are many in progress .

Alefacept has been evaluated in a limited number of patients with nail psoriasis. Cassety et al. reported improvement of NAPSI by 30% in three out of six patients receiving alefacept intramuscularly for 12 weeks. Korver et al. reported improvement of NAPSI in two out of five patients with moderate nail psoriasis NAPSI greater than 15, while patients with milder severity displayed variable results. No adverse events were reported.

Infliximab has shown extremely beneficial results in the treatment of nail psoriasis. Reich et al. reported significant improvement from as early as week 10 of therapy with infliximab 5 mg/kg in 240 patients with a mean NAPSI of 4.6 Improvement of NAPSI at week 22 reached 56.3% in this vehicle-controlled, randomized, double-blind study. Bianchi et al. reported even more impressive results in severe nail involvement. Nine patients with plaque psoriasis and a mean NAPSI of 28.3 and 16 patients with PsA and a mean NAPSI of 33.3 received infliximab and were without nail lesions (NAPSI: 0) at week 22. Although no adverse effects were reported, infusion reactions with infliximab are not uncommon. Reactions range in severity from mild fever and chill to anaphylactic reactions and acute coronary artery syndrome .

Avulsion therapy with chemical or surgical means can be used as an alternative therapy for psoriatic nail disease. Chemical avulsion therapy includes the use of urea ointment in a special compound to the affected nail under occlusion for 7 days, and the nail is removed atraumatically. Chemical avulsion therapy is painless, involves no blood loss, and is less expensive than surgical avulsion.

Surgical Care Surgical avulsion therapy can be performed for psoriatic nail disease when other treatments have failed. During surgery, the matrix can be electively ablated to prevent regrowth of the nail. This procedure is performed under local anesthesia. Inform patients of postoperative discomfort, limitations, and possible physical nail disfigurement.

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Smoking can trigger psoriasis

Cigarette smoking is a risk factor for many chronic diseases, including psoriasis, and it has been widely considered as an important preventable cause of morbidity. However, little is known about the effect of smoking on psoriasis severity. studies have shown that smoking more than 10 cigarettes per day by men who are psoriasis patients may be associated with a more severe expression of disease in their extremities. In addition, smoking among both men and women who are psoriasis patients has been shown to reduce improvement rates. These data demonstrate the importance of discouraging smoking, particularly among psoriasis patients.

Over 4,000 different chemicals are present in cigarette smoke. Many of these are carcinogenic, or capable of causing changes in the genetic material of cells that can lead to cancer. Cigarette smoke contains nicotine, an addictive chemical, and carcinogenic tars. Tobacco smoke contains many harmful  components such as carbon monoxides , nicotine and polycyclic hydrocarbons (ex benzo[a]pyrene)  . Cigarette smoking can induce several disease such as

1-Cardiovascular Disease, Coronary artery disease (2-4 fold risk) Stroke (2-fold risk) and Abdominal aortic aneurysm.

2-      Cancer, LUNG (90%), bladder, oral cavity, pharynx, larynx (voice box), esophagus, cervix, kidney, lung, pancreas, and stomach, and causes acute myeloid leukemia

3-      Lung,  chronic obstructive pulmonary disease [ COPD (>90%) ] , Other -including an increased risk for infertility, preterm delivery, stillbirth, low birth weight, and sudden infant death syndrome (SIDS) .

In a multicenter case-control study, they reported an increased risk of psoriasis among smokers and ex-smokers compared with subjects who never smoked. It has been hypothesized that excess mortality is also related to alcohol intake coupled with smoking among psoriasis patients. The effect of cigarette-years on psoriasis severity was stronger for women than for men.

It has long been known that smoking induces functional and morphologic alterations in polymorphonuclear leukocytes, and it may also cause an exaggerated release of chemotactic factors. Some studies have shown that cigarette smoking induces an overproduction of interleukin 1β and increases the production of tumor necrosis factor α and transforming growth factor β, which have been associated with psoriasis severity and support the dermatologist’s recommendation to patients with psoriasis to quit smoking to prevent worsening of their psoriasis.

  

Surprising Ways Smoking Affects Your Looks and Life

Differential diagnosis with psoriasis

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The characteristics already defined are usually sufficient to enable the diagnosis to be made, but doubt may arise in atypical cases, in particular sites, and when psoriasis is complicated by or alternates with other diseases. In seborrhoeic dermatitis, the lesions are lighter in colour, less well-defined and covered with a dull or branny scale. Eczema at times develops a psoriasiform appearance, especially on the legs. Hyperkeratotic eczema of the palms is a common cause of misdiagnosis. Colour, scratch-evoked scaling and well-defined margins are suggestive of psoriasis, and nail changes may be diagnostic. Lichen planus should give rise to difficulty only when the two diseases alternate or coexist, especially when present as hypertrophic lesions on the legs, as penile lesions and on the palms. The violaceous colour, glistening surface and presence of oral changes are usually decisive. Lichen simplex can resemble psoriasis closely, particularly on the scalp and near the elbow. The intensified skin markings, rather ill-defined edge and the marked itching are characteristic, and the point of the elbow tends to be avoided. Pityriasis lichenoides chronica can closely resemble guttate psoriasis, but the lesions are usually less evenly scattered, have a brownish red or orange brown colour and are capped by an opaque soft "mica-like" scale. Candidiasis shows a glistening deep red colour suggestive of psoriasis, particularly in the flexures, but scaling tends to be confined to the edge, and small satellite pustules and papules are usually evident outside the main area. Tinea cruris has a well-defined, often polycyclic edge, but Trichophyton rubrum infections, especially of the palm, cause difficulty. If corticosteroids have been applied, scaling may be absent and the diagnosis must be made by microscopy and culture. Less common causes of confusion are pityriasis rubra pilaris and secondary syphilis. The resemblance to pityriasis rubra pilaris . An association of psoriasis and cardiovascular disease (CVD) has long been recognized. CVD risk is highest in those with more severe disease, with standarized mortality rates reaching , particularly in younger patients. Much of this risk is due to coexistence of known CVD risk factors, including type II diabetes mellitus, dyslipidaemia, hypertension and obesity, increasingly referred together as the " metabolic syndrome". However, emerging evidence suggests that the risk may in part remain even after controlling for known risk factors. Taken together, these studies indicate that treating patients with moderate or severe psoriasis requires attention to these important general medical issues.

Dermatitis, Atopic , Pityriasis Rosea , DermatitisContact , Reactive Arthritis , Gout and Pseudogout , Syphilis , Pityriasis Alba , Tinea
See also for more informations about misdiagnose of psoriasis

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1-" THE HISTOPATHOLOGY OF PSORIASIS ", G. DE ROSA, C. MIGNOGNA, Department of Biomorphological and Functional Sciences, Pathology Section, “Federico II” University of Naples, Italy

Psoriasis and sexual health

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It can be hard to feel desirable when your body is covered with the results of psoriasis, an autoimmune disease that causes skin cells to mature too rapidly, resulting in thickened areas with silvery scales. Although the disorder can affect people of any age, most cases of psoriasis begin between ages 15 to 35 - prime time in an adult's sexual life.

Genital Psoriasis  Genital psoriasis, whether on the labia, penis or scrotum, generally doesn't flake as much as lesions elsewhere, showing up instead as reddened areas that can itch intensely. Steroids have the tendency to cause skin to thin. Because skin of male genitalia, in particular, is naturally thin, doctors often prescribe non-steroidal creams and ointments for genital psoriasis, such as Protopic (tacrolimus), Elidel (pimecrolimus) and Dovonex (calcipotriene).

Men coping with genital psoriasis may find more comfort wearing a condom, which not only can preserve lubrication but keep abraded skin from becoming more inflamed. Men with genital psoriasis who wear a condom should apply lubricant prior to applying the condom. Men and women using psoriasis medications on their genitals are advised to wash medication off before sexual intercourse and re-apply afterward.

Talk about it up front  Most people fear that the disease will take someone by surprise. By putting it out there, you’re taking control. You might say, 'I'm having an outbreak' with great confidence, or if you have the courage, show it to someone. The anxiety and stress around the disease will ease up.

Focus on the pleasure  It’s a matter of tuning into the situation, focusing on your partner and the joy you are creating together, and allowing any self-conscious thoughts to disappear .
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Water Therapy

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Water therapy is the combination of sea salts and water and is the basis of many powerful therapeutic treatments. There are numerous types of Water Therapy administered at spas, ayurvedic & holistic centers, and health clinics around the world. Sports therapy clinics use Hydrotherapy Baths to help patients recover from joint and muscle injuries. Dermatologists are recommending Bokek Dead Sea Salt baths for patients with psoriasis, eczema and other dry skin conditions. Estheticians emphasize the cleansing properties of a sea salt bath to clean pores and to detoxify the body. Cancer patients use water therapy to help deal with radiation treatments. There are even Water Therapies & therapeutic bath salts you can use on a daily or weekly basis in your own home.

Hippocrates, the Father of Medicine, discovered the therapeutic qualities of seawater by noticing the healing affects it had on the injured hands of fishermen. The seawater not only restricted infection risks, but patients who followed treatments involving the use of seawater found that it also promoted pain relief. It is now known that sea salt therapy is an effective treatment that assists in the rejuvenation of the cells and also induces a healthy exchange of minerals and toxins between the blood and the water.

Types of Water Therapies

Balneotherapy - a range of treatments with warm mineral salt water, from bathing or underwater massage jets to plain drinking. Alkaline water helps stimulate the secretion of bile, while hypnotic water has diuretic effects and is often used for treating kidney stones.

Heliotherapy - use of the sun’s creative properties. Despite recent awareness of skin cancers, sun remains an excellent source of energy, boosts immunity and stabilizes mood when used appropriately. Skin treatments combine this with sea salt baths but should only be used together under the supervision of a doctor.

Phytotherapy - treatments with wild-growing herbs, plants, flowers or leaves. Used in salt baths, oils or infusions, their effect can be superior to pharmacological treatments for some medical conditions. Try making your own bath salts by combining these ingredients with sea salts.

Thalassotherapy - therapeutic baths using warm seawater. The application of seawater (which is very similar to the body’s own internal fluids) allows magnesium and potassium to be drawn into the blood stream while toxins are actively eliminated.

Climatotherapy of Psoriasis at  Safaga Red Sea - Climatotherapy has become a well-established modality for the treatment of psoriasis. It involves various regimens of seawater bathing and sunlight exposure, combined with application of emollients, rest and relaxation over several weeks

Safaga at the Red Sea was found an ideal area for climatotherapy of psoriasis. Many natural factors and present there: plentiful sunshine due to cloudless sky prevailing at least 350 days a year, warm, clear, non-polluted or dusty weather. These elements constitute the main components of the natural therapy of the disease at this area.

A natural selective ultraviolet phototherapy along with bathing in the sea was utilized in the management of psoriasis at Safaga – Red Sea. In 80 patients with psoriasis, 90% achieved complete clearing or excellent improvement. The results compare favorable with other therapeutic regiments used in the treatment of psoriasis. Since systemic medications are avoided, the advantage of Safaga – Climatotherapy is that the treatment is natural, pleasant and without the serious side effects sometimes associated with other methods.

Dead Sea Psoriasis Treatments - The Dead Sea area has become a major center for health research and psoriasis treatment for several reasons. The mineral content of the waters, the very low content of pollens and other allergens in the atmosphere, the reduced ultraviolet component of solar radiation, and the higher atmospheric pressure at this great depth each have specific health effects. For example persons suffering reduced respiratory function from diseases such as cystic fibrosis, seem to benefit from the increased atmospheric pressure.

Sunlight at the Dead Sea is high in therapeutic UVA rays and low in burning UVB, so extended exposure is safe and low-risk. The filtering effect comes from a thick atmosphere: the Dead Sea is about 1,200 feet below sea level and the ozone layer above it is minimally depleted. The Dead Sea is the only place on Earth where you can sunbathe for extended periods with little or no sunburn because harmful ultraviolet rays are filtered through three natural layers: an extra atmospheric layer, an evaporation layer that exists above the Dead Sea, and a rather thick ozone layer.

Ichthyotherapy ( therapy with theso-called‘ Doctorfish of Kangal’, Garrarufa ) has been shown to be effective inpatients with psoriasis in the Kangal hot springsin Turkey. This treatment was first mentionedin The Lancetin 1989 but the details of the treatment were published only recently by Ozcelik etal. According to the authors two Different types of fish live in the pools of the Kangalhot spring: Cyprinionm acrostomus and Garrarufa. Both fish are members of the carpandminnow family (Cyprinidae). Garrarufa is regarded as the main therapeutic. Garrarufa is normally a bottom dweller ,where it adheres by suction to rocks with its ventral crescent shaped mouth to feed on phyto and zooplankton However , in the hot pools of Kangal , where phyto - and zooplankton are scarce , these fish feed on the skin scales of bathers, reportedly reducing illnesses such as psoriasis and atopic dermatitis .Whether this remarkable treatment is also effective outside of the Kangal hot spring in Turkey is unknown . Since there have been many unscientific and misleading names for this kind of therapy , we suggest the term ‘ichthyotherapy’ , in accordance with other so called biotherapy concepts such as maggot therapy (use of sterile fly larvae), hirudo therapy(use of leeches) and apitherapy ( use of bee venom).

Role of the Dermatology Nurse in Managing Hand and Foot Psoriasis

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The dermatology nurse's primary goal with all patients is to improve their quality of life, and this is especially important for patients with hand and foot psoriasis. As nurses, we have responsibility for helping these patients become functional again in their jobs, with families, and in relationships. Meeting these patients' physical, psychological, and emotional needs is a key priority. Patient screening is one important method that dermatology nurses must use in an effort to determine these needs. A sound approach here is designing a quality of life questionnaire that assesses the patient's recent, overall well-being by asking such questions as:

• How itchy, sore, painful, or stinging has your skin been?
• How embarrassed or self-conscious have you been because of your skin?
• How much has your skin interfered with you going shopping, or looking after your home or garden?
• Has your skin prevented you from working or studying?

Patient counseling, support, and education are important to achieving therapeutic success. Educating patients about their disease and the prescribed treatment is paramount. For example, dermatology nurses who give patients injection training for biologic agents should also emphasize to them the importance of compliance with that particular therapy. treatment with efalizumab showed statistically significant improvement in patients with chronic moderate-to-severe plaque psoriasis involving the hands and feet .