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dermato verineology
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    1   DISCUSSION Depression/suicide Psoriasis is associated with lack of self esteem and increased prevalence of mood disorders including depression. The prevalence of depression in patients with psoriasis may be as high as 60%. Depression may be severe enough that some patients will contemplate suicide. In one study of 217  patients with psoriasis, almost 10% reported a wish to be dead and 5% reported active suicidal ideation. Treatments for psoriasis may affect depression. One study demonstrated that patients with psoriasis treated with etanercept had a significant decrease in their depression scores when compared with control subjects. However, clinically diagnosed depression was an exclusionary criterion for entry into this study. 3  Therefore, treatment of psoriasis with etanercept lessened symptoms of depression in patients without overt clinical depression. 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. 3 in case we find the patient she get a stress in her life and she never talk to her son and daughter. And when he getting start to remember her kid she always feel the symptom going severe, like itch and red spot, in that case related with the literatur. Multivariate analysis demonstrated that the relative risk of developing  psoriasis was highest in those with the highest BMIs. In contrast, a low BMI (21) was associated with a lower risk of psoriasis, further supporting these findings. Furthermore, the average weights of pa-tients with psoriasis in the large clinical trials of the biologic agents have been in the 90-to 95-kg range (although these clinical trials all enrolled more men than women) whereas the average body weight for the US population from the NHANES database from 1999 to 2002 was 86 kg. An association between psoriasis and elevated BMI appears to be yet another factor that predisposes individuals with psoriasis to cardiovascular disease. 3 in that case the patient occurrence of obesity with psoriasis vulgaris related with the literature, she have a BMI >30 that condition show she get a obesity.    2   The major manifestation of psoriasis is chronic inflammation of the skin. It is characterized by disfiguring, scaling, and erythematous plaques that may be  painful or often severely pruritic and may cause significant. Psoriasis is a chronic disease that wax es during a patient’s lifetime, is often modified by treatment initiation and cessation and has few spontaneous remissions   Inverse psoriasis is characterized by lesions in the skin folds. Because of the moist nature of these areas, the lesions tend to be erythematous plaques with minimal scale. Common locations include the axil-lary, genital, perineal, intergluteal, and inframammary areas. Flexural surfaces such as the antecubital fossae can exhibit similar lesions. 3 Psoriasis is universal in occurrence how ever different population varies from 0.1 percent to 11.8 percent. Psoriasis may begin at any age, but is uncommon under age 10 years. It most likely appears 15-30 years. It certain HL-A CW6 antigen carier from family. Psoriasis is a chronic inflammation skin deases with a strong genetic basic characteristic by complex dermal growth epidermal diferentation and multiple biochemical, immunologic, vascular abnormality. It caused poor keratinocyte. 4  Initial lesion in the pin head sized macular lesion there marked edema, and monoclear cell inflarates are found in the upper dermis. the overlying epidermis soon becomes spogiotic with the focal loss of the granular layyer. 4  Plaque  psoriasis is the most common form, affect-ing approximately 80% to 90% of  patients. The vast majority of all high-quality and regulatory clinical trials in  psoriasis have been conducted on patients with this form of psoriasis. Plaque  psoriasis manifests as well-defined, sharply demarcated, erythematous plaques varying in size from 1 cm to several centi-meters These clinical findings are mirrored histologically by psoriasiform epidermal hyperplasia, parakeratosis with intracorneal neutro-phils, hypogranulosis, spongiform pustules, an infiltrate of neutrophils and lymphocytes in the epidermis and dermis, along with an expanded dermal papillary vasculature. Patients may have involvement ranging from only a few plaques to numerous lesions covering almost the entire body surface. The  plaques are irregular, round to oval in shape, and most often located on the scalp, trunk, buttocks, and limbs, with a predilection for extensor surfaces such as the    3   elbows and knees. Smaller plaques or papules may coalesce into larger lesions, especially on the legs and trunk. Painful fissuring .3  in case we find the lesion at regio thorax posterior patch demarcated hypopigmented with firm boundaries,  plaque size, the number of multiple over rough scaly lesions found generalized distribution premises and on regio extrimitas superior patch demarcated hypopigmented with firm boundaries, plaque size, the number of multiple over smooth scaly lesions found generalized distribution premises with the chief complaint Itch and red spot on the back side around the body and hand. itchy sensation. The red spott were getting bigger 4 months ago. In the first of the symptom start with a small of white lesion with the severe itching then the patient starching the lesion every time until the last month before she goes to polyclinic the lesion begin a red spot with the bigger plaque. The patient admitted she had ever felt like this condition 5 year ago. Combination of topical therapies Since all topical medications for the treatment of psoriasis have limitations, combination regimens, utilizing medications from different categories, have been studied and shown to be  potentially beneficial. 5  Corticosteroids and salicylic acid The combination of topical corticosteroids and salicylic acid may be valuable because of the ability of salicylic acid to enhance the efficacy of corticosteroids by increasing penetration. To ensure that there is not an increase in steroid toxicities when adding salicylic acid to topical corticosteroid preparations, it is recommended that this combination belimited to no more than medium-potency (class 3-4) topical corticosteroids. The strength of recommendations for the treatment of psoriasis using topical corticosteroids and salicylic acid. 6  Corticosteroids and vitamin D analogues The combination of topical corticosteroids and vitamin D analogues appears to be more efficacious than either therapy alone, with fewer side effects noted in most, but not all, studies. This point has been demonstrated for several different corticosteroid - calcipotriol combinations (please also see prior section on combination calcipotriene/betamethasone ointment). The strength of recommendations for the treatment of psoriasis using topical corticosteroids and vitamin D analogues. 5      4   Corticosteroids and tazarotene Owing to the potential irritancy of topical tazarotene, adding topical corticosteroids to a regimen of tazarotene is an appropriate option. In fact, one study has shown that the combination of tazarotene and either mid- or high-potency topical corticosteroid is more effective than therapy with tazarotene alone; however, this study did not determine if tazarotene plus topical steroid is superior to topical corticosteroid alone. There may be a synergistic effect between tazarotene and topical corticosteroids as a clinical trial comparing tazarotene gel plus mometasone cream to mometasone cream alone showed superior efficacy of the combination over mometasone cream used alone both for efficacy during the therapy and for the duration of therapeutic effect. Combination therapy may increase the duration of treatment benefit as well as length of remission. Another potential advantage of using combination tazarotene and topical corticosteroid is potential decrease in steroid-induced atrophy. The strength of recommendations for the treatment of psoriasis using topical corticosteroids and tazarotene. 6 in that case we find the   Patients received systemic and topical therapy when she get on the polyclinic of dermatology RSUZA Banda Aceh as follow up of the patient is on the bellow:    S/ -Itch and red spot on the back side around the body and hand -Stress - BMI >30 (obesity)    O/ - Status of Dermatology: At regio: thorax posterior patch demarcated hypopigmented with firm boundaries, plaque size, the number of multiple over rough scaly lesions found generalized distribution premises. At regio: extrimitas superior patch demarcated hypopigmented with firm boundaries, plaque size, the number of multiple over smooth scaly lesions found generalized distribution premises
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