The scaling develops when the cells push to the surface of the skin faster than they can be shed, causing them to dry out and harden. Because the underlying cells have not yet matured into the enclosed outer layer of skin, called the stratum corneum , the capillaries just below remain largely unprotected. If scales are removed prematurely, they can rupture the still-developing tissues along with the walls of the capillaries. Diagnosis The Auspitz sign is diagnosed by visual inspection.
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In this study 2 the Auspitz sign was present in only 41 of patients with psoriasis. The frequent absence of the Auspitz sign in psoriasis indicates a lack of sensitivity, whereas its occurrence in other diseases indicates a lack of specificity. Psoriasis is a chronic proliferative and inflammatory condition of the skin 3. Psoriasis is characterized by erythematous plaques covered with silvery scales particularly over the extensor surfaces, scalp, and lumbosacral region 4.
Psoriasis can also affect the joints and eyes. Psoriasis has no cure and the disease waxes and wanes with flareups. Many patients with psoriasis develop depression as the quality of life is poor. There are several subtypes of psoriasis but the plaque type is the most common and presents on the trunk, extremities, and scalp. Close examination of the plaques usually reveals white silvery scales.
In general, the eye is rarely involved alone; it is almost always associated with skin features. It can start at any age including childhood, with peaks of onset at 15—25 years and 50—60 years. It tends to persist lifelong, fluctuating in extent and severity. It is particularly common in Caucasians but may affect people of any race. About one-third of patients with psoriasis have family members with psoriasis. The cause of psoriasis is multifactorial.
Psoriasis is classified as an immune-mediated inflammatory disease 5. Genetic factors are important. This major histocompatibility complex is not associated with arthritis, nail dystrophy or late-onset psoriasis. Theories about the causes of psoriasis need to explain why the skin is red, inflamed and thickened. Figure 1. Auspitz sign Footnote: Dermoscopy of psoriatic plaque showing white scales with regularly distributed dotted vessels on a light erythematous background.
Psoriasis treatments reduce inflammation and clear the skin. Treatments can be divided into three main types: topical treatments, light therapy and systemic medications.
There are benefits from not smoking, avoiding excessive alcohol and maintaining optimal weight. Treatment considerations Although doctors choose treatments based on the type and severity of psoriasis and the areas of skin affected, the traditional approach is to start with the mildest treatments — topical creams and ultraviolet light therapy phototherapy — in those patients with typical skin lesions plaques and then progress to stronger ones only if necessary.
Patients with pustular or erythrodermic psoriasis or associated arthritis usually need systemic therapy from the beginning of treatment. The goal is to find the most effective way to slow cell turnover with the fewest possible side effects. Topical treatments Used alone, creams and ointments that you apply to your skin can effectively treat mild to moderate psoriasis.
When the disease is more severe, creams are likely to be combined with oral medications or light therapy. Topical psoriasis treatments include: Topical corticosteroids. These drugs are the most frequently prescribed medications for treating mild to moderate psoriasis.
They reduce inflammation and relieve itching and may be used with other treatments. Mild corticosteroid ointments are usually recommended for sensitive areas, such as your face or skin folds, and for treating widespread patches of damaged skin.
Your doctor may prescribe stronger corticosteroid ointment for smaller, less sensitive or tougher-to-treat areas. Long-term use or overuse of strong corticosteroids can cause thinning of the skin.
Topical corticosteroids may stop working over time. Vitamin D analogues. These synthetic forms of vitamin D slow skin cell growth. Calcipotriene Dovonex is a prescription cream or solution containing a vitamin D analogue that treats mild to moderate psoriasis along with other treatments.
Calcipotriene might irritate your skin. Calcitriol Vectical is expensive but may be equally effective and possibly less irritating than calcipotriene. This medication helps slow skin cell growth. Anthralin Dritho-Scalp can also remove scales and make skin smoother. But anthralin can irritate skin, and it stains almost anything it touches. Topical retinoids. These are vitamin A derivatives that may decrease inflammation.
The most common side effect is skin irritation. These medications may also increase sensitivity to sunlight, so while using the medication apply sunscreen before going outdoors. The risk of birth defects is far lower for topical retinoids than for oral retinoids. Calcineurin inhibitors. Calcineurin inhibitors — tacrolimus Prograf and pimecrolimus Elidel — reduce inflammation and plaque buildup. Calcineurin inhibitors are not recommended for long-term or continuous use because of a potential increased risk of skin cancer and lymphoma.
They may be especially helpful in areas of thin skin, such as around the eyes, where steroid creams or retinoids are too irritating or may cause harmful effects. Salicylic acid. Available over-the-counter nonprescription and by prescription, salicylic acid promotes sloughing of dead skin cells and reduces scaling.
Salicylic acid is available in medicated shampoos and scalp solutions to treat scalp psoriasis. Coal tar. Derived from coal, coal tar reduces scaling, itching and inflammation. Coal tar can irritate the skin. Coal tar is available in over-the-counter shampoos, creams and oils. Moisturizers in an ointment base are usually more effective than are lighter creams and lotions. Apply immediately after a bath or shower to lock in moisture. Light therapy phototherapy This treatment uses natural or artificial ultraviolet light.
The simplest and easiest form of phototherapy involves exposing your skin to controlled amounts of natural sunlight. Other forms of light therapy include the use of artificial ultraviolet A UVA or ultraviolet B UVB light, either alone or in combination with medications. Exposure to ultraviolet UV rays in sunlight or artificial light slows skin cell turnover and reduces scaling and inflammation. Brief, daily exposures to small amounts of sunlight may improve psoriasis, but intense sun exposure can worsen symptoms and cause skin damage.
Before beginning a sunlight regimen, ask your doctor about the safest way to use natural sunlight for psoriasis treatment. UVB phototherapy. Controlled doses of UVB light from an artificial light source may improve mild to moderate psoriasis symptoms.
UVB phototherapy, also called broadband UVB, can be used to treat single patches, widespread psoriasis and psoriasis that resists topical treatments. Short-term side effects may include redness, itching and dry skin. Using a moisturizer may help decrease these side effects. Narrow band UVB phototherapy. Narrow band UVB phototherapy may cause more-severe and longer lasting burns, however. Goeckerman therapy. Some doctors combine UVB treatment and coal tar treatment, which is known as Goeckerman treatment.
The two therapies together are more effective than either alone because coal tar makes skin more receptive to UVB light. This form of photochemotherapy involves taking a light-sensitizing medication psoralen before exposure to UVA light. This more aggressive treatment consistently improves skin and is often used for more-severe cases of psoriasis. Short-term side effects include nausea, headache, burning and itching. Long-term side effects include dry and wrinkled skin, freckles, increased sun sensitivity, and increased risk of skin cancer, including melanoma.
Excimer laser. This form of light therapy, used for mild to moderate psoriasis, treats only the involved skin without harming healthy skin. A controlled beam of UVB light is directed to the psoriasis plaques to control scaling and inflammation. Excimer laser therapy requires fewer sessions than does traditional phototherapy because more powerful UVB light is used.
Side effects can include redness and blistering. This is known as systemic treatment. Because of severe side effects, some of these medications are used for only brief periods and may be alternated with other forms of treatment.
Side effects may include lip inflammation and hair loss. And because retinoids such as acitretin Soriatane can cause severe birth defects, women must avoid pregnancy for at least three years after taking the medication. Taken orally, methotrexate Rheumatrex helps psoriasis by decreasing the production of skin cells and suppressing inflammation. It may also slow the progression of psoriatic arthritis in some people. Methotrexate is generally well-tolerated in low doses but may cause upset stomach, loss of appetite and fatigue.
When used for long periods, it can cause a number of serious side effects, including severe liver damage and decreased production of red and white blood cells and platelets. Cyclosporine Gengraf, Neoral suppresses the immune system and is similar to methotrexate in effectiveness, but can only be taken short-term. Like other immunosuppressant drugs, cyclosporine increases your risk of infection and other health problems, including cancer.
Cyclosporine also makes you more susceptible to kidney problems and high blood pressure — the risk increases with higher dosages and long-term therapy. Drugs that alter the immune system biologics.
Medical College, Dr. E-mail: moc. This article has been corrected. See Indian Dermatol Online J.
Auspitz sign is not sensitive or specific for psoriasis.
An Overview of the Auspitz Sign