Psoriasis

Psoriasis is much more than just a skin condition.  It is actually a life-long disease of the immune system that, in addition to causing skin lesions, is associated with a number of other health issues including arthritis, depression, and an increased risk of heart disease and diabetes. Psoriasis affects around 7.5 million Americans, with most people developing their initial symptoms in young adulthood.
 
Types of psoriasis. There are five types of psoriasis with each type affecting the skin in a different manner. The most common of these, affecting approximately 80%, is called “plaque psoriasis”.  In this type, skin lesions appear as raised, red patches (plaques) covered with a silvery white buildup of dead skin cells (scale).   Other less common types of psoriasis are named guttate, pustular, inverse and erythodermic.  Guttate psoriasis is the second most common type of psoriasis, occurring in 10% of cases. This type often starts in childhood or young adulthood following a streptococcal (strep) infection.  Erythrodermic is a rare form of psoriasis but is considered to be a dermatological emergency.

What causes the skin lesions?  For reasons yet to be determined, psoriasis triggers an inflammatory response from the immune system  that causes skin cells to reproduce more rapidly than normal.  Instead of taking around a month to mature, skin cells mature in a matter of days. This causes them to “pile up”, forming the characteristic thickened, scaly rash.  The most common locations for the skin lesions are the outside of knees and elbows, the scalp, the lower back, the face, the palms and soles of feet. The rash can also appear on the fingernails, toenails, the genitals and inside the mouth.

Psoriasis Triggers.   Psoriasis is characterized by flare-ups and remissions.  Typically the initial outbreak as well as later flare-ups occurs as a result of a trigger.  Some of the most common triggers are:

• Infection---Commonly reported infections that have caused flare-up include those caused by yeast (candida albicans), staphylococcal skin infections (boils), streptococcal pharyngitis (strep throat) and viral upper respiratory infections.
   
• Reaction to Certain Medications –Antimalarial drugs (especially Plaquenil), lithium and some blood pressure medications have been associated with outbreaks of psoriasis.
    
• Skin Injury---Even minor injuries, such as bug bites or scratching can lead to a psoriasis flare.
   
• Stress---Most likely due to the effect of stress on the immune system.
   
• Cold weather
   
• Others--- (smoking, heavy alcohol consumption)

Risk for other medical conditions.  People with severe psoriasis are around 50% more likely than the general population to have a heart attack, stroke, or to develop Type 2 diabetes. Psoriasis patients also have a higher incidence of inflammatory bowel disease, certain types of cancer (lymphoma and skin cancer), and depression. Because of the increased risk of diabetes and cardiovascular disease, it is important that people with psoriasis keep their weight, blood pressure, and cholesterol level in an acceptable range, and receive screening for diabetes.  Additionally, a serious form of arthritis (psoriatic arthritis) develops in approximately 30% of people with psoriasis.  Features of psoriatic arthritis include stiffness, pain and swelling of the joints and abnormalities of the finger and toe nails.
 
How is psoriasis treated?   Psoriasis is a life-long condition with no cure currently available. There are, however, a number of treatments that can reduce flare-ups of the rash.  The main goal of treatment is to slow the growth of skin cells.  This treatments fall into 3 categories:

• Topical (applied to the skin) –  Used primarily in mild-to-moderate cases of psoriasis, topicals include coal tar, corticosteroids, a vitamin A derivative, tazarotene (Tazorac, Avage) and a synthetic form of vitamin D, calcipotriene (Dovonex)).
   
• Phototherapy---Exposing the skin lesions to a type of ultraviolet light (UVB) slows the growth of new skin cells.  A second type of phototherapy “PUVA” combines ultraviolet light with a medication called psoralen. Phototherapy is used in moderate-to-severe cases.
   
• Systemic (taken orally or by injection or infusion) – Usually reserved for severe cases of psoriasis, these medications include cyclosporine, methotrexate and a new class of medications called immunomodulators.  The immunomodulators include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira) and ustekinumab (Stelara).  The systemic medications work by suppressing or modulating the immune system. 

Since treatment must be individualized and there are a number of potential side effects associated with psoriasis therapies, it is recommended that treatment be initiated and supervised by a Dermatologist.

The Great American Smokeout, November 20

Recent statistics indicate that over 46 million Americans still smoke despite widespread knowledge that tobacco use is a leading cause of disease and premature death. However, of these, almost 70% would like to quit. Why don’t they? Because most smokers find smoking to be pleasurable and nicotine is one of the most addicting drugs around. Being addicted does not mean that it is impossible to stop smoking, but it does means that there are powerful urges and needs that have to be overcome in order to do so. Many ex-smokers say quitting was the hardest thing that they ever had to do.  If they were able to do it, so can you, your friend, or family member. Let’s look at some of the reasons to quit smoking.

In regular or heavy smokers, stopping smoking can produce almost immediate beneficial effects.  The benefits derived from long-term cessation, however, have the greatest positive impact on health. Look at a few of the benefits from stopping smoking reported by the Centers for Disease Control and the U.S. Surgeon General:

• Within twenty minutes of quitting, your heart rate and blood pressure drop to a more normal level.
   
• Twelve hours after quitting, carbon monoxide and nicotine related to smoking is eliminated from the body.
   
• A few months after quitting, the senses of taste and smell improve and breathing comes more easily with less coughing.
   
• By one year of quitting, the additional risk imposed by cigarette smoking on the development of heart disease is cut in half.
   
• Five years after quitting the risk of stroke risk reverts to that of a person who had never smoked. The risk of developing cancer of the mouth, throat, esophagus, and bladder is cut in half.
   
• Ten years after quitting the risk of dying from lung cancer is about half that of a person who is still smoking.
   
• Fifteen years after quitting the risk of coronary heart disease is that of a non-smoker.

Along with the health benefits, wouldn’t it be nice not to worry about where and when you can light up legally or if you are offending someone?  Wouldn’t it be nice to have the money spent on cigarettes to use for something else?


Those are a few of the personal reasons for quitting. But what about the impact of smoking on others?  It is now well known that even a little second-hand smoke is dangerous. Second-hand smoke is linked to the development of certain cancers, breathing problems, and heart disease in non-smokers. People who breathe second-hand smoke get colds and flu more easily. Children who breathe second-hand smoke are much more likely to develop asthma and are more likely to have ear and lung infections, including pneumonia. It is now recognized that pregnant women who smoke or breathe second-hand smoke are more likely to have stillbirths, low birth weight babies, and babies who die of Sudden Infant Death Syndrome (SIDS).

If that’s not enough rationale to convince you to quit smoking, consider that there are more than 7,000 chemicals in cigarette smoke. Some of these chemicals are also found in paint thinners (toluene), embalming fluid (formaldehyde), and chemical weapons (hydrogen cyanide).

Set a quit date and choose a quit plan.   Many tobacco users choose the day known as the Great American Smokeout to quit smoking.  This year, the American Cancer Society has designated it to be November 20. Click on this link to the American Cancer Society for tips and tools to help you quit or contact us at eDocAmerica for more suggestions.

More "Stuff That Works" --- Effective Home Remedies

“Stuff that works, stuff that holds up
The kind of stuff you don't hang on the wall
Stuff that's real, stuff you feel
The kind of stuff you reach for when you fall”
Guy Clark---“Stuff that Works”;

Regular readers of our Health Tips may remember a previous edition of “Stuff That Works” that described several simple, yet effective home remedies.  In addition to being time-honored methods of self-treatment, these have also received varying degrees of research or scientific validation.

1. Use a tennis ball for heel pain. Plantar fasciitis is a painful condition caused by inflammation of a band of tissue that runs along the bottom of the foot near the heel. Its most common symptom is pain at the bottom of the heel when taking the first few steps out of bed in the morning. Since tightness of the muscles and tendons connecting with the foot can contribute to this problem, stretching is one of several modalities used to treat plantar fasciitis. One effective way to stretch and massage the area of the plantar fascia involves the use of a tennis ball.  Placing a tennis ball on the ground and gently rolling it under foot for a few minutes helps to loosen up the plantar fascia and relieve inflammation.
    
2. Wash away poison ivy.  Poison ivy rash develops when the allergenic oil from the poison ivy plant (urushiol) comes in contact with the skin of an allergic individual.  By removing the oil from the skin soon after exposure, the allergic reaction can be avoided or reduced in severity.  A common dishwashing detergent (Dial) was compared to a commercial oil-removing product (Tecnu) and found to be nearly as effective, at a much lower cost.  The sooner that washing occurs following exposure, the more likely the rash will be prevented.
    
3. Take ginger for motion sickness. Ginger is a tropical plant whose rhizome (underground stem) is used primarily as a spice in cooking. Ginger has long been used as an alternative medication to prevent motion sickness, although the exact way that it works is not known.   Studies have been inconsistent on how well ginger works, but many have shown a positive effect in preventing nausea from chemotherapy, motion sickness, post-surgical vomiting, and sea sickness.  Various preparations including powdered ginger in capsules, crystallized ginger, and ginger powder mixed in water have been used effectively.
    
4. Soak in oatmeal for eczema.  Colloidal oatmeal (oats that have been ground into a fine powder) has been used for decades for a variety of skin conditions including eczema, allergic dermatitis, and excessively dry skin.  Many studies have confirmed the anti-inflammatory, moisturizing, and reparative properties of oatmeal.  An oatmeal bath can be made by adding colloidal oatmeal (available commercially) directly to bathwater or by placing a cup of oatmeal into a muslin bag or handkerchief and letting it float in the bathtub. Soaking in the bath for at least 15 minutes is the recommended period of time to allow the oatmeal to work.
    
5. Elevate the head of the bed for reflux.  Gastroesophageal reflux disease (GERD) is a condition in which digestive juices reflux (back up) from the stomach into the esophagus.  GERD is a common cause for heartburn, noted particularly when someone with this condition lies down to go to sleep.  With the help from “gravity”, however, it is possible to keep digestive juices in the stomach where they belong.  Placing 4 to 8 inch blocks beneath the legs at the head of the bed will elevate the head so that stomach acid is prevented from backing up into the esophagus.  Another self-care measure for managing this condition is to avoid certain foods that contribute to reflux. These foods include citrus fruits, peppermint, caffeinated or alcoholic beverages, chocolate, garlic, onions, and tomato-containing foods.
    
6. Drink cranberry juice to prevent bladder infections. Cranberries won’t cure a urinary tract infection (UTI), but they may help prevent UTI from occurring in someone prone to bladder infections.  Cranberries for preventing UTIs have been studied primarily in women since women are the most likely group to experience recurrent bladder infections. At one time, it was thought that by making the urine more acidic, cranberry juice made it difficult for bacteria such as E. coli to reproduce. More recently, it has been found that chemicals in cranberries keep bacteria from multiplying by preventing them from sticking to the bladder walls.  Studies have been performed using both cranberry juice and cranberry extract tablets or capsules, but the best preparation or dosage has not yet been determined.  Eight ounces of cranberry juice cocktail taken twice daily or capsules containing 500 mg of cranberry extract are two of the sources of cranberries that have been tested.
    
7. Apply Vicks for nail fungus.  Admittedly, this home remedy has less scientific validation than the others, but there is a great deal of information in the lay press regarding the use of Vicks VapoRub in the treatment of toenail fungus (onychomycosis).  Vicks VapoRub is an ointment containing camphor, eucalyptus oil, and menthol.  When rubbed on the chest, it is primarily intended to help with cough due to the common cold.  In the single study that I found testing its effectiveness in the treatment of nail fungus, 15 (83%) of the 18 participants enrolled in this study, showed a positive treatment effect with the use of VapoRub.  After 48 weeks of treatment with VapoRub, 5 were found to have complete cure of their fungus.  When you consider that none of the current medication treatments can assure 100% effectiveness and that many of the medications currently used have serious side effects, this method may become a reasonable treatment alternative. 

Look for more “Stuff that Works” in the future.

What is a goiter and what do you do about it?

A goiter is not a specific disease, but is a term used to describe an enlarged thyroid gland.  The thyroid gland is a small butterfly-shaped gland located at the base of the front of the neck. It secretes hormones that help in the regulation of a number of functions in the body including heart rate, body temperature, and metabolism.

Are all goiters the same?  Goiters can be very different, both in terms of their cause as well as their seriousness.  They can be so small as to only be detected during physical examination or large enough to be seen protruding from the lower neck. They can develop for no apparent reason, or be associated with other diseases. They can lead to an overproduction or an underproduction of thyroid hormones or be present in someone with normal thyroid function.  Some of the reasons for enlargement of the thyroid gland are:   

• Simple goiter. These can occur without a known cause.   They can also develop when the thyroid gland is unable to make enough thyroid hormone to meet the body’s needs.  One reason for this is a diet deficient in iodine, since iodine is necessary for the production of thyroid hormones.   Without an adequate supply of iodine, the thyroid becomes larger in order to increase its production of thyroid hormone.  The addition of iodine to salt in the 1920’s has markedly reduced the occurrence of this type of goiter in the U.S.
   
• Multinodular goiter is associated with several small growths called nodules that develop inside the thyroid gland.   In many cases, one or more of these nodules will produce an excess of thyroid hormone.
   
• Graves’ disease is an autoimmune disease in which antibodies produced by the immune system mistakenly attack the thyroid gland.   This results in swelling of the thyroid gland and an overproduction of thyroid hormone (hyperthyroidism).
   
• Hashimoto’s disease. This is another autoimmune disease that causes inflammation and swelling of the thyroid gland.  Hashimoto’s disease is typically associated with an underproduction of thyroid hormone (hypothyroidism).
   
• Thyroid cancer is the most serious reason for enlargement of the thyroid gland. Typically this will appear as an enlargement of only one side (lobe) of the thyroid gland.

What are the symptoms of goiter?  Symptoms associated with a goiter can be due to the physical size of the goiter or due to the effects of too high or too low levels of thyroid hormone.  Visually, a goiter may appear as a swelling in the front of the neck.   As the goiter gets larger, it can compress the trachea (windpipe) and esophagus (swallowing tube). This can cause a tight feeling in the throat, coughing, difficulty swallowing, hoarseness, and shortness of breath.  Symptoms of thyroid hormone deficiency (hypothyroidism) include fatigue, constipation, dry skin, weight gain and menstrual irregularities.   Symptoms of excess thyroid hormone production (hyperthyroidism) include rapid heartbeat, diarrhea, shaking, sweating, and heat intolerance.  
 
How are goiters diagnosed?  Once a goiter is discovered, the next step in its evaluation is to determine what is responsible for the thyroid enlargement. This can require several types of tests, since there are a number of reasons why the thyroid could be enlarged.  Blood tests for thyroid function testing can tell the doctor if the thyroid is over-producing or under-producing thyroid hormone. Antibody tests look for evidence of an autoimmune disorder.  Imaging tests including ultrasound and a radioactive scan of the thyroid can provide information about the size and possible presence of nodules.  A CT or MRI scan may be needed to assess the size and nature of any nodules or masses. A fine-needle aspiration may be used to further evaluate a nodule or mass suspected of being cancer. 
 
How is goiter treated?  Treatment of the goiter depends primarily on the underlying cause for the thyroid enlargement. In situations in which there is no apparent cause for the goiter, the thyroid functions are normal, and the patient has no symptoms due to the goiter, the best approach is usually to monitor the thyroid enlargement periodically without treating. Other ways to manage a goiter include:

• Medications.  If iodine deficiency is the cause for the goiter, using iodinized salt will lead to shrinking of the thyroid.  Thyroid hormone replacement pills (Levothroid®, Synthroid®), can reduce the size of the goiter if it is due to underactive thyroid production. For goiters associated with an excess of thyroid hormone, anti-thyroid medications (eg, PTU, methimazole) or medications to reduce hyperthyroid symptoms (e.g. beta blockers) may be used while awaiting a more permanent treatment.
   
• Radioactive iodine destroys thyroid cells and is used primarily for goiters that are producing an excessive amount of thyroid hormone.  Multinodular goiters or a goiter associated with Graves’ disease could fall into this category. This treatment is effective in reducing the size of the goiter, but may also destroy so much of the thyroid that thyroid replacement becomes necessary.
   
• Surgery. This treatment is typically used only with large goiters that are causing symptoms due to compression of the trachea or esophagus, or when the goiter is due to cancer.

From this discussion, it is obvious that there are a number of possible causes for goiters and there is no “one size fits all” treatment.  Since goiters can range from being totally benign to life-threatening, it is important that the specific underlying cause is determined so that the most appropriate treatment (if treatment is necessary) can be provided.