HERPES ZOSTER

Shingles (herpes zoster) is a painful, blistering skin rash due to the varicella-zoster virus, the virus that causes chickenpox. It usually clears up in 2 to 3 weeks and rarely returns.

INCIDENCE

CAUSES
After you get chickenpox, the virus remains inactive (becomes dormant) in certain nerves in the body. Shingles occurs after the virus becomes active again in these nerves years later. The reason the virus suddenly becomes active again is not clear. Often only one attack occurs.

RISK FACTORS
Shingles may develop in any age group, but you are more likely to develop the condition if:

You are older than 60 You had chickenpox before age 1 Your immune system is weakened by medications or disease

SYMPTOMS one-sided pain tingling

burning red patches on the skin, followed by small blisters, form in most people the blisters break, forming small sores that begin to dry and form crusts. The crusts fall off in 2 to 3 weeks. Scarring is rare.

 the rash usually involves a narrow area from the spine around to the front of the belly area or chest. Also it may involve the face, eyes, mouth, and ears. Other symptoms may include:

Abdominal pain Fever and chills General ill feeling Genital sores Headache Joint pain Swollen glands (lymph nodes)

Difficulty moving some of the muscles in the face Drooping eyelid (ptosis) Hearing loss Loss of eye motion Taste problems Vision problems

SIGNS AND TESTS

Blood tests (may show an increase in white blood cells and antibodies to the chickenpox virus)

TREATMENT

Antiviral drug (helps reduce pain, prevent complications, and shorten the course of the disease) eg. Acyclovir, famciclovir, and valacyclovir. It is best to start taking them before the blisters appear Corticosteroids eg. prednisone (may be used to reduce swelling and pain) Antihistamines to reduce itching (taken by mouth or applied to the skin) Pain medicines Zostrix, a cream containing capsaicin (an extract of pepper) that may reduce the risk of postherpetic neuralgia Cool wet compresses can be used to reduce pain. Soothing baths and lotions, such as colloidal oatmeal bath, starch baths, or calamine lotion, may help to relieve itching and discomfort. Bed rest Keep the skin clean. Wash nondisposable items in boiling water or disinfect them before using them again Keep away from people while the sores are oozing to avoid infecting those who have never had chickenpox -- especially pregnant women.

COMPLICATIONS

Another attack of shingles Bacterial skin infections Blindness (if shingles occurs in the eye) Deafness Infection, including encephalitis or sepsis (blood infection) in persons with a weakened immune system Ramsay Hunt syndrome if shingles affects the nerves in the face

PREVENTION
Avoid touching the rash and blisters on persons with shingles or chickenpox if you have never had chickenpox or the chickenpox vaccine. Herpes zoster vaccine is available. It is different than the chickenpox vaccine. Older adults who receive the herpes zoster vaccine are less likely to have complications from shingles.

PSORIASIS
Psoriasis is a common skin condition that causes skin redness and irritation. Most people with psoriasis have thick, red skin with flaky, silver-white patches called scales. It is not contagious. You cannot spread it to others. Psoriasis is a life-long condition that can be controlled with treatment. It may go away for a long time and then return.

INCIDENCE
very common most commonly begins between ages 15 and 35 around one-third of people with psoriasis report a family history of the disease onset before age 40 usually indicates a greater genetic susceptibility

CAUSE

The cause of psoriasis is not fully understood There are two main hypotheses about the process that occurs in the development of the disease. o The first considers psoriasis as primarily a disorder of excessive growth and reproduction of skin cells. The problem is simply seen as a fault of the epidermis and its keratinocytes. o The second hypothesis sees the disease as being an immune-mediated disorder in which the excessive reproduction of skin cells is secondary to factors produced by the immune system. T cells (which normally help protect the body against infection) become active, migrate to the dermis and trigger the release of cytokines (tumor necrosis factoralpha) which cause inflammation and the rapid production of skin cells. It is not known what initiates the activation of the T cells.

RISK FACTORS

Bacteria or viral infections, including strep throat and upper respiratory infections Dry air or dry skin Injury to the skin, including cuts, burns, and insect bites Some medicines, including antimalaria drugs, beta-blockers, and lithium Stress Too little sunlight Too much sunlight (sunburn) Too much alcohol AIDS Autoimmune disorders (such as rheumatoid arthritis) Cancer chemotherapy

TYPES OF PSORIASIS
There are five main types of psoriasis:

Erythrodermic: The skin redness is very intense and covers a large area. Guttate: Small, pink-red spots appear on the skin. Inverse: Skin redness and irritation occurs in the armpits, groin, and in between overlapping skin. Plaque: Thick, red patches of skin are covered by flaky, silver-white scales. This is the most common type of psoriasis. Pustular: White blisters are surrounded by red, irritated skin.

PATHOPHYSIOLOGY
Usually, skin cells grow deep in the skin and rise to the surface about once a month. In persons with psoriasis, this process is too fast. Dead skin cells build up on the skin's surface.

SYMPTOMS
appear suddenly or slowly red patches on the scalp, elbows, knees, and middle of the body pruritis silver, flaky scales genital lesions in males joint pain or aching nail changes: thick nails, yellow-brown nails, dents in the nail, and nail lifts off from the skin underneath severe dandruff on the scalp

DIAGNOSIC EVALUATION

biopsy will show clubbed rete pegs if positive for psoriasis when the plaques are scraped, one can see pinpoint bleeding from the skin below (Auspitz's sign)

MANAGEMENT
MEDICAL TREATMENTS Cortisone creams and ointments Creams or ointments that contain coal tar or anthralin Creams to remove the scaling (usually salicylic acid or lactic acid) Dandruff shampoos (over-the-counter or prescription) Moisturizers Prescription medicines containing vitamin D or vitamin A (retinoids) Adalimumab (Humira) Alefacept (Amevive) Etanercept (Enbrel) Infliximab (Remicade) Stelara Phototherapy can be given as ultraviolet A (UVA) or ultraviolet B (UVB) light Oatmeal baths may be soothing and may help to loosen scales. over-thecounter oatmeal bath products Or, mix 1 cup of oatmeal into a tub of warm water

COMPLICATIONS

Arthritis Pain Severe itching Secondary skin infections Side effects from medicines used to treat psoriasis Skin cancer from light therapy

PREVENTION
There is no known way to prevent psoriasis. Keeping the skin clean and moist and avoiding your specific psoriasis triggers may help reduce the number of flare-ups. Doctors recommend daily baths or showers for persons with psoriasis. Avoid scrubbing too hard, because this can irritate the skin and trigger an attack.

SEBORRHEIC DERMATITIS
AKA Dandruff; Seborrheic eczema; Cradle cap Seborrheic dermatitis is a common, inflammatory skin condition that causes flaky, white to yellowish scales to form on oily areas such as the scalp or inside the ear. It can occur with or without reddened skin. Cradle cap is the term used when seborrheic dermatitis affects the scalp of infants.

INCIDENCE CAUSES
Seborrheic dermatitis is thought to be due to a combination of an over production of skin oil and irritation from a yeast called malassezia Seborrhoeic dermatitis is caused by seborrhea, a pathologic overproduction of sebum, and subsequent infection and inflammation Seborrheic dermatitis appears to run in families.

RISK FACTORS
Stress Fatigue Weather extremes Oily skin Infrequent shampoos or skin cleaning Use of lotions that contain alcohol Skin disorders (such as acne) Obesity Neurologic conditions:Parkinson's disease, head injury, and stroke may be associated with seborrheic dermatitis. Human immunodeficiency virus (HIV) has also been linked to increased cases of seborrheic dermatitis.

SYMPTOMS
Seborrheic dermatitis can occur on many different body areas. Usuallky it forms where the skin is oily or greasy. Commonly affected areas include the scalp, eyebrows, eyelids, creases of the nose, lips, behind the ears, in the outer ear, and middle of the chest. Seborrheic dermatitis in infants, also called cradle cap, is a harmless, temporary condition. It appears as thick, crusty, yellow or brown scales over the child's scalp. Similar scales may also be found on the eyelids, ear, around the nose, and in the groin. Cradle cap may be seen in newborns and small children up to age 3 . Cradle cap is not contagious, nor is it caused by poor hygiene. It is not an allergy, and it is not dangerous. Cradle cap may or may not itch. If it itches, excessive scratching of the area may cause additional inflammation, and breaks in skin may cause mild infections or bleeding. In general, symptoms of seborrheic dermatitis include:

Skin lesions Plaques over large area Greasy, oily areas of skin Skin scales -- white and flaking, or yellowish, oily, and adherent -"dandruff" Itching -- may become more itchy if infected Mild redness Hair loss

SIGNS AND TESTS

The diagnosis is based on the appearance and location of the skin lesions.

TREATMENT
You can treat flaking and dryness with over-the-counter dandruff or medicated shampoos. Shampoo the hair vigorously and frequently (preferably daily). Loosen scales with the fingers, scrub for at least 5 minutes, and rinse thoroughly. Active ingredients in these shampoos include salicylic acid, coal tar, zinc, resorcin, ketoconazole, or selenium.

Shampoos or lotions containing selenium, ketoconazole, or corticosteroids may be prescribed for severe cases. To apply shampoos, part the hair into small sections, apply to a small area at a time, and massage into the skin. If on face or chest, apply medicated lotion twice per day. Recently, creams classified as topical immune modulators are being used. Seborrheic dermatitis may improve in the summer, especially after outdoor activities. For infants with cradle cap: 1. Massage your baby's scalp gently with your fingers or a soft brush to loosen the scales and improve scalp circulation. 2. Give your child daily, gentle shampoos with a mild soap while scales are present. After scales have disappeared, you may reduce shampoos to twice weekly. 3. Be sure to rinse off all soap. 4. Brush your child's hair with a clean, soft brush after each shampoo and several times during the day. 5. If scales do not easily loosen and wash off, apply some mineral oil to the baby's scalp and wrap warm, wet cloths around his head for up to an hour before shampooing. Then, shampoo as directed above. Remember that your baby loses a lot of heat through his scalp. If you use warm, wet cloths with the mineral oil, check frequently to be sure that the cloths have not become cold. Cold, wet cloths could drastically reduce your baby's temperature. 6. If the scales continue to be a problem or concern, or if you child seems uncomfortable or scratches his scalp, contact your physician. He may prescribe a cream or lotion to apply to your baby's scalp several times a day. Expectations (prognosis) Seborrheic dermatitis is a chronic (life-long) condition that can be controlled with treatment. It often has extended inactive periods followed by flare-ups. A more extreme form of this condition overlaps with psoriasis of the scalp and is called sebopsoriasis.

COMPLICATIONS

Psychological distress, low self esteem, embarrassment Secondary bacterial or fungal infections

PREVENTION
The severity of seborrheic dermatitis can be lessened by controlling the risk factors and by paying careful attention to skin care.