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I Everyone welcome back on. So a session at the moment now is with doctors. Knew to Oprah is a consultant. A dermatologist on we're looking and be looking at the psoriasis, please. As usual, put your name university in your group on where you're located. At the moment. If you got any questions, please put them in the chat. Um, keep yourself muted. If you got anything on, they want to ask a day and then, uh, raise your hand will call upon you. So without further dio on hand over to Dr Dopa, I will do it. Backs Rice is today. We'll talk about how to describe the merits rashes of any once you know what they are. So I says is very important. Is this very common, unfortunately, very, very badly managed and so useful to know about how to diagnose and manager. It's common. It's chronic. It's day happened in all ages to seven population of people, one in 50. That's a lot of people. Most people will have a first degree relative with rice is there are environmental factors such as alcohol intake, a little stress. It has the emphasize that it's not contagious because with a lot of rash is the worry off. Other people exactly catching on me after emphasized the patient of the relatives that this is not catching no contagious and it's definitely or Maliti. Now there are peaks when it happens, many late teens and in the fifties, men and women are equally affected. So I'm not actually to have a whole normal basis. 5% of those patients with prices with joint page for a cirrhotic off prophecy off, right? Okay, How did you diagnose psoriasis? Where it's red, the scale itself, the silver, and I'll show you on example of it. It is very typical. The other thing is, if well defined, that is. But when we talked about extra, we have a day. Remember, I said, that's poorly defined. Um, it's scratch it itchy, whereas this isn't itchy, often thrice is not. Get your call, and therefore you do not get scratch marks over, and therefore you don't holy to find the edges. There will be fine. It's often semester. This is the silvery stale. It's well defined. It's only extensive surfaces with rice is notorious, extensive surfaces of the elbows and the knees on basis. How do you assess psoriasis? The age Max is because if they're busy going to school, it's really going to affect whether they can attend so Serapio or whether they can put creams on their school sticky stuff. The sites themselves of visible and therefore, when you put the cream on will be visible to everyone else during the day. Sometimes it can be itching all solar, since psoriasis is within catch. Private psoriasis. Is it localize? Is it just one of two parts on the elbows? Was it generalized or they lost a lot of little ones assess the severity on how much that affects the patient states today. Activities. Now this is very important. The next one, the book body Mass Index, because recent worth of shown that the psoriatic plaques themselves may release substance is that increase your body mass index on a large proportion of patients with psoriasis will have what we call the metabolic syndrome. They'll have a raised in chilling a normal glucose. I'm in the community. It's the glucose level checked, not the insulin levels you may find with the into the level the high, in which case they need endocrine opinion. Because if you put them on a medication called metformin. It helps with insulin resistance and the body mass index drops. And that does help in this. Rice is, and there is an increased incidence of strokes and cardiac disease in psoriasis patients. Because we're not treating the metabolic syndrome adequately. So you see slices, not just a problem of the skin. It is surely a systemic problem. Dealt with a such smoking makes a big difference. Alcohol intake is a huge difference. Certain medications that just said that certain medications such a beach book makes rashes work. It's also important to know whether the these other treatments and what effect they have. There's no point in repeating the treatment has failed in the fall. And then there's get a photo car Baskin patients more likely to tolerate so two Serapio on being less risk of skin. Also, products retaining topical steroids will decrease the pigmentation of the normal skin in people of color, which may not look very nice. So you have to keep that in mind when you treat the patients certain medications of I said lithium antidepressants may make psoriasis worse. You can use the hospital, which mainly gait is problem. As I said, you're on Proctor's antimalarials non story. No, we do our very best not to give systemic steroids in psoriasis is no role for systemic steroids in psoriasis. However, you may have a patient with asthma when you have to give him steroids. Problem is, when we stop the steroids, this can lead to a a cute exacerbation of the psoriasis itself, on even what we call postural a psoriasis, which can be faithful. So you have to be very careful in prescribing systemic steroids on the withdrawal of such steroids. As we've done very slowly, you may want a tough tail it with so to therapy, to stop in exacerbation. Also, there is no role. Four strong topical steroids in psoriasis. You can ease topical steroids in the flexion is a stronger there's anti fungal way to because this is where the yeasts such a small a cc left so stopping strong topical steroids cancel, eat postule a shin so liver is catheter in the use of steroids, it's rice is how do we treat psoriasis? When we talked about expired size, the fact that the barrier was a crucial important because the barrier of the skin has multiple functions. The area of the skin is disrupted in psoriasis. It's just like a next month, and therefore you need the money and you need my striver. There's woods loss. You need the emollients for barrier methods to stop warm to us, and I take this game. You do use topical steroid, but it's often combined with between D You're tall, gossipy trial specifically made to treat psoriasis that the vitamin D L. A law. It's prescription only no particularly effective on its own. It's more effective when it's combined with a little steroid. One. My favorite, the tops. A new religion. It is the queen's that I mentioned about Protopic about Elavil. Protopic Make a Linus on back. These are like topical steroids do not because the rebound or in exacerbation ulcer nothing. They do not fill the skin. They do not cause decreased pigmentation of people of color. So they're very stable. It can be used on the face. You have to buy the patient, not have you be exposure Because of the theoretical risk of skin cancer, you're suppressing T cells so you cannot combine it. You need me now. I took about Malassezia the yeast that lives in the factions. Therefore, you use topicals irritants, rices. They have to be combined with that yeast product. They're specifically available. And in the UK, the anyone this veil. But moment is tremoring green horrible stuff. But it works really well in the factions in the groin and the exit once a day at night, you know, because these are still in areas of the body and, you know, until the skin and give them specials. Let's rice. Is that expected? Mals? That will make you a very good dermatologist. No, A bit more detail in the creepers occlusive moisturizer provide a layer of oil would stop water loss that by in consequence increase the moisture content of the stopped in Collin. Are you? Medicines are different. These are inserted into the spark, um, poorly, um, and the whole water molecules and thereby peace with water holding capacity of the scale, which is very helpful in the condition where there's water loss. What are the occlusive ones? The bar soils. You can put them in the bath. Very good lotions more closer than oil Seems like the more civil appointments of the most use it a big catheter would use them in areas like the space you can give people at me. It's a weight mints. Often you do not use on the face Now. Occlusive best leave after the patient. What they live areas. Body is important, whether they're going to work or not. Lotions can be used for the scalp and hairy areas. Creams where you want more heavy duty moisturizing anointment alike. Hands, feet, legs. Air is a really heavy duty moisturizing. Humana tens. Let's swim urea alpha hydroxy acids that was like two half it or black Harley Kassid. These are the ones molecules that retain water, and you find them in a lot of moisturizer. The capsule about using two higher concentration of alpha hydroxy aphids, as they can then cause peeling of the skin. So there's a fine balance between the humidity polities of the alpha hydroxy acids and the peeling ability at higher concentration. So they shouldn't really be about 15 topical steroid A class five according to the strength of me trying to use the mildest available because of potential side effects of skin thickening, which is what we talked about the next month. So then the mild, moderate motor for very potent, very totem. Up to six times 100 times potent are deported. It's four beats, it'll propylene and then puts him pizza, medicine, right or doctor? More meat so very useful. Those are the main ones we use in the UK border. It beats. It'll be tiring. Remember, mention the cream of eight you're on. I'm still our forties. Very short range is a specialist practice because it doesn't do much. Families for face isn't a sip child between D. L0. As I said, it's much more effective. Little combine with a message after human in hip is is that you're on of us. Several advantages is no skin feeling. They're very effective, highly effective, and it leaves on the face. It should be used twice a day. Problem is, the Pradaxa quite recent round of the show with faith, which is an idea a medicine like greasy also cause the burning sensation. There's an FDA warning that warns about possible risk of skin cancer. Patients read it, they have it and don't use it now. The problem is, after 32 years opposed market surveillance. There is absolutely no evidence the cultural really inhibitors predisposed in cancer. Most dermatologists low back, but unfortunately, that's not well learning, probably on the warning. Still there. What can you do? Empty fungals Maybe using the section because that's where these colonizes and thereby, if you have a steroid that imminent suppresses, you'll get overgrowth of the East. You have to tackle least a Z well, so this purple spirit has become buyer with a topical at least for a doctor, a systemic one. How do you treat a different prices? There's different forms of them. There's a clinic observation, this elbows and means, as I said earlier on, and what we call seborrheic carriers. Sweaty area. Yeah, the one that everyone knows values acute. Got it. Psoriasis. This is what we get a sore throat and you get white bread effective almost the whole body with psoriasis. Military examples of all of this. It's on the points rices where the farms and solder affected. Sometimes you'll only get the nails affected. We got on a colossus, yellowing and rigid. You can get what's for the geographical town, where psoriasis affects the road and also try cyst. It's a herbal arise I eat. If you damage normal skin tend to get the psoriasis in that skin. Is it heals. There are not many conditions that curb your eyes. The other one is like planus. Wolves can cut your eyes but try assesses a major one but certainly arises comes up a lot in exams. I have a read of it. Then this photosensitivity rice is a little slices in every way off for the dentist pasta which maybe generalized all the lives that just generalized it will be faithful awful happened or withdrawal of systemic steroids. Yeah, in besides so no or using topical steroids and then suddenly be doing them arrested MX rices can be faithful. This is when you know the night sent of the body is inflamed and in this case you get this blood supply to the scale and hypotension and also because the skin barrier is disrupted. You also get water off contributing to the hypertension. And also due to the fact you've got barrier damage, you're more likely to die of sex is no very nice. Also, as I mentioned earlier on, 5% of patients with psoriasis will have a strike. Two puff right joint disease related to strive sexual rice is off the exiting. The same rules apply. You can see the silvery ms to the scale. You can see it's well defined. You can easily detect the normal skin from the affected skin. This is factual prices. It follows a little rules. Sexual psoriasis of the memory area stocks rice. It's in the nuclear after the neck. Okay, silvery scales. It's well defying. Takes rices. This is when you get a sore throat. Streptococcal Sore throat leading Teo widespread. That tape. Light psoriasis. Almost rifle. Plan to psoriasis. The nails rices. Where you go on a colossus region. A nail pitting little holes. This isn't nail picture. Now pit here. Nope. It here. Word of advice and exams. Nail pitting. You have to go right up to the fingers. We often can see it from a distance. You should tell you, Examiner from here. Oh, I can see little pitting. You know you're lying. You can't see it from that distance. So make the meal of it. Look put. Put it and say, Well, this picking there from close the exam again. We've got your ridging here, coming down here. Very typical of strife. Okay. What? And this is strikes it off. Tom Circle. Geographical tongue. The same moves of time. There's a silvery stale. It's well defined. Examiners love this geographic I would do in the membership anyone geographic, tongue covered, arising. Patient had a piece off stuff. Shingles, and where that shingles happened, there was damage the skin and leave them off or Isis. It follows a little rules. It's called a silvery scales. It's just about the fire, too. Sensitive psoriasis after a sunburn postular strikes is a lot of questions. If it's generalized, it will be faithful. And rice pastas try. Cyst is metformin. Patient has to be admitted. You have to maintain a fluid balance and feet. Any associative infections. Postular slices mainly happens in smoke. This, unfortunately, also possibly a psoriasis has been established. Awesome. Giving up smoking, although it helps, does not get rid of the after that. So smoking is really in thrice is yeah, try to get him. Stop it. Also, remember, I mentioned that they have the metabolic syndrome or more likely to get strokes and heart disease. Well, smoking. On top of that, I'm gonna help rested Emmick psoriasis. Medical emergency In the 19 sixties, the death rate used to be in 57. Those are five potential and definite infection. If you need to be admitted, maintain fluid dollars feet. Any associative conclusion you know how to diagnose drives this. You have to have a multifactorial approach in the management. We have to think about the metabolic syndrome on the patient's future. The time avoid strokes. Is developing diabetes. Slow about the principles of the treatments? Such a lotion Weight minutes lotion's going to scour creams. Go on the body. Hairy areas, motion that useful lectures. You need anti fungal with it. Yeah, learn about the pharmacology and the flyer. Thank you very much. Now, I would also like to share with you psorisis in people of color because you see no, everyone's why we also need to be able to diagnose. It's rice is in people color. So I'm going to see 100 now, so I might stop sharing for a better one. So, uh, yeah, no, I get my so this is it. But, um, that is psoriasis in a very short, uh, all from our. That's probably all you need to know. I'm the graduate level. I would know. Keep it complicated it all. What I've told you is more or less what you need to know. When you have your rheumatology lectures, though, you will be told about the different properties. Then basically, there's five different forms. There's a rheumatic off rightist patted osteoarthritis back to single joy. Multiple joints on D. Also arthritis meat. Elam's where you get destruction of all of the joints of the hands but that I hope, will be covered in rheumatology. Thank you. Any questions, please? Great. Thank you so much for today's lecture. Very informative yell and quite a bit about So, Isis. We've got one question in the chat. If a patient with psoriasis needs high dose off steroids for different unrelated disease, their standard way to tape of them or should he just ask a dermatologist for their opinion? There is no standard way you have to one, because often be conditioner treating will be. I'm not in more important than the psoriasis. But conditioner asked Martin, Be it can be fatal on you didn't give systemic steroids in cases of severe asthma, and so you're more or less dictated by the Astra specialist. It's up today because then once we're gonna be reducing it. And it's up to us dermatologists trying to mitigate any exacerbation you then many ways. And one of them is a slower reduction off the steroids. The other side dovetail another sleep with the expected therapy. Yeah, so that you do not get exacerbation as the steroids or withdrawn the other is. You can make sure that there's adequate topical treatment. So you do not get in the exacerbation but a terry situation. Often it's good because they're impatient until you can keep an eye on them. And you have to inform the patients that it's there for hostels on the palms. Anywhere on the body they have to have a telephone number or some form of contact because that when they need medical intervention, it is one thing for postulating we can be in trouble. Great. Thank you. I'm I'm a disaster thing. Continue, please. Sure. The slide way sure to serve ice is in poc in he Oh, see, um, it could you just expand? What do you mean by poc? Maybe. Um, you just off? Oh, in people of color. Oh, and we weren't able to show that. All right? Yeah. No, it was a picture, but unfortunately, I don't have that. But in fact, what I got up there with the research project that we were involved in And, um, I don't if you can see this, and not at the moment. No, let me see. Shared screen again. Our chest cream. Look. Oh, here we are. Uh, this is psoriasis, um, people off color, and you will see that it's not red. So I live in people of color. It can be brown, but there's still the silvery scale on the geographical area where you find it is the same. However, you get post inflammatory hyperpigmentation of people color. So the lesion there not being well defined with the silvery scale but our not read the Camry Red Relations or people with color The cavalry brown of this too well to file, they still have a silvery scales. Elizalde the rules. It's well defined in this case, the patients. Psoriasis was itchy, so you can see there's excoriations here with been scratching away. It's just quite interesting. Psoriasis does tend to be itchy in Asians. Um, better. Why? Extensive surfaces still follow the same rules, but you can confuse this fax murmur but experts on the factual surface Yeah, there'll be other evidence at your nails, right? Well, the front, however, this is a little, uh, and as a differential, diverse is you have to exclude fungal infections. However, the giveaway is here on the elbow, there's a park of psoriasis, so likely he's got two conditions like it to be psoriasis again, well defining people of color. You can see that it's dark but still have a silvery scale be. Everything was less evident then, in white skin, you can get inflamed. Psoriasis were cold. Talk some substance of irritated it. Okay, well, if he fired clocks that looked up well defined, dark, where it's itchy like terrified. And you can see the nail on ical isis and the nail pitting on the crumbly nous of the nails. So this is, well, the pharmacy. Well, it's rice is again crumbly nails, but I know rice is. You can get cramping like vitamin D's again. Nail pitting. Let's have to get there are pits normally to learn, see them close up. You got your prompt. It's psoriasis with article Isis sickening of the nails and lifting away from the nail bed. Well defined. It's right, it's arthritis. There's the psoriasis. And that's the arthritis mutilations, probably. Or osteoarthritis. Okay, Arthritis, PTO. We've got mutilations. One necking better. Rheumatoid arthritis factor here is, well, osteoarthritis. Back to distal off. Throw up fee. See that swelling there a lot. It's just righteous right there. So this is Ah, just say sure paper. We did remember where are published, which just tells you a bit more about, uh, prices in people. Great. Thank you. Um, the question is how we did differently between guttate psoriasis on Petraeus. That's a brilliant question. Absolutely brilliant question. Because, you know, it's difficult, and often we are asked you ourselves that question Is this guttate psoriasis? Or is this pityriasis rosea ear some awful? Luckily, they've got a previous scirosis of psoriasis. In which case, Yeah, it's rice is, but things you can have both those pretty righteous rosiest by common, especially as it's it's a major dental audible feature of the copay. So we're seeing a lot of pityriasis rosea and realize this thing a lot of gut. It's rice is for the first time in pityriasis rosea here there is a In both cases, you've got a history of a sore throat. But in Pityriasis rosea a, there is the Herald on really packs that looks out. Fungal infection, which out there in the community is awesome. Diagnosis is on your infection, and they distribute with Palestine, and it doesn't work. So the Herald packs is a biggie. Just rice is rosy is often itchy. Arthritis is, um, look for the mail or Nikolai system psoriasis, cause you don't get that now or local Isis in pity Rice is rozerem. You may want to do a a eso types anti structure license because if it's got it's rice is the ace eso titers likely to be elevated. There's no point in giving antibiotics in that it's rice is because, um by then the infection's coming going on. The cutaneous reaction happens days afterwards, but you're right. It can be a very difficult differential. On the other difficulty is that been pityriasis rosea attempt to use topical steroids, which you shouldn't really be using that in order to overcome back problem, And sometimes you just can't make different shape between the two. A way out of it is to use the culture urine inhibitors like Protopic or elidel because they treat, but it's twice a sandpit. Your sister is here. Mineral steroids done with all of them. You're not going to make the strikes. It's worse. But it is a big problem. Alone. Least help actually gives it away. Great. Thank you. Um, which treatment is better for spiciness? Which treatment is better? Well, depends again. How you've assessed the strikes is where is the psoriasis is in, the scalp is on face is on the elbows. Um, how extensive is that psoriasis? Um So as I mentioned throughout the whole lecture, you have to assess the severity of it. The men assess what's best for the patient is complicated. Then we can give a one line dance on it. In fact, that's what the whole lecture was about. Assessment of severity, and then learning the pharmacology and applying the pillow just swatted up, I'm afraid. Thank you. I had a question of in terms of when you're assessing patients on going to see which treatment is best for them. At what point would you ask for their what they would prefer? You see a lot of these patients about Trifexis for years, so they got a fairly good idea. What million? It's good for them. What made give, um, acne. What makes it sticky? What? They don't smell off. So you really you want to start by saying What have you used before? What does work? It's good to know what has worked in also just a Z important to know what hasn't worked. Um, I'm also it's very useful to give patient arrangeable shoes in terms of the emollients, anyway, when patients get less choice but with they get the active treatment such of the topical steroids. Well, with the topical steroids, it almost always combine it with either constipate trial or cold. Um so I mean, I would say the best treatment of the week of ones in order to give you the most effect. Thank you. Um, the question is, can survive this be mistaken for hepatitis? Yes, it can. As I pointed out, in Asians can often psoriasis in Asians, panties itchy on you can scratch away at it, and therefore it's not well defined anymore because it's fractional around her. And in that case, yeah, it's again often difficult to differentiate between the two. In that case, you know, this is where the calcium. You're in the hip. It's just coming because it's useful in both conditions. It's a fair bit stock. It's useful to use calcium urine inhibitors because you want to avoid using need topical steroid since rices. Oh, great. Thank you dot Anyone have any other questions? Please feel free to meet yourself now. No, I can't see anything in the chapter either. So thank you so much for your time dot Thank you. Um, and I will share the feedback with full one small with everyone. Please make a note. I'll keep the trial running for a couple of minutes. Um, so please make a note of it and pull it in. Thank you. Everyone on our next session will be at 11 o'clock today.