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Accutane is given to patients for treating severe acne that do not respond to other medicines. Accutane is a retinoid. It works by reducing skin oil production, changing the characteristics of the skin oil, and preventing abnormal hardening of the skin.

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Infectious Erithemas

Multiforme exudative erythema

Erythema multiforme is a heterogeneous syndrome. Idiopathic and symptomatic variants are distinguished.

Idiopathic exudative erythema multiforme associated with the action of infectious agents (most likely viruses of herpes group). Simtomaticheskaya exudative erythema multiforme often caused by intake of medicines (sulfonamides, antibiotics, non-steroidal antiinflammatory agents), vaccine and others. It is also assumed to allocate a small form of the disease (type algebra), larger form (Stevens-Johnson syndrome) and toxic epidermal necrolysis (Lyell syndrome which Described in a separate chapter).

Clinic. For a small form of multiforme exudative erythema, a sudden appearance on the rear of the hands and feet, less often on the forearms and lower legs, swollen spots and papules of red color, 0.5-1 cm in diameter. Elements are prone to peripheral growth and can reach several centimeters in diameter, their central part becomes cyanotic and sinks. Often, in the future, bubbles form in the center of the elements. Occurrence of rashes may be preceded by prodromal phenomena (fever, weakness, headache). The mucous membrane of the oral cavity and the red border of the lips may be involved in the process. Bubbles appear on the mucous membrane of the mouth on the erythematous background, they are quickly opened with the formation of extensive painful erosions. On the red border of the lips is characterized by the formation of hemorrhagic crusts in the places of the opened blisters. Maybe also the appearance of rashes in the genital area (especially on the head of the penis and the inner leaf of the foreskin). Subjectively, burning, soreness is concerned. The disease often occurs with seasonal relapses in the spring and autumn.

A large form (Stevens-Johnson syndrome) is characterized by a severe general condition of the patient and can result in a fatal outcome. The beginning is acute. Characterized by fever up to 39 - 40 ° C, general malaise, headache, sore throat. The patient's condition progressively worsens. There are bubble rashes on the oral mucosa, the red border of the lips. Bubbles are quickly opened with the formation of erosions and ulcers. Soon similar rashes occur on the nasal mucosa, nasopharynx, genitals, eyes. Skin lesion is usually noted somewhat later and is represented by multiple small blisters on the erythematous background. Possible involvement of the mucosa of the stomach, esophagus, bronchi.

Diagnosis is carried out taking into account a typical clinical picture.

Treatment. The choice of optimal therapy is determined by the etiology of the disease. It is necessary to carefully collect the anamnesis and examine the patient. In all cases, antigenic stimulation should be stopped and the immune response suppressed. It is necessary to cancel all medicines, and also to abolish UFO, as the latter can stimulate the development of herpetic infection. In cases where the etiological role of herpetic infection is proven or the disease is recurrent with exacerbations in the cold season, it is recommended that a prophylactic course of antiviral drugs is prescribed (acyclovir 400-800 mg per day). If other causes of infectious nature are clarified, appropriate etiologic therapy should be prescribed. In severe cases, systemic glucocorticosteroids (prednisolone at a dose of 60-100 mg per day, followed by a dose reduction before complete withdrawal after achieving a clinical effect) should be administered as early as possible.

External therapy is symptomatic: anti-inflammatory, epithelializing agents are prescribed, as well as antiseptics to prevent the attachment of secondary infection.

Pink lichen

It is assumed the viral origin of the disease. It occurs usually in the spring and autumn. Often the appearance of rashes is preceded by colds. The disease is prone to self-cure. Relapses are extremely rare and occur almost exclusively in immunocompromised patients.

Clinically, the appearance of spots (less infrequently infiltrated plaques) pink in the skin of the body. The skin of the extremities is rarely affected. Spots oval or round, oriented along the lines of skin cleavage. A few days later, a small rapid peeling appears, leaving the collar of the flaking horn on the periphery of the focus. Subjective sensations are often absent, sometimes patients are concerned about moderate itching. Usually the appearance of a generalized eruption is preceded by the appearance of a larger element - the "mother plaque". A part of patients have a mild general malaise, an increase in cervical and submandibular lymph nodes.

The duration of the disease is usually 5-6 weeks. Progression of the disease and increasing its duration is facilitated by any skin irritation, including water procedures.

In most cases, patients with pink deprive in treatment do not need. It should be prohibited water procedures, heavy physical work, sports. With irritated pink deprive, antihistamines and topical steroids are prescribed.

Vaskulites

Vasculitis refers to diseases in which the vascular wall primarily suffers.

Etiopathogenesis. As a cause of vasculitis development, an infection, more often chronic, and the effects of chemicals, especially medicines, are considered. The pathogenesis of vasculitis can be associated with both HNT (immunocomplex mechanism) and with HRT.

The variety of clinical manifestations of vasculitis is due to the fact that vessels of different caliber in different organs may suffer. For vasculitis of the skin, which can act as an independent disease and be a manifestation of the systemic process, the small vessels of the dermis are characterized.

The most common is the so-called polymorphic dermal angiitis. With this disease on the skin can be a variety of rashes. Depending on the prevalence of certain elements, hemorrhagic, papulonecrotic, pustuloacus and ulcerative necrotic types of disease are distinguished.

Hemorrhagic type in most cases manifestation of a systemic disease. This variant is usually found in childhood (from 4 to 15 years) and develops after an infectious disease (after 1-2 weeks). Characterized by the appearance on the skin of hemorrhagic spots, less often plaques. As manifestations of the systemic nature of the process can be pain in joints, severe abdominal pain (can be misinterpreted as an "acute abdomen"), hematuria. Duration of flow from one to several months.

When the papulonecrotic type of systemic manifestations is usually not detected. On the skin there are small (a few millimeters in diameter) nodules in red in the center of which there is necrosis. It formed ulcer healing to form the "extruded hem" After sloughing. Typical localization is the extensor surfaces of the limbs. In addition to the papulonecrotic elements, there may be hemorrhagic spots. Characteristically chronically recurrent course. Clinically, this option vasculitis is almost impossible to distinguish from acnitis.

When pustuleznoyazvennom type (pyoderma gangrenosum) small grouped blisters quickly merge to form a large painful ulcers with infiltrated raised edges. The ulcer tends to a fairly rapid peripheral growth. Characteristic of the formation of new ulcers in the places of traumatization of the skin. Typical localization of skin lesions is the lower leg and abdomen.

Yazvennoecrotic type is the most severe. A lethal outcome is possible. The various sizes of necrosis are caused by thrombosis of small vessels. Typical localization - the lower extremities and buttocks.

Hemosiderosis (chronic pigment purpura) is a group of diseases of unknown origin, in which the erythrocytes go beyond the vessel and hemosiderin is deposited in the skin. The most characteristic localization of pigment hemosiderin spots is the skin of the shins. Disease subjectively does not bother. Signs of systemic lesions are not detected. The treatment is almost indecisive.

Nodular erythemastrong (nodular angiitis) is a deep vasculitis. Isolate acute and chronic erythema nodosum.

In acute erythema nodosum, usually on the anterior surface of the shins symmetrically formed painful inflammatory nodes with fuzzy boundaries due to the surrounding edema up to several centimeters. As the inflammation subsides, the soreness of the nodes passes, the bright red color changes to cyanotic, and then to yellow-green. The duration of the disease is usually 2-3 weeks.

For chronic erythema nodosum, chronically recurrent course is typical. Exacerbations, as a rule, are recorded in the cold season. The disease usually develops against the backdrop of chronic infections, it can act as a pair of neoplastic condition. It is more common in middle-aged women. The nodes are painless, do not have a bright inflammatory color and exist for several months.

When appointing a treatment, it is necessary to establish whether the given vasculitis is a manifestation of the systemic process or if only the skin suffers, and try to establish an etiological factor (in about a third of cases, this can not be done). With a widespread process and a suspicion of its systemic nature, patients are assigned to bed rest (usually in a hospital). With the infectious origin of vasculitis, a broad-spectrum antibiotic is prescribed. The sanation of foci of chronic infection is being carried out. With medical etiology of the disease in mild cases, antihistamine drugs, calcium preparations, ascorutin are administered. With widespread skin lesions, suspicion (or clear signs) of a systemic process and changing laboratory parameters, systemic steroids are prescribed (40-80 mg of prednisolone per day). At the same time, heparin therapy is usually performed. It is possible to conduct plasmapheresis. In cases of erythema nodosum, usually, in addition to the antibiotic, non-steroidal anti-inflammatory drugs are prescribed.

External treatment is symptomatic. With erythema nodosum, the use of dry warming dressings is essential.

Psoriasis

Psoriasis (scaly lichen) - a chronic relapsing skin disease, manifested by the eruption of scaly papules. Psoriasis affects up to 5% of the world's population, often in the age of 20-50 years. In addition to the skin, psoriasis can affect the joints (psoriatic polyarthritis).

Etiopathogenesis. Psoriasis refers to multifactorial diseases. The share of heredity in its development is about 70%, the role of the external environment corresponds to 30%. In the development of psoriasis, the great importance of provoking factors is recognized: infectious (the role of streptococcal and herpetic infections is proved), psychogenic factors, some medicines (lithium, gold preparations, (3-adrenoblockers, antimalarials, oral contraceptives, interferon), injuries.

Clinic. Primary rash with ordinary psoriasis is a flat inflammatory papule of round shape with clear boundaries, 1-2 mm in size, red. Papules are prone to rather rapid peripheral growth and fusion with the formation of plaques. The surface of the papules is covered with silvery-white scales. The localization of psoriatic eruptions can be any. However, the extensor surfaces of the extremities are most often affected, especially in the area of ​​the elbow and knee joints, the scalp and the sacrum. Characteristic symmetry of rashes. Subjectively sick can be bothered by itchy skin.

In some patients (more often with endocrine disorders) psoriatic rashes are localized on the skin of large folds, flexural surfaces of the extremities. Such psoriasis is called inverse.

Depending on the amount of rashes on the skin, a widespread and limited psoriasis is isolated. In severe cases, it is possible to damage the entire skin-universal psoriasis.

In the course of ordinary psoriasis, three stages are distinguished: progressive, stationary and regressive. The progressive stage of the disease is characterized by the appearance of new small rashes on the skin and peripheral growth of the more "old" elements. As an objective confirmation of the peripheral growth of papules and plaques, there is the presence of a peeling-free erythematous margin. For the progressing stage, the so-called Kebner phenomenon or isomorphic skin reaction is typical: the appearance (usually in 1.5-2 weeks) of psoriatic rashes in the places of skin trauma (in places of scratches, friction with clothing, use of irritating external means, UFOs, ). For a stationary stage, the appearance of new rashes and the growth of existing ones is characteristic. Peeling comes to the edge of papules and plaques. Around the papules and plaques appears "Collar" is somewhat paler than the surrounding healthy skin with increased folding (pseudoatrophy). Regression of papules usually begins in their central part. Therefore regressing plaques often take a ring-like shape. At the places of the resolved elements, there usually remains a secondary hypo- or hyperpigmented spot.

With all clinical forms of psoriasis, nail plates are often affected. The most common are dystrophic changes in the nail plate, in which dotted impressions resembling a thimble are visible on their surface. It is also possible the formation of subungual papules, which are manifested by the yellowish coloration of the part of the nail plate ("oil stain"). Often there are changes in the nail plates due to subungual hyperkeratosis (reminiscent of mycotic lesions).

In most patients, psoriasis is chronically recurrent. Exacerbations are usually recorded in autumn and winter. Remissions can be complete and incomplete (some patients have so-called "on-call plaques", more often on the extensor surface of the elbows and knee joints). At the same time, both long (long-term) remissions and current are possible disease with little or no periods of remission.

For the diagnosis of psoriasis vulgaris widely used simple diagnostic method - layer poskablivanii (scratchboard) at poskablivanii scalpel psoriatic papules (plaques) are first detected symptom "stearin spots" (silver psoriatic scales poorly adhere to each other and easily scraped off), then the symptom "terminal film "(caused by a thickening spinous layer of the epidermis) and, finally, the symptom" blood dew "(with more vigorous poskablivanii injured apex elongated dermal papillae Appropriate close to the surface of the epidermis thinned over them).

It is customary to identify a number of varieties of psoriasis. Thus, under seborrheic psoriasis understand psoriasis, seborrhea develop in patients with localization of lesions in seborrheic areas (scalp, forehead, cheeks, the nose wings, BTE folds, the upper part of the chest, large folds). Infiltration of papules and plaques is weak, the scales on the surface of fat, are glued to each other. The psoriatic triad may not be defined.

With exudative psoriasis, the scales glue together with exudate to form scabs. Patients are usually concerned about burning and itching of the skin. When checking the presence of the psoriatic triad, there is no symptom of a "stearin stain".

In women of menopausal and post-menopausal age, as well as in persons injuring the skin of the palms and soles during professional activities, the development of palmar-plantar psoriasis is possible. With this form of the disease, the localization of the rashes can be limited only by the skin of the palms and soles. In this localization, hyperkeratotic papules are more common. Help in the diagnosis of clear boundaries of lesions. If necessary, a diagnostic skin biopsy is performed.

When the skin of a patient with psoriasis is irritated (irrational therapy, insolation, traumatism), which is in the progressing stage of the disease, the development of psoriatic erythroderma is possible. In such cases, edematous erythema forms on all areas of the skin that are free from psoriatic eruptions. As a result, the defeat of the skin becomes total. All skin is red, dry, infiltrated. On its surface - large-plate peeling. Because of total skin damage, thermoregulation is disrupted: the body temperature rises to subfebrile and even febrile digits. Possible violations of the liver and kidneys.

In a number of cases, the accumulation of neutrophils characteristic of psoriasis in the epidermis becomes large and clinically manifested as amicrobial pustules. In such cases, talk about pustular psoriasis. Isolate pustular psoriasis of the palms and soles and generalized pustular psoriasis. Both variants of the disease are more often observed in patients with endocrine disorders. The palmar-plantar variant is often found (can be a fragment of a common psoriatic lesion). More often it is observed in women of menopausal and postmenopausal age. On the palms and soles, psoriatic plaques are formed, on the surface of which small yellowish pustules are visible, usually drying out without opening. Generalized pustular psoriasis occurs significantly rarer and refers to severe variants of psoriasis. Its development is facilitated by various factors: severe stress, pregnancy, abortion, taking certain medications, etc. The patient with ordinary psoriasis suddenly have multiple amykrobic pustules. Perhaps the development of erythroderma. Characteristic rise in body temperature to febrile figures, general malaise, changes in the clinical analysis of blood (leukocytosis, increased ESR).

Approximately in 10% of cases with psoriasis there is a lesion of the joints - psoriatic arthritis. Correlations between activity and severity of skin lesion and joint pathology may not be observed, but more often it is present. Most often, interphalangeal joints of the hands and feet are affected, but any joints, including the spine, can be affected. Possible as mild joint damage, clinically manifested by small arthralgia, and severe destructive changes leading to disability of patients.

Treatment of psoriasis depends on the prevalence of the skin process, its stage, the clinical form of the disease, the frequency of relapses, the age of the patient, the presence of concomitant diseases.

First of all, whenever possible, factors that provoke exacerbations of the disease (sanitize the foci of chronic infection, normalize skin care, and if necessary prescribe psychotropic drugs, etc.) should be eliminated.

With limited skin lesion, it is usually sufficient to prescribe an external treatment that includes adequate skin care (mild detergents and preparations with obesity), keratoplastic agents (most often 2% salicylic ointment). With the progressing stage of the disease, it is possible to use topical steroids (usually betamethasone derivatives) in the form of ointments - on smooth skin and lotions - on the scalp. The use of this group of drugs can achieve a rapid clinical effect, but their long-term use is unacceptable because of the risk of side effects. Often use combined preparations containing, in addition to steroids, keratoplastic agents. Permissive agents are widely used in the stationary stage of psoriasis. Most often these are preparations containing tar (ointments with a tar concentration of 2% to 30% and shampoos) and naphthalan oil (ointments, emulsions). The stationary and regressive phase also uses the derivatives of calicipotriol (diveonex).

With a greater prevalence of skin lesions, systemic therapy is included. Detoxifying and hyposensitizing agents are prescribed in the progressive stage of the disease (calcium preparations, sodium thiosulfate, hemodesum). In stationary and regressive stages, UFO is widely used. In the absence of the effect of the therapy, PUVA therapy is sometimes used (skin irradiation with long-wave ultraviolet rays against the background of photosensitizers) and systemic cytotoxic drugs from the group of antimetabolites (methotrexate). Currently, in severe psoriasis, cyclosporin A is also prescribed, a drug that has an immunosuppressive effect. With the development of psoriatic erythroderma and generalized pustular psoriasis, in some cases, systemic glucocorticosteroids are prescribed in an average daily dosage (usually about 40 mg per day). Patients with psoriatic polyarthritis are shown non-steroidal anti-inflammatory drugs.

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