This document provides guidelines for the clinical treatment of psoriasis. It describes the main types of psoriasis including plaque, guttate, pustular, erythrodermic, inverse and psoriatic nails. It outlines assessment measures for disease severity including PASI, BSA and DLQI. Treatment approaches discussed include topical therapies, phototherapy, systemic medications and supportive treatments. Specific therapies covered in detail include corticosteroids, vitamin D analogues, methotrexate, retinoids, cyclosporine and phototherapy/photochemotherapy. Adverse effects and monitoring requirements are provided for systemic treatments.
This document contains a logic proportionality work with various exercises involving propositional logic. It includes truth tables testing the validity of statements with connectives like implication, conjunction, disjunction, equivalence and negation. The exercises cover tautologies, contingencies and validity testing across different combinations of propositional variables.
The document contains several logic exercises involving propositional logic statements and truth tables. Specifically, it includes 10 different exercises labeled a-j with propositional statements and their corresponding truth tables showing the truth values for all combinations of variable assignments.
This document contains a logic proportionality exercise with multiple parts. It includes truth tables to determine whether statements are tautologies, contingencies or contradictions. The statements involve propositional logic with various connectives such as implication, conjunction, disjunction, negation and equivalence.
This document summarizes common skin problems seen by Dr. Sanjeeva Hulangamuwa. It discusses several conditions including eczema, psoriasis, infections (bacterial, viral, fungal, parasitic), drug eruptions, nutritional deficiencies, vasculitis, skin cancers, blistering diseases, diabetes manifestations, and more. Treatment options are provided for each condition.
This document contains a logic proportionality work with various exercises involving propositional logic. It includes truth tables testing the validity of statements with connectives like implication, conjunction, disjunction, equivalence and negation. The exercises cover tautologies, contingencies and validity testing across different combinations of propositional variables.
The document contains several logic exercises involving propositional logic statements and truth tables. Specifically, it includes 10 different exercises labeled a-j with propositional statements and their corresponding truth tables showing the truth values for all combinations of variable assignments.
This document contains a logic proportionality exercise with multiple parts. It includes truth tables to determine whether statements are tautologies, contingencies or contradictions. The statements involve propositional logic with various connectives such as implication, conjunction, disjunction, negation and equivalence.
This document summarizes common skin problems seen by Dr. Sanjeeva Hulangamuwa. It discusses several conditions including eczema, psoriasis, infections (bacterial, viral, fungal, parasitic), drug eruptions, nutritional deficiencies, vasculitis, skin cancers, blistering diseases, diabetes manifestations, and more. Treatment options are provided for each condition.
Eczema - A Case Presentation (by Dr. Julius King Kwedhi)Dr. Julius Kwedhi
Eczema: Come from the Greek name for boiling, a reference to the tiny vesicles (bubbles) that are commonly seen in the early acute stage of the disease
An immune-mediated inflammation of the skin arising from an interaction between genetic (e.g. epidermal barrier function, immune system) and environmental factors (foods, airborne allergens, Staphylococcus aureus colonization on skin due to deficiencies in endogenous antimicrobial peptides, topical products)
The eczemas are a disparate group of diseases, but unified by the presence of itch and, in the acute stages, of oedema (spongiosis) in the epidermis
Most Common Skin Disorders - Causes and Treatment | Sehat.comSehat.com
Almost everyone might have experienced at one time or the other the horror of dealing with a skin disorder/disease. Irrespective of the age, one can be affected by various skin ailments and if not treated properly the condition may get aggravated.
This document summarizes psoriasis, including its epidemiology, etiology, pathogenesis, diagnosis, clinical features, and treatment. Psoriasis is a chronic inflammatory skin condition that affects about 2-3% of the population. It is caused by genetic and environmental factors that trigger an immune response resulting in increased skin cell turnover. Diagnosis is usually based on appearance of red, scaly plaques. Treatment includes topical therapies like corticosteroids and vitamin D analogues as well as phototherapy and systemic drugs for more severe cases.
This document discusses cell structure and organelles. It notes that cells are the basic unit of structure and function in living things. Cells range widely in size but are generally 10-20 micrometers. Organelles such as the nucleus, mitochondria, chloroplasts, and vacuoles are enclosed within the cell membrane. Larger organisms are made of many cells organized into tissues, organs and organ systems.
1. Fungal and bacterial counts were obtained from indoor air samples collected from different areas of a hospital over multiple days.
2. The most common fungal genera identified were Aspergillus, Penicillium, and Cladosporium. The most common bacterial genera were Staphylococcus, Micrococcus, Pseudomonas, and non-fermenting gram-negative bacilli.
3. Fungal and bacterial counts varied between areas of the hospital, with higher counts observed in the neonatal intensive care unit compared to other areas like general patient rooms.
Eczema - A Case Presentation (by Dr. Julius King Kwedhi)Dr. Julius Kwedhi
Eczema: Come from the Greek name for boiling, a reference to the tiny vesicles (bubbles) that are commonly seen in the early acute stage of the disease
An immune-mediated inflammation of the skin arising from an interaction between genetic (e.g. epidermal barrier function, immune system) and environmental factors (foods, airborne allergens, Staphylococcus aureus colonization on skin due to deficiencies in endogenous antimicrobial peptides, topical products)
The eczemas are a disparate group of diseases, but unified by the presence of itch and, in the acute stages, of oedema (spongiosis) in the epidermis
Most Common Skin Disorders - Causes and Treatment | Sehat.comSehat.com
Almost everyone might have experienced at one time or the other the horror of dealing with a skin disorder/disease. Irrespective of the age, one can be affected by various skin ailments and if not treated properly the condition may get aggravated.
This document summarizes psoriasis, including its epidemiology, etiology, pathogenesis, diagnosis, clinical features, and treatment. Psoriasis is a chronic inflammatory skin condition that affects about 2-3% of the population. It is caused by genetic and environmental factors that trigger an immune response resulting in increased skin cell turnover. Diagnosis is usually based on appearance of red, scaly plaques. Treatment includes topical therapies like corticosteroids and vitamin D analogues as well as phototherapy and systemic drugs for more severe cases.
This document discusses cell structure and organelles. It notes that cells are the basic unit of structure and function in living things. Cells range widely in size but are generally 10-20 micrometers. Organelles such as the nucleus, mitochondria, chloroplasts, and vacuoles are enclosed within the cell membrane. Larger organisms are made of many cells organized into tissues, organs and organ systems.
1. Fungal and bacterial counts were obtained from indoor air samples collected from different areas of a hospital over multiple days.
2. The most common fungal genera identified were Aspergillus, Penicillium, and Cladosporium. The most common bacterial genera were Staphylococcus, Micrococcus, Pseudomonas, and non-fermenting gram-negative bacilli.
3. Fungal and bacterial counts varied between areas of the hospital, with higher counts observed in the neonatal intensive care unit compared to other areas like general patient rooms.
This clinical practice guideline provides recommendations for the treatment of urticaria and angioedema. It discusses the classification of urticaria into acute vs chronic and spontaneous vs inducible subtypes. Diagnostic tests and criteria for differentiating subtypes are presented. Treatment recommendations include second-generation antihistamines as first-line, with corticosteroids and ciclosporin as options for chronic urticaria. Anaphylaxis treatment involves epinephrine and other supportive measures.
1. Many physiological changes during pregnancy can affect how drugs are absorbed, distributed, metabolized and excreted from the body. This may increase or decrease their effects.
2. Some drugs taken during pregnancy can cause birth defects or other problems in the developing fetus. These are called teratogens and their effects depend on factors like dosage and the stage of pregnancy when exposed.
3. Guidelines categorize drugs into groups from A to X based on their risks during pregnancy, with Category X drugs having the highest risk of teratogenic effects like the drug thalidomide.
1. This document provides instructions for a field trip from 13:00 to 16:00. It outlines 21 items that students must bring and safety measures they should follow.
2. Students are advised to bring necessary items like clothes, shoes, water, and sunscreen. They are also instructed to follow rules like staying with the group and not littering.
3. The document provides detailed guidelines to ensure a safe and productive field trip for the students.
The document discusses various drugs used to treat gastrointestinal conditions. It describes:
1) Anti-emetic drugs that work by blocking receptors like muscarinic M1, dopamine D2, histamine H1, and 5-HT3 to treat nausea and vomiting.
2) Agents for peptic ulcers like antacids, anti-secretory drugs that block receptors like H2 and muscarinic M3, and cytoprotective drugs.
3) It explains the mechanisms of gastric acid secretion mediated by receptors, second messengers like cAMP and calcium, and the hydrogen potassium ATPase pump.
1. The document discusses various topics related to biology such as blood vessel formation, respiration, cell organelles, and meiosis.
2. Key points include the formation of blood vessels from different germ layers, the role of alveoli in gas exchange during respiration, and the division of homologous chromosomes during prophase I of meiosis.
3. Various biological structures and processes are defined, such as organelles like mitochondria and chloroplasts, and cellular processes like photosynthesis, cellular respiration, and the nitrogen cycle.
1. The document discusses various topics related to biology such as blood vessel formation, respiration, cell organelles, and meiosis.
2. Key points include the formation of blood vessels from different germ layers, the role of alveoli in gas exchange during respiration, and the division of homologous chromosomes during prophase I of meiosis.
3. Various organ systems, cell structures, and biological processes are defined such as the mesoderm contribution to supporting tissues and organs, the role of flagella and cilia in cell movement, and the multi-step process of nitrogen fixation.
1. The document discusses various topics related to biology such as the development of blood vessels, respiration, cell organelles, and meiosis.
2. Key points include the formation of blood vessels from different germ layers, the role of hemoglobin in transporting gases, and the process of cellular respiration utilizing oxygen.
3. Various biological structures and processes are defined such as organelles, mitosis, meiosis, and the nitrogen cycle. Comparisons are made between plant and animal cells and between different types of reproduction.
The effect of weight parameter on accuracy of classification by neural networkskulachai
เอกสารนี้ตีพิมพ์ในประมวลการประชุมวิชาการระดับชาติ ครั้งที่ 2 (The 2 nd. National Conference of Academic of All Business. Disciplines Research) มหาวิทยาลัยบูรพา
แนวทางการจัดการความเสี่ยงที่ส่งผลต่อต้นทุนการจัดการสินค้าคงคลัง
ของร้านขายยา CDE ในจังหวัดขอนแก่น
The Approach of Risk Management that Affecting the
Inventory Management Cost of CDE Drugstore in Khonkaen Province
Best Practice in Communication
ราชวิทยาลัยกุมารแพทย์แห่งประเทศไทย สมาคมกุมารแพทย์แห่งประเทศไทย
บรรณาธิการ วินัดดา ปิยะศิลป์ วันดี นิงสานนท์
ISBN 978-616-91972-1-8
Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoeaUtai Sukviwatsirikul
This systematic review and meta-analysis evaluated the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhea in children and adults based on 21 randomized controlled trials involving 4780 participants. The administration of S. boulardii compared to placebo or no treatment reduced the risk of antibiotic-associated diarrhea from 18.7% to 8.5%. S. boulardii was effective in reducing the risk of antibiotic-associated diarrhea in both children and adults. It also reduced the risk of Clostridium difficile-associated diarrhea in children but not adults. Overall, the results confirm that S. boulardii is effective for preventing antibiotic-associated diarrhea in children and adults.
This document provides information on drugs used to treat acute diarrhea. It begins with definitions of diarrhea from WHO. It then discusses estimates of child mortality due to diarrhea in Thailand from 2010 to 2012. It presents data on the age distribution of diarrhea cases and hospital admissions. It lists common bacterial, viral, and parasitic pathogens that cause childhood diarrhea. It discusses the pathogenesis of acute diarrhea and describes fluid and electrolyte losses and consequences of dehydration and nutritional deficits. It provides details on fluid and electrolyte composition of diarrheal stool from different pathogens. It outlines the objectives of diarrhea treatment and causes of death. It then discusses use of oral rehydration therapy and solutions. It recommends probiotics, continued feeding, and zinc supplementation. It
Systematic review with meta-analysis: Saccharomyces boulardii in the preventi...Utai Sukviwatsirikul
This systematic review and meta-analysis evaluated the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhea in children and adults based on 21 randomized controlled trials involving 4780 participants. The administration of S. boulardii compared to placebo or no treatment reduced the risk of antibiotic-associated diarrhea from 18.7% to 8.5%. S. boulardii was effective in reducing the risk of antibiotic-associated diarrhea in both children and adults. It also reduced the risk of Clostridium difficile-associated diarrhea in children. The quality of evidence was rated as moderate to low based on limitations in the design and reporting of the included studies. This meta-analysis confirms the effectiveness of
Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea ...Utai Sukviwatsirikul
Saccharomyces boulardii in the prevention of antibiotic-associated
diarrhoea in children: a randomized double-blind placebo-controlled
trial
M. KOTOWSKA, P. ALBRECHT & H. SZAJEWSKA
Department of Pediatric Gastroenterology and Nutrition, The Medical University of Warsaw, Warsaw, Poland
Accepted for publication 24 November 2004
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central19various
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
3. 74
(psoriasis) ˈ
F F F
F F F (psoriatic arthritis), inflammatory bowel disease,
F ˈ ˆ F F F F F
ˈ F F
F F
F F 1-2 F
F F ˁ 2,400
2 F F F (22.5 ʾ) (55 ʾ)(1, 2)
F ˁ F
F F F F ˁ ˈ
F
F F ˆ F F ˆ F F F
F ˆ F
Plaque psoriasis
ˈ F F 80-90 F ˁ
ˈ F 1 F
F F extensor F F F ˈ F F 80
F ˁ F F 20 F
F F F 10 F F F F
F ˈ F
Guttate psoriasis
ˈ ˈ F (fine scale) F F 1
F F F F F F 10-20 F ˁ F ˁ F F 30 ʾ
F group A beta-hemolytic streptococci F
2-3 F ˈ F ˁ ˈ F ˁ plaque psoriasis
F
4. 75
Pustular psoriasis
ˈ F F F ˈ
- Generalized pustular acute generalized variant (von Zumbusch variant) ˈ
F
- Localized pustular variant ˁ ˁ F plaque psoriasis F F F
Erythrodermic psoriasis
ˈ F F
plaque psoriasis F F F
F (dehydration and hypoalbuminemia) F F F
Inverse psoriasis
F F F F
F ˈ F F F F F F
Psoriatic nails
F F F F 50
F F F 35 F ˁ F F pitting, onycholysis, subungual
hyperkeratosis oil-drop sign F F (psoriatic arthritis)
F F F F 90
Psoriatic arthritis
F F
F F F F F F F ˁ
F F F 1-40 F ˁ
F ˈ
1. ˈ
2. F
3.
4. F F F lithium,
antimalaria, beta-blocker, NSAIDS alcohol
5. 76
F
F F F
F F (Auspitz s
sign) F
(Koebner phenomenon)
(pitting) F (onycholysis) F (subungual
hyperkeratosis) F (oil spot)
F F ˈ F F F F ˈ F F
F F distal interphalangeal joint ˈ F
F
• The Psoriasis Area and Severity Index (PASI) ˈ
body surface area involvement, erythema, induration and scaling F F
F PASI F F
( PASI score )
• Body surface area (BSA) ˈ ˈ
F ˁ F ˁ ˈ F 1 ˁ F ˁ ˈ F 1
• Dermatology Life Quality Index (DLQI) ˈ F ˁ
(2)
( )
F
• Mild psoriasis F < 10% body
surface area (BSA), PASI<10, DLQI <10
• Moderate to severe psoriasis
>10% BSA, PASI > 10, DLQI> 10
• F F F F F 10%
F F F F ˁ F F moderate to severe psoriasis
6. 77
F
F F ˈ F
F F
ˆ
F F ˁ F F
1. F F F
2. F F F rheumatoid factor
rheumatoid arthritis
3. ˆ anti HIV antibody
F (Medical comorbidities associated with psoriasis )
Metabolic syndrome: F F obesity, diabetes mellitus, dyslipidemia
(hypertriglyceridemia and low high-density lipoprotein) hypertension F F ˁ
metabolic syndrome F F ˁ F ˈ F cardiovascular
disease F (3-8)
F F BMI
F F fasting blood sugar, lipid profiles F metabolic syndrome F ˁ
Autoimmune diseases: F F Crohn s disease
ulcerative colitis F ˁ 3.8-7.5 F (9)
multiple sclerosis ˈ F
F F F (10)
Lymphoma lymphoma F ˁ
3 F F F (11)
ˈ F ˈ
(combination therapy) F F ˈ F F F F
F F (rotational therapy)
F F F
1. (Standard treatment)
1.1.
1.2.
7. 78
1.3. F (Phototherapy, Photochemotherapy)
1.4. F
2. (Supportive treatment)
3. (Psychotherapy)
F F F F ˁ (Education)
- ˈ F F F F
F ˈ F F
- ˈ F F
- ˆ F F F F
F F (stress) ˈ F
- F F
- F F F beta-blocker, lithium F
F F
- F F F F F
F (Topical therapy)
F ˆ F F
1. Corticosteroids
2. Tar
3. Dithranol (Anthralin)
4. Calcipotriol
5. Calcineurin inhibitor
6. Salicylic acid
F F (Topical steroids)
- F glucocorticoid receptors
F
- F F F F F
F F F F F
F F F F F F F F
- F 1-2
8. 79
- 2 F F 2 F F
F 1-2
monotherapy F
F 2 F (12, 13)
(
1 A)
F F
-
- (Striae) F ˈ F F F F
- F F F F ˈ F F
F 2 F
- F F ˈ F (Tachyphylaxis)(14)
-
F topical steroid class I F F F 2-4 F F F
50 F F(15)
(Tars) ( 2 B)
- F DNA F
-
F
F F
- Tar bath F coal tar solution F F ˁ F 10
- F Tar cream ointment F F
(genital area)
- F Tar shampoo
F F
- F F F F
- F tar bath 15-30 F UVB
- Goeckerman F F 8-12 F F
F UVB
F F placebo(16)
9. 80
F F
- (folliculitis)
- (irritant contact dermatitis)
- F (allergic contact dermatitis)
- ˀˊ F
- ˈ F F F F F F
F UVB, PUVA
Anthralin (Dithranol) ( 3 C)
- F F F
F
- short contact anthralin F 15-30 F F F
F F F F F F F F
F F F F
- Ingram F F F UVB anthralin
F
short contact therapy F F 10-72(17)
F F
-
- ˀˊ F
- F F
F Vitamin D3 analogues (calcipotriol,calcitriol, tacalcitol, maxacalcitol) ( 1
A)
- vitamin D receptors
- F differentiation F F
F
F Calcipotriol F
- psoriasis plaque 2
10. 81
- F F
F F
- F F F F F calcipotriol
F F
- F F UVB PUVA
8 F F ˁ (18)
F F
-
- hypercalcemia F(19)
F F 100 / F
Calcineurin inhibitors (tacrolimus, pimecrolimus) ( 2 B)
- FK506-binding protein F F cytokine F
F
- 2 F F F F F F
(plaque type)
facial and flexural psoriasis F F F F (20, 21)
F F
-
- F F F ˁ F 2 ʾ
Salicylic acid ( F F F F 22)
- F F
F
- Salicylic acid F F F F
F F F 1-2
F F
- F F 20 F F F F F F F
F ˁ
11. 82
- Salicylic acid F UVB
- F F
F F (Systemic therapy)
ˆ F F ˈ F F
F
1. Methotrexate
2. Retinoid
3. Cyclosporine
F
1. Sulfasalazine
2. Hydroxyurea
3. Mycophenolate mofetil
4. 6-Thioguanine
5. Fumaric acid esters
F F
Methotrexate ( 2 B)
Methotrexate F F F F ˈ F ˁ
ˈ
- F dihydrofolate reductase
- F F F DNA
-
F F
- Psoriatic erythroderma
- Pustular psoriasis
- Severe palmoplantar psoriasis F F
- Severe plaque type psoriasis > F 10
- Psoriatic arthritis
F F F F
- F F ( F F F )
12. 83
- F F F 3
- F F F ˁ , HIV
- F ˁ renal insufficiency,
- F ˁ
-
- F ˁ
- F ˁ F
- F ˁ F F
- F ˁ F F ˁ F F F F F
F
- F 2.5-25 . . F F F F F F ˈ 3
F 12 F F F 2.5-5 . 1 F F ˈ 2
F F F 2.5-5 .
F 15-25 . F F
- F F F F 7.5-25 . F F F F F
F F
- F folic acid F F F F F methotrexate F F
F ˈ F F F 1-5 . F F
F
psoriasis F F F F 50 F 75 F ˁ
16 F(22)
F
- complete blood count, BUN, creatinine, liver function test F F F
ˈ 4-6 F ʾ F F
- F F ˁ ˆ Anti-HIV Immunosuppression F F
-
- F ˁ ˆ F F 1 1.5 liver biopsy F ˁ
F F liver biopsy liver biopsy F
1
- F ˁ F ˆ liver biopsy F 3.5-4 (23)
13. 84
- Amino-terminal peptide of procollagen III (PIIINP) F ˈ marker liver fibrosis
F ( F ˆ F )
F
- F F
- F
- F
- F ˈ
- F F ˆ F ˁ
- ˆ ˈ ˆ (nephropathy)
- F F F
-
- F (reactivation of sunburn response)
F
- methotrexate F F F alcohol, salicylates, cotrimoxazole,
trimethoprim, probenecid, phenytoin, retinoids, pyrimethamine furosemide
- F methotrexate (acute methotrexate toxicity) F F F F
leucoverin 20 . (10 ./ ) F F 6 .
Pregnancy category X
Retinoids ( 2 B)
Retinoids F F F F ˈ F ˁ ˈ
F F F F ˁ
- retinoic acid receptor
- F differentiation F F
F F
- Pustular psoriasis F
- Extensive plaque type psoriasis F F F
- Erythrodermic psoriasis F ˈ
F F F F
- F F F
14. 85
- F ˁ F ( F F F F F F F ˁ
F 3 ʾ)
- F
- F ˈ F liver function test
-
- F F F ˁ F F F F tetracycline ( F intracranial hypertension)
phenytoin (competition of plasma-protein binding)
F
F
- Acitretin 0.5-1 / / F 0.25-0.5 / / F F
3
F F
- F F UVB PUVA F F 0.25-0.5 / / F 5 14
F
monotherapy F F (22)
F
- F F ( F ˁ )
- complete blood count, liver function test, cholesterol,triglyceride, HDL F
- Pregnancy test
- F liver function test 1-3
- triglyceride F F ˂ F ˁ F
ˈ F F triglyceride 800 mg/dl
- bone density F F ˁ F F F
ˈ ʾ
F
- Cheilitis (100%), F , F , F (20-50%), F (100%), ˁ ˁ F ,
(bruising), , (20%), , F F
F
15. 86
- F
- F F
- F
- F F (teratogenicity) F F F F
F F F F F 3 ʾ
- F (spur) DISH syndrome
(Diffuse Interstitial Skeletal Hyperostosis)
- (degenerative spondylosis) (osteoporosis)
- ʽ F (premature epiphyseal plate closure)
Pregnancy category X
Cyclosporine A (CyA) ( 2 B)
- cyclophilin calcineurin F F cytokine F
- F F (immunosuppressive properties)
F F
- Psoriatic erythroderma
- F F ˁ F F methotrexate acitretin
F F F F
- F, F
- F ˁ
- F ˁ ˈ
- F ˁ ˈ
- F ˁ F F ˈ F
- F ˁ F F
F
- : F 3-5 / / F F ˈ 2 F F 1-3
F F F 5 / /
- Maintenance: F F 0.5-1 / F F F 2.5-3 / /
F 2 ʾ F F Cy A 5 / / ˈ 6 F F F F
F F F
16. 87
F F 90 F ˁ Psoriatic erythroderma(24, 25)
F
- F (nephrotoxicity) F BUN, creatinine F F 30
F F
- (squamous cell carcinoma) F ˁ skin type I-II
- F ˈ F Human papilloma virus
- F F F
- (hypertrichosis)
- (gingival hyperplasia)
-
F
- Complete blood count
- Uric acid
- Liver function test
- Blood electrolyte magnesium
- Urinalysis
- F BUN, creatinine F 2-3 F F
F 3 F 4-6 F F creatinine F F 30
baseline F cyclosporin A 0.5 1 / / 1 F
creatinine F baseline 10% F cyclosporin A
- F F F F calcium channel blocking F F F
F F Cy A(26)
F F F
- F F aminoglycoside, amphotericin B, ciprofloxacin, trimethoprim,
- Non-steroidal anti-inflammatory drugs, lovastanin colchicine
- F F Cy A F ketoconazole,erythromycin, oral contraceptives, diltiazem,
nifedipine, verapamil, doxycycline, methylprednisolone
- F Cy A F phenobarbitone, phenytoin, carbamazepine, rifampicin
Pregnancy category C
17. 88
F (Phototherapy and photochemotherapy) 4 (
2 B)
F (UV) F T cell
F apoptosis of T cell cytokine F T helper
cell F Th1 Th2
Ultraviolet B light (290-320 nm) Narrowband UVB (NB-UVB; 311-313nm)
ˈ ˆ F NB-UVB F F BB-UVB
phototherapy (290-320nm)
Psoralen and ultraviolet A light (PUVA)
ˈ F Psoralen F UVA F
F
Excimer laser (308 nm) Targeted UVB Therapy
ˈ F F F F F F
F F F ˁ stable recalcitrant plaques F F F
F (Biologic drugs)
F 2 F F F
1) F Tumor Necrosis Factor α (Anti-TNF-α)
- Etanercept (Enbrel™)
- Infliximab (Remicade™)
- Adalimumab (Humira™) ˆ (2552) F F
2) F T cells (Targeting pathogenic T cells)
- Efalizumab (Raptiva™) ˆ (2552) F F
- Alefacept (Amevive™) ˆ (2552) F F
F F Anti-Tumor Necrosis Factor α (Anti-TNF-α) ( 1,
A(34, 35)
Etanercept (Enbrel™)
recombinant human TNF-α receptor (p75) protein
18. 89
Fc portion IgG1 F F soluble membrane-bound TNF-α
F F
- Refractory moderate to severe psoriasis
- Refractory moderate to severe psoriatic arthritis
F
- F F : 50 . F F 1-2 F ˈ 3 50 .
F F 1
- : 0.8 . F 1 .( F 50 .) F
F
- F F F 37
3-5 F ˈ F F
F
- F F (Dose related response)
- F ˈ (rebound) F F F
F F F (antibody) F
- F F F F latex F latex ˈ F
F Pregnancy category B
Infliximab (Remicade™)
Chimeric monoclonal antibody F murine (variable region) human DNA (IgG1-α
constant region)
soluble transmembrane TNF-α molecules
F F
- Severe psoriasis
- Generalized pustular psoriasis
- Moderate to severe psoriatic arthritis
F
- 3-5 . F ( .) F F F F 2 F 0, 2, 6
6-8 F
F
- F F
19. 90
F
- F F F human antichimeric antibodies
F
- Serum sickness
F
- F F F F
-
F F methotrexate F F F F (antibody) F F(36)
F Pregnancy category B
F F F F Anti-TNF-α
Absolute contraindications
- F ˁ F
- F ˁ congestive heart failure class III IV (New York Heart Association Classification)
F ˁ congestive heart failure class I or II ejection fraction <50%
- F (live vaccine)
Relative contraindications
- F ˁ ˈ F (first-degree relatives) ˈ F demyelinating disease
F multiple sclerosis
- F F F (inactive) recombinant vaccine
F
- F F
- F F
F F F F Anti-TNF-α
- PPD (Purified Protein Derivative) tuberculin test
- CBC
- Liver function test
- Hepatitis profile, HIV
- CXR
F F ˁ F F Anti-TNF-α
- CBC 3-6
20. 91
- Liver function test 3-6
- PPD ʾ, CXR ʾ
F F Anti-TNF-α ( )
- F
- F F ˆ (drug induced lupus) F F F
F F (reversible)
- F F (cytopenia)
- F F multiple sclerosis
- F (new onset) F (exacerbation) F (Congestive
Heart Failure)
F F Anti-TNF-α
- F (extrapulmonary TB)
F F (disseminated TB)
etanercept F F infliximab adalimumab
- F histoplamosis, listeriosis,
coccidioidomycosis, cryptococcosis, aspergillosis, candidiasis pneumocystis
ˈ ˈ F F
F F
- (Hepatitis B and C)
- F F F F demyelinating disease
- F F ˁ F (congestive heart failure, CHF) ˈ F
F F F F Anti-TNF-α F ˁ F (CHF
class III or IV) F F (new onset) F F
(exacerbation)
F F ˆ (drug induced lupus-like syndrome)
- F F Anti-TNF-α F circulating antinuclear antibodies F
F (reversible) F F ˈ F
antinuclear antibodies F F F F
21. 92
- F transaminase enzyme infliximab
F
- F F F F F
F F Anti-TNF-α F ˈ F ˁ
F
melanoma non-melanoma
- F F ˁ F Anti-TNF-α
(solid cancers) F F F F
- aplastic anemia, isolated leucopenia thrombocytopenia F
Anti-TNF-α
F
- leukocytoclastic vasculitis rheumatoid arthritis
1 The strength of recommendation for the treatment of psoriasis using topical, traditional systemic and
biologic therapies(15, 38, 39)
/ Level of evidence Strength of recommendation
Topical Therapies
Class I topical corticosteroid 1 A
Class II topical corticosteroid 2 B
Class III/IV topical corticosteroid 1 A
Class V/VI/VII topical corticosteroid 1 A
Coal tar 2 B
Vitamin D analoques 1 A
Anthralin (Dithranol) 3 C
Topical tacrolimus and pimecrolimus 2 B
Topical corticosteroid + salicylic acid 2 B
topical corticosteroid + vitamin D analoque 1 A
Topical tacrolimus + salicylic acid 2 B
Traditional systemic therapies
Methotrexate 2 B
22. 93
Acitretin 2 B
Cyclosporine 2 B
Azathioprine 3 C
Hydroxyurea 3 C
Leflunomide 2 B
Sulfasalazine 2 B
Biologic therapies
Infliximab 1 A
Etanercept 1 A
Adalimumab 1 A
Alefacept 1 A
23. 94
Psoriasis
No arthritis Arthritis
Limited disease
(<10% BSA, PASI < 10)
Extended disease
(> 10% BSA, PASI >10)
Follow the guideline of Thai
Rheumatism Association
Topical/Targeted phototherapy
UVB/PUVA + Topical Rx
Lack of efficacy Lack of efficacy
Combination UVB/PUVA and systemic drugs
Lack of efficacy
Biologic drugs*
+/-UVB/PUVA
+/-Systemic drugs
Systemic drugs + Topical Rx
Lack of efficacy
1 F ˁ
* ˈ F F F F
F F
25. 96
3 F
Topical Systemic Phototherapy
Tar steroid Vit D3 Dithranol MTX Retinoid Cyclosporine Biologics PUVA UVB/Narrowband UVB
Recalcitrant plaque psoriasis F
F
Pustular psoriasis
• Limited
(< 10%BSA, PASI <10)
- 1 - - 1 1 3 - 2
(local PUVA)
3
-
• Extended
(> 10%BSA, PASI >10)
- 3 - - 1 1 2 4 3 -
Psoriasis erythroderma - 3 - - 1 3 1 4 2 3
Psoriasis in pregnancy 2 1 1 1 - - - - - 1
Psoriasis in HIV or
Immunocompromised host
1 1 1 1 - 1 - - - 2
F
F
F monotherapy, F ˁ F combination therapy F F
26. 97
4 F F (Phototherapy and photochemotherapy)(27)
Narrowband UVB
(NB-UVB 310-
313nm)
Broadband UVB
(BB-UVB 290-
320nm)
Psoralen&UVA
(PUVA)(28-31)
Excimer laser
(308nm)(32)
Dosing
( )
MED F
F
50% MED 3-
5 F F
F F
10% MED
MED F
F
75% MED 3-
5 F F
F F
10% MED
MPD F
F
MPD F F
F
0.5-2 J/cm2
2 F
F
40% F F
F
F
F 20%
12 J/ cm2
MED F
F F
6MED (2-
6MED) 2
F F
Efficacy
( )
> F 70
F
F
F ˁ 9 11
F
BB-UVB (
B1)
> F 47
F
F
F ˁ 1 11
(
B1)
F
(remission) 70-90%
F ˁ
F F NB-UVB
F
F (
B1)
> F 75
(PASI 75)
F ˁ 6.2
(
B2)
Safety
( )
Photodamage, PMLE, skin aging, skin cancer Photodamage, skin
aging, increased risk
on nonmelanoma
skin cancers ±
Melanoma, ±ocular
damage
Erythema, blisters,
hyperpigmentation,
erosions. Long term
side effects not yet
clear but likely
similar to NB-UVB
27. 98
Contraindicatons
( F F F)
Absolute : severe photosensitivity
Relative : photosensitizing drugs, melanoma
and nonmelanoma skin cancer
Absolute :
- Severe
Photosensitivity
- Lactation
- Melanoma
Relative :
- age < 10 yrs
- pregnancy
- photosensitizing
drugs
- nonmelanoma skin
cancer
- severe organ
dysfunction
Absolute :
- Photosensitivity
Relative :
- photosensitizing
drugs
- melanoma and
nonmelanoma skin
cancer
F F coal tar (Goeckerman
regimen) anthralin (Ingram regimen)
F
200
≤2000 J/ cm2
F oral
retinoids F
UVA
F
squamous cell
CA F F 30(33)
ˈ
ˈ
F
ˈ F
Minimal erythema dose (MED) F F
F 24
28. 99
1
Psoriasis Area and Severity Index (PASI)
Tick ONE box for each region for A,B,C,D
Head(h) Upper limb(u) Trunk(t) Lower limb(l)
A. Extent of None (0)
Involvement (%) <10 (1)
10-30 (2)
30-50 (3)
50-70 (4)
70-90 (5)
Tick one box for
each body
region.
90-106 (6)
B. Erythema (E) None (0)
score Slight (1)
Moderate (2)
Severe (3)
Tick one box for
each body
region. Very severe (4)
C. Induration (I) None (0)
score Slight (1)
Moderate (2)
Severe (3)
Tick one box for
each body
region. Very severe (4)
D. Desquamation None (0)
(D) score Slight (1)
Moderate (2)
Severe (3)
Tick one box for
each body
region. Very severe (4)
PASI SCORE = 0.1 (Eh + lh + Dh)Extent(h) + 0.2 (Eu + lu + Du)Extent(u) + 0.3 (Et + lt +
Dt)Extent(t)+ 0.4 (El + ll + Dl)Extent(l)
29. 100
2
F ˁ
DLQI Score: _____________
______ ʾ ____________________
Case No. _______ ___ / ______ / ______
F F F ˆ F F F F ?
aaaa F ( F )
1. F F F , , ,
F
(3)
(2)
(1) F
(0) F
2. F F F F F , F (3)
(2)
(1) F
(0) F
3. F F F F ˆ F
F F , F F
(3)
(2)
(1) F
(0) F F F
4. F F F F F
F F
(3)
(2)
(1) F
(0) F F F
5. F F F F F F
F F
(3)
(2)
(1) F
(0) F F F
6. F F F F F
F
(3)
(2) F F
30. 101
(1) F
(0) F
7. F F F F F
F F F F F F ˆ
F
F
(3)
(2)
(1) F
(0) F
F F
8. F F F F F ˆ F F
F
(3)
(2)
(1) F
(0) F F F
9. F F F F ˆ F F (3)
(2)
(1) F
(0) F F F
10. F F F F F ˆ F F
F F ˀˊ F , F ˈ F
(3)
(2)
(1) F
(0) F F F
31. 102
3
F Tuberculin skin test F F
( guideline of Thai Rheumatism Association)
Tuberculin test
F F
F *
F
F
< 15
> 15
F F
F F F
BCG F F
* F ˈ F tuberculin test F F F
F F F tuberculin
test F F ˁ F F F anti-TNF
F F BCG F F F
˂ F F F F ˈ F
F F 15 ʾ
BCG F F F F F BCG F F
F F 15 F ˈ F ˈ
32. 103
3.1
F Tuberculin skin test
F F F F F
(ATS-CDC Criteria For Tuberculin Reactivity, By Risk Group)
( guideline of Thai Rheumatism Association)
ˈ
> 5
ˈ
> 10
• F F ˁ
F 1 ʾ
F ˁ F
• F ˁ anti-HIV
• F ˁ F F ˁ
F F F F
F 15 . F F
F F 1
• F ˁ F
F 5 ʾ
• F F
F F F
F F F F F
• F ˁ F
• F ˁ F
F F F ˁ , silicosis,
F F ˁ ( F
leukemias, lymphomas), F ˁ
F ˁ gastrectomy
jejunoileal byapass F
F F F 10
F F ˈ F 3 F
ˈ F F F
* Centrers for Disease Control and Prevention. Screening for tuberculosis and tuberculosis infection
in high risk populations: Recommendation of the advisory Council for the elimination of tuberculosis. MMWR
1995
33. 104
F
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