This study analyzes a group of 73 patients suffering of various forms of psoriasis, focusing on a subgroup of 42 patients suffering of generalized… [614259]

2. SPECIAL PART

2.1 The purpose of the study

This study analyzes a group of 73 patients suffering of various forms of psoriasis, focusing on a
subgroup of 42 patients suffering of generalized psoriasis vulga ris. The patients had been admitted in
the DV department of the Clincal County Hospital of Arad over a period of one year (1.01.2016 –
31.12.2017)
The study was retrospective and the analyzed data were collected from the medical records, which
provided infor mation regarding anamnesis, clinical aspects, biological and imagistic investigations and
the treatment that was administered during the hospitalization.
The study is aimed to evaluate certain aspects:
– patient distribution according to age, sex, environm ent
– most frequently associated comorbidities and triggering factors
– most frequent biological tests modifications
– the treatment that had been administered

2.2. Materials and methods
2.2.1. Indicators

 The incidence of psoriasis patients in all patie nts admitted to Dermatology Department of Arad
County Hospital
 Incidence by: -the age group
-sex
 The environment of origin

 The occurrence of psoriasis according to the favorable factors: – alcohol
– smoking
– Nutrition status
 The required period of hospitalization
 The type of psoriasis diagnosed
 Association with other diseases
 How long was the patient diagnosed with psoriasis
 Degree and intensity of pruritus
 Type of treatment administered

2.2.3. Methods and techniques of data p rocessing and interpretation To evaluate the proposed theme we
used as a working method:

• method of document analysis
• method of socio -medical observation Technique of evaluation of proposed theme:
• harvesting, processing and interpreting data
• method of so cio-medical observation Technique of evaluation of proposed theme:
• harvesting, processing and interpreting data
• the technique of direct observation, participatory observation and indirect observation
• statistical, demographic, histori cal studies
• documents from the archives of Arad County Dermatology Hospital

2.3. Results and discussions

We performed a retrospective study on a group of 42 patients admitted to the DV department of the
Clinical County Hospital of Arad during the period 1.1.2016 until to 31.12.2016 with the diagnosis of
generalized vulgar psoriasis. Of the 42 patients, 5 required two hospitalizations in the above mentioned
time frame, and one patient required 3 hospitalizations, totaling a number of 49 hospita lizations.

2.3.1. Forms of psoriasis

The number of hospitalizations for all types of psoriasis from the total number of hospitalizations in the
mentioned time frame and hospital department represented a percentage of? (73 out of?), and the
number of hosp italizations for generalized vulgar psoriasis accounted for 67.12% of total psoriasis
hospitalizations.

The distribution of the forms of psoriasis suffered by patients admitted to DV department in 2016 was
the following: 1 admission for psoriatic art hropathy (1.37%), 4 admissions for erythrodermic psoriasis
(5.48%), 7 for guttate psoriasis (9.59%), 1 for inversed psoriasis (1.37%), 11 admissions for palmo –
plantar psoriasis (15.07%) and a total of 49 admissions for generalized vulgar psoriasis (67.12%) , the
latter amounting to a total of 42 patients.
According to several sources, the prevalence of psoriasis forms is the following: vulgar psoriasis –
90%1, erythrodermic psoriasis – 1% -2.25%2, arthropathic psoriasis 1.3% -34.7%3, guttate psoriasis 2%
-3%4 and palmo -plantar psoriasis occurs at a rate of 3%5. The data of the present study can not
strengthen existing epidemiological data because they are not collected from the general population.
However, one can draw a conclusion with regard to the forms of psoriasis requiring admission.

2. Number of hospitalization days

1 Lowell A. Goldsmith, Stephen I.Katz, Barbara A Gilchest, Amy S. Paller, David J. Leffell,
Klaus Wolff (2011 ), Fitzpatrick’ s Dermatology in General Medicine , 8th edition.
2 Erythrodermic psoriasis: pathophysiology and current treatment perspectives (Singh RK, Lee
KM, Ucmak D, Brodsky M, Atanelov Z, Farahnik B, Abrouk M, Nakamura M, Zhu TH, Liao W )
3 Global report on psoriasis. WHO
4 Psoriasis and Streptococci: the Natural Selection of Psoriasis Revisited
J.P. McFadden; B.S. Baker; A. V . Powles; L. Fry
5 http://www.psoriasiscouncil.org/docs/1._epidemiology___classification.pdf
Arthropathic psoriasis
(1 hospitalisations) 1 1,37%
Erythrodermic psoriasis
(4 hospitalisations) 4 5,48%
Guttate psoriasis
(7 hospitalisations) 7 9,59%
Inversed psoriasis
(1 hospitalisations) 1 1,37%
Palmo-plantar psoriasis
(11 hospitalisations) 11 15,07%Generalized vulgar
psoriasis
(49 hospitalisations) 49 67,12%

The goal of hospitalization was to reduce the severity of skin symptoms, and most patients remained
hospitalized until the scales were absent and erythema showed signs of remission . The period of
hospitalization required for each patient varied. Thus, the average period of hospitalization was 8.65
days, with variations between 2 days and 16 days. Most patients showed an improvement compatible
with discharging after 7 days of admissi on.

3. Seasonal variations

< /=5 days 4
6 days 5
7 days 12
8 days 7
9 days 6
10 days 2
11 days 3
12 days 5
13 days 1
14 days 2

Some authors claim that psoriasis has certain seasonal variations that translate into the exacerbation of
symptomatology in winter and its improvement in summer6. However, the number of admissions for
generalized vulgar psoriasis was relatively homogeneous throughout the year.

4. Gender distribution

6 Seasonal variation of acne and psoriasis: A 3 -year study using the Physician Global Assessment
severity scale Vanessa Linds ay Pascoe , MD, Alexandra Boer Kimball , MD, MPH

Season Nr. of hosp. Percentage
Spring 12 24,49%
Summer 11 22,45%
Autumn 14 28,75%
Winter 12 24,49%

The literature suggests that gender distribution of patients suffering from psoriasis is equal7. However,
this study demonstrates a slight prevalence of male patients: 29 patients (69.05%) were males and 13
female (30.94%) females out of a total of 42 patients.

5. Rural -urban distribution

7 Lowell A. Goldsmith, Stephen I.Katz, Barbara A Gilchest, Amy S. Paller, David J. Leffell, Klaus
Wolff (2011 ), Fitzpatrick’ s Dermatology in General Medicine , 8th edition.

Female 13 30,95%
Male 29 69,05%

Distribution by place of origin was also homogeneous, with 18 patients (42.86%) coming from rural
areas and 24 (57.14%) urban patients.

6. Level of education

Distribution by education levels reveals an inversely proportional relationship of the level of education
with the number of hospitalized patients. Thus, most of the persons hospitalized for generalized vulgar
psoriasi s have completed the middle school (14 patients), followed by the group of vocational school
graduates (11 patients). The number of those who completed high school (4 patients), post -secondary
school (3 patients) and those with higher studies (3 patients) is significantly lower, and 4 of the patients
were unable to specify the level of study. This inverse proportionality of the level of education and the
number of hospitalizations can be explained by higher adherence to the outpatient treatment of people
with a higher level of education.

Rural 18 42.86%
Urban 24 57.14%
Grade
School 3 7,14%
Middle
School 14 33,33%
Vocational
School 11 26,19%
Highschool 4 9,52%
Post
Secondary 3 7,14%
Superior
Studies 3 7,14%
Unspecified 4 9,52%

7.Profession

Data on the occupation of the patients involved in the study reveals that 13 of them are employed
(30.95%), 27 are retired (64.29%) and only one patient is unemployed (2.38%). This statistic could be
important to assess the social integration of patients with psoriasis. Many studies indicate that psoriasis
is a debilitating disease both physically and psychosocially. Patients often experience feelings of shame
and low self -esteem. In addition, today ther e are preconceptions about the etiology of this disease,
some people believing it is contagious. So many patients, especially those with severe forms and who
have lesions on the visible regions of the body, become stigmatized by society and are expected to have
difficulty in integration into the workplace. On the other hand, work -related stress may aggravate
psoriasis in some cases. The statistics of this study, with only one patient out of the 42 unemployed,
show that most of the admitted patients had no d ifficulty in maintaining a job.

8.Distribution by age group

Employed 13 30.95%
Retired 27 64.29%
Unemployed 1 2.38%
Other 1 2.38%

Figure 1Age distribution of evaluated the patients

With regard to distribution by age group, this study observed a peak incidence of admissions in the year
2016 in the 50 -59 age group (18 patients), followed by the group of those aged between 60 and 69 (9
patients) and those aged between 70 -79 years (6 patients). It is known that with aging the symptoms of
psoriasis may worsen. In addition, aging brings about the accumulation of comorbidities, which can
also precipitate this symptomatology. However, a gradual decrease in the number of admissions after
the age of 69 can be explained by the fact that after a certain age the aesthetic concern decreases, the
patient pr esenting not himself to the doctor. The younger the patient is, the lower the number of annual
admissions: 6 admissions for those aged between 70 -79 years and 3 admissions for patients aged 30 -39
years.

9. Body mass index

Age Nr. of patients Percentage
30-39 years 3 7.14%
40-49 years 6 14.28%
50-59 years 18 42.85%
60-69 years 9 21.42%
70-79 years 6 14.28%

Figure 2Body mass index

Until now, clinical trials have been able to demonstrate an association between psoriasis and obesity.
However, a causal relationship remains to be established8. This study gives information about the body
mass index of admitted indi viduals for psoriasis: 15 of the patients had normal body weight (only
35.71%) and the rest (64.29%) had a weight above the WHO limit: 12 were overweight (28.57%), 9
suffered from grade I obesity (21.43%), 4 had grade II obesity (9.52%) and two were morbid obese
patients (4.76%). Correlated with the obesity rate in the general population (21.3%) and its distribution
by age groups (in adults up to 39 years obesity is present in 9.9% of them, the percentage increases to
30.1% in age group 40 -59 years and rea ches 41.6% in people over 60)9, these data demonstrate an
association between obesity and psoriasis.

10. Age of onset

8 Psoriasis and the Metabolic Syndrome
Arnon D. COHEN1,2, Harel GILuTz3, Yaakov HENkIN3, Doron zAHGer3, Jonathan
SHAPIRO1, Dan Y . BONNEH1,2 and Daniel A. V ARDY1,2
9 https://www.agerpres.ro/comunicate/2015/07/03/comunicat -de-presa -studiul -oro-13-39-08

Figure 3Age of onset

Out of the 42 patients admitted during 2016, only 20 were able to accurately state the age of onset of
the disease. Thus, a peak incidence of 30 -39 year -old onset (8 patients) was observed, followed by 4
patients who had a disease onset between 20 and 29 years of age. Groups aged between 40 and 49 years
and under 20 had both 3 members an d only two reported that the disease started after the age of 50
years.
Although the onset of the disease can occur at any age, most cases are recorded for the first time
between the ages of 15 and 30 years. Specialty studies suggest splitting psoriasis in to two types,
depending on the age of onset, which is correlated with the presence or absence of HLA class I
antigens, namely HLA -Cw6: type I, onset under 40 years of age and associated with HLA and Type II,
onset over 40 years and not associated with HLA10. However, the clinical significance of these two
subtypes is not important because it does not influence the response to treatment.

10 https://www.agerpres.ro/comunicate/2015/07/03/comunicat -de-presa -studiul -oro-13-39-08
onset before 20 3 15,00%
onset between 20 and 29 4 20,00%
onset between 30 and 39 8 40,00%
onset between 40 and 49 3 15,00%
onset after 50 2 10,00%

11. Endogenous risk factors

In the present study, 19 of the total of 42 patients (45.24%) were smoking or con suming alcohol or held
both vices and the remaining 23 patients (54.76%) reported no consumption of toxins. Four patients
(9.52%) were both smokers and alcohol consumers.

11.1 Smoking

Many previous studies have shown a causal relationship between psorias is and smoking11. In the
present study, 14 of the 42 patients (33.33%) reported that they are smokers, a higher percentage than
the general population (27%)12. However, it was not possible to establish an association between the
degree of severity of the dis ease and smoking, association which other studies define clearly13.

11 Epidemiology, pathophysiology, clinical manifestations, and diagnosis of psoriasis, Steven R
Feldman, MD, PhD

12 http://ec.europa.eu/commfrontoffice/publicopinion/archives/ebs/ebs_429_fact_ro_en.pdf
13 https://www.ncbi.nlm.nih.gov/pubmed/16365261
Alcohol consumption 9 21.42%
Tabacco smoking 14 33.33%
Alcohol+smoking 4 9.52%
23 54.76%Patients that do not
Consume alcohol or smoke

11.2 Alcohol consumption

In the present study, 9 of the 42 patients suffered from chronic etilism, this figure representing 21.42%.
Alcohol is known to have a negative effect on psoriasis , exacerbating symptoms not only by direct
effect but also by lowering adherence to treatment of patients. In addition, it influences the treatment of
psoriasis, increasing the hepatic toxicity of Methotrexate14. Moreover, for the hospitalized patients
alcohol withdrawal is also an issue, because it requires a special therapeutic and disciplinary approach.

12. Comorbidities

Figure 7 Comorbidities

14 Epidemiology, pathophysiology, clinical manifestations, and diagnosis of psoriasis, Steven R
Feldman, MD, PhD
Arterial Hypertension 20 47.61%
8 19.04%
6 14.28%
12 28.57%
Diabetes 9 21.42%
7 16.66%
15 35.71%
2 4.76%Chronic Venous
Insufficiency
Ischemic
Cardiopathy
Hepatosteatosis,
Liver cirrhosis
Hypercolesterolemia,
Hyperglicerydemia
Other forms
Of psoriasis
Anxious-depressive
disorder

Of the comorbidities most common in the 42 hospitalized patients, the most frequent was arterial
hyperten sion (20 patients), this being 47.61%. 9 patients had diabetes (21.42%), 7
hypercholesterolemia or hyperglyceridemia (16.66%) and 6 ischemic cardiopathy (14.28%). According
to a study conducted in 2007, these comorbidities are expected to be found in patie nts with psoriasis,
along with obesity and metabolic syndrome15. Chronic venous insufficiency was found in a proportion
of 19.04% (8 patients), and another common comorbidity was liver disease, affecting 12 patients
(28.57%).

According to the statistical d ata from this study, vulgar generalized psoriasis has been associated with
other forms of psoriasis in 15 out of 42 hospitalized cases (35.71%). These were reversed psoriasis,
palmo -plantar psoriasis, erythrodermic psoriasis. Forms that were studied separa tely were arthropathic
and nail psoriasis. Joint involvement occurred in 5 patients (11.90%) and 8 patients (19.04%). In the
general population suffering from psoriasis, it is estimated that nail manifestations are met up to 40%.

13. Medication before adm ission

13.1. Medication before admission for psoriasis

Figure 8 Medications before admission

The 42 patients analyzed totalised a number of 49 admissions. Before being admitted, 14 of them were
taking no chronic medication for psoriasis or associated c omorbidities, and in 28 cases the patients had
been prescribed medication. Out of these 28 cases, in 11 cases (22.44%) the patients were already
taking medication for psoriasis, and in spite of that their lesions still progressed, due to various
exacerbati ng factors.
The Most frequent systemic drugs that the patients were taking for psoriasis before admission were
systemic corticosteroids (3 cases) and Methotrexate (3 cases) followed by Neotigasone (2 cases) and
Antihistaminics (1 case) and the most frequen t local medications were Corticosteroids (4 cases)
followed by Salicilic Acid (3 cases) and in one case Cignolin had been used locally before admission
into the hospital.

15 Psoriasis and the Metabolic Syndrome Arnon D. COHEN1,2, Harel GILuTz3, Yaakov
HENkIN3, Doron zAHGer3, Jonathan SHAP IRO1, Dan Y . BONNEH1,2 and Daniel A. V ARDY1,2

13.2. Medication before admission for comorbidities

Figure9 Medication before ad mission for comorbidities

Because the most common comorbidity met in the studied group of patients was arterial hypertension,
the most common drugs administered before admission into the hospital were Diuretics (12 cases),
Betablockers (11 cases) and ACE inhibitors (7 cases). Frequent were also cholesterol lowering
medication (7 cases), Hepatoprotectors (6 cases), and insulin (5 cases). NSAIDs had been administered
in 3 cases and Anxiolitics in 2 cases. Out of the drugs mentioned above, betablockers and N SAIDs are
known to possibly trigger a psoriatic flare.16

14. Biological tests results

16 Lionel Fry MD FRCP, An Atlas of Psoriasis , The Encyclopedia of visual medicines series, 2th
edition Taylor and Francis group

Figure 10 biological tests results

Among the total of 49 admissions, the most common biological abnormalities were an increased ESR
found in 29 cases (59.18%), incr eased liver enzymes found in 20 cases (40.81%), increased glucose
was seen in 8 cases (16.32%), abnormal kidney function in 15 cases (3061%), increased WBC count
and eosinophilia were found in 6 cases (12.24%) respectively 5 cases (10.20%).
ESR and WBC c ount are two of the genera l and nonspecific markers used in medicine or the
assessment of acute inflammation (alongside fibrinogen, ferritin, and C -reactive protein), and in some
cases they are also used to evaluate the biological response to treatment.17 An increased WBC count
can a lso indicate a superinfection of the psoriatic lesions. Increased liver enzymes values can count for
the methotrexate toxicity and chronic alcohol intoxication which was seen in many of the patients.
Glucose levels are also the result of one of the comorbi dities the studied patients were affected by
(diabetes mellitus) and abnormal kidney function is frequently seen in patients of old age.

17 The role of inflammatory markers in assessing disease severity and response to treatment in
patients with psoriasis treated with etanercept . Kanelleas A 1, Liapi C
29 59.18%
20 40.81%
8 16.32%
15 30.61%
6 12.24%
Eosinophilia 5 10.20%Increased
ESR
Increased
Liver
Enzymes
Increased
Glucose
Abnormal
Kidney
Function
Increased
WBC count

15. Treatment during hospitalization

From the 49 cases admitted, 23 patients (46.94%) only needed local treatment an d UV therapy for the
psoriasis to improve, and in 26 cases (53.06%) systemic etiological therapy was also needed.

15.1. Systemic treatment

The first line etiological systemic treatment used for most hospitalized cases of psoriasis (total of cases
was 49) was Methotrexate in association with Folic acid (19 patients, 38.77% of all cases). Second
most frequent medication were Corticosteroids, used in 7 cases (14.28%), alone or in association with
MTX or Neotigasone (which was only administered in one ca se, accounting for 2.04% of all cases).
Associated systemic medications were Antihistaminics to soothe the itching in 37 cases
(75.51%), NSAIDs for arthropatic forms and associated illnesses in 10 cases (20.40%), Antibiotics for
cutaneous superinfections or infections of other origins in 6 cases (12.24%) and benzodiazepines in 29
cases (59.18%) in order to deal either with the associated anxiety and depression that is well known to
affect psoriasis patients, or in some cases with alcohol withdrawal symptom s.

15.2. Local treatment

The
gen
eral
guid
elin
es
of
the
topi
cal
treat
men
t were: first keratolytic agents were used in order to reduce the scaling and soften the plaques, thereby
favorizing the absorption of other therapeutical agents, and af terwards local corticosteroids or Cignolin
(Dithranol) were used in order to deal with the altered pathogenetic mechanism of formation of the
psoriatic lesions.
19 38.77%
7 14.28%
Neotigasone 1 2.04%
Antihistaminics 37 75.51%
NSAIDs 10 20.40%
Antibiotics 6 12.24%
Benzodiazepines 29 59.18%MTX +
Folic acid
Systemic
Corticosteroids
Fluocinolone N 22 44.89%
Hydrocortisone 19 38.77%
Clobetazole 3 6.12%
Travocort 8 16.32%
Neopreol 2 4.08%
Diprosalic 9 18.36%
Nidoflor 2 4.08%
7 14.28%
Salycilic acid 45 91.83%
Cignolin 32 65.30%Topical
Antibiotics

Of the keratolytic agents, Salycilic acid was the most commonly used (in 45 cases, 91.83%),
followed by Diprosalic (a combination between Betamethasone dipropionate and salycilic acid), which
was used in 9 cases (18.36% of the total). Topical corticosteroids were used according to the
morphology of the lesions. They ranged from ultra high potency t opical corticosteroids to high,
medium and low potency ones. Some of the preparations were an association between corticosteroids
and antifungal or antibiotic therapeutic agents. The frequency was as follows: Fluocinolone N
(Fluocinonide acetonide + Neomic in) was used in 22 cases (4.89%), Hydrocortisone was used in 19
cases (38.77%), Diprosalic (Betamethasone dipropionate + salycilic acid) was used in 9 cases (18.36%
of the total), Fluocinolone (Fluocinonide acetonide) was used in 8 cases (16.32%), Travocor t
(Isoconazole + Diflucortolone valerate) was also used in 8 cases (16.32%), Clobetasole was used in 3
cases (6.12%), Neopreol (Prednisolone + Neomicin) and Nidoflor (Nistatin + Neomicin +
Triamcinolone) were both used in 2 cases each (4.08% each). Another etiological therapeutic agent
used in association with corticosteroids or alone was Cignolin, with a frequency of 65.30% (a total of
32 cases). In 7 cases (14.28%) the association of other topical antibiotics was needed.
It is worth mentioning that for mo st of the patients more than one topical agent were used, according to
the morphology, localization, severity of the lesions and their evolution.

Case P resentations

Case number 1

We present the case of patient M.T., male, aged 71 years, from rural environment, with no previous
allergies to medication or foods.
Symptoms: erythematous scaly plaques situated on the extensor surfaces; multiple erythemathous
scaly papules situated on the anterior and posterior thorax
Family history: irrelevant
Person al Pathological history: Arterial Hypertension stage III; Psoriasis Vulgaris
Living conditions: Corresponding
Consumption of toxins: Alcohol daily
Medication before admission: Ramipril -AC 10 mg/daily
History of present illness: The patient, 71 years, Known to suffer from Arterial Hypertension and
Psoriasis Vulgaris presents himself with erythematous scaly plaques situated on the extensor
surfaces and multiple erythematous scaly papules situated on the anterior and posterior thorax.
He is being admitted i nto the DV department for investigations, diagnosis and specialty
treatment.
General clinical examination
General state: satisfactory
Height: 171 cm
Weight: 105 kilograms

Nutritional status: Obesity (BMI=35, severely obese)
State of consciousness: Normal
Facies: Normal
Skin: Multiple erythemato -scaly plaques of variable dimensions and round -oval shape, localized on
the extensor surfaces of the body, elbows, knees and dorsal region of the hands. The scales are
white, thick and adherent on the elbows and knees. Multiple erythematous scaly papules, round –
oval with dimensions between 2mm -1cm disseminated on the entire anterior and posterior
thorax, with thin white scales that can be easily removed.
Mucous membranes: normal
Hair and nails: normal
Adipose ti ssue: very well represented
Lymph nodes: superficially impalpable
Muscular system: normotrophic, normotonic, normokinetic
Osteo -articular system: apparently morphologically and functionally integer
Respiratory system: Normally conformed thorax; Pulmonary m urmur present bilaterally; Respiratory
amplitude symmetrical bilaterally, Without perceptible rales
Cardiovascular system: Normally conformed precordial area; Apical impulse perceptible in the V
intercostal space on the left medioclavicular line; Rhytmic heart beats; No perceptible murmurs;
Present pulse in the peripheral arteries; BP= 180/125 mmHg; HR=75 bpm
Digestive system: flexible abdomen, no pain at superficial and profound palpation; regular bowel
transit
Liver, gall bladder, spleen: Liver palpabl e at 5 cm under the costal rim; Impalpable spleen
Uro-genital system: Free kidney beds; Nicturia; Giordano maneuver negative
Nervous, endocrine system, sense organs: Positive deep tendon reflexes, Temporally and space
oriented, no sign of meningeal irrita tion
Clinical diagnosis: Generalized psoriasis vulgaris
Differential diagnosis: having in mind that the patient has previously been diagnosed with psoriasis
vulgaris the positive diagnosis is almost obvious. Nevertheless, other possible diagnoses for psori asis
vulgaris in general are: seborrheic dermatitis, dermatophytosis, eczema, pityriasis rosea, secondary
syphilis, cutaneous lupus erythematosus, lichen planus, squamous cell carcinoma.
Biological findings: within normal limits
Imagistic evaluations:
Abdominal echographic evaluation: Pancreas masked by intestinal gas. Meteorised abdomen.

Poor echographic visibility. Steatosic liver, empty gall bladder, main billiary tract and portal
vein of normal calibers. Urinary bladder with regular contour. Prost ate of normal dimensions.
Both kidneys with normal echostructure. Homogenous spleen of normal dimensions. No liquid
in the abdominal cavity.
Positive diagnosis: The main diagnosis of generalized vulgar psoriasis and secondary diagnoses of
Arterial Hyper tension III stage, Severe Obesity, Liver steatosis and Chronic alcoholism are
being sustained on: Anamnesis: patient with pathological history of psoriasis vulgaris, chronic
consumption of alcohol; Clinical evaluation: BMI=35, psoriasis lesions; Imagisti c evaluations:
echographic evaluation: Liver steatosis
Recommended treatment: Systemic treatment: Hepatoprotectors, Folic acid, Captopril, Indapamid;
Topical treatment: 5% salicylic acid ointment.
Evolution: improvement of the cutaneous lesions
Prognosis : good prognosis if adherence to the treatment is ensured
Complications: the general complications of vulgar psoriasis plus those of the comorbidities
Recommendations: salt restriction, hypocaloric, low fat diet; avoidance of alcohol consumption;
avoidan ce of psychological stress; Systemic treatment with folic acid tablets 5mg/day;
Management of the comorbidities; Dermatological reevaluation in 2 weeks.

Case number 2

We present the case of patient S.M, female, aged 59 years, from urban environment, with previous
allergic reactions to detergents and nuts.
Symptoms: multiple erythematous scaly lesions disseminated on the entire body surface; articular
pains
Family history: irrelevant
Personal Pathological history: Arterial Hypertension; Psoriasis V ulgaris; Chronic Ischemic Disease
Obesity, Breast neoplasm, strabismus, disc hernia
Living conditions: Corresponding
Consumption of toxins: Denies consumption of toxins
Medication before admission: Methotrexate 10 mg, Omeran 20 mg, Vimovo 500 mg, Lagosa 10 0 mg,
Tertensif 1.5 mg, Atoris 10 mg, Desloratadina 5 mg, Auronal 5 mg, Milgamma 100 mg, Metaspar
History of present illness: The patient aged 59 years with previous pathological history of psoriasis and
multiple cardio -vascular, oncological and articular comorbidities is being admitted in the DV

department presenting multiple erythematous scaly lesions of various dimensions disseminated on the
entire body surface; articular pains. The patient solicitates specialty consultation, diagnosis and
treatment.
General clinical examination
General state: altered
Height: 167 cm
Weight: 100 kilograms
Nutritional status: Obesity (BMI=35.9, severely obese)
State of consciousness: Normal
Facies: Normal
Skin: Multiple erythematous scaly plaques and placards of various di mensions (ranging between 1mm
and 15cm) and various shapes (from spherical to irregular) disseminated on the entire body
surface (elbows, knees, thorax, scalp, ears, abdomen, limbs), respecting the face. The scales
have an adherent characteristic, are l ayered, greyish -white.
Mucous membranes: normal
Hair and nails: normal
Adipose tissue: very well represented
Lymph nodes: superficially impalpable
Muscular system: normotrophic, normotonic, normokinetic
Osteo -articular system: apparently morphologically an d functionally integer, joint pains
Respiratory system: Normally conformed thorax; Pulmonary murmur present bilaterally; Respiratory
amplitude symmetrical bilaterally, Without perceptible rales
Cardiovasculary system: Normally conformed precordial area; A pical impulse perceptible in the V
intercostal space on the left medioclavicular line; Rhytmic heart beats; No perceptible murmurs;
Present pulse in the peripheral arteries; BP= 145/80 mmHg; HR=80 bpm
Digestive system: flexible abdomen, no pain at superf icial and profound palpation; regular bowel
transit
Liver, gall bladder, spleen: Impalpable liver and spleen
Uro-genital system: free kidney beds; physiological micturitions; Giordano maneuver negative
Nervous, endocrine system, sense organs: Positive dee p tendon reflexes, Temporally and space
oriented, no sign of meningeal irritation; strabismus
Clinical diagnosis: Generalized psoriasis vulgaris
Differential diagnosis: having in mind that the patient has previously been diagnosed with psoriasis

vulgaris the positive diagnosis is almost obvious. Nevertheless, other possible diagnoses for psoriasis
vulgaris in general are: seborrheic dermatitis, dermatophytosis, eczema, pityriasis rosea, secondary
syphilis, cutaneous lupus erythematosus, lichen planus, squ amous cell carcinoma.
Biological findings: AST=36 U/l (n=5 -32); ALT=44 U/l (n=6 -33);
Imagistic evaluations:
Cervical spine x -ray: diffuse spondilosic and discarthrosic lesions, more advanced in the C4 -T1
region
Lumbo -sacral spine: diffuse spondilosic and discarthrosic lesions, more advanced in the L4 -L5
region, spinal rectitude, on a background of diffuse osteoporosis.
Positive diagnosis: The main diagnosis of generalized vulgar psoriasis and secondary diagnoses of
Arterial Hypertension; Chronic Isch emic Disease, Obesity, breast neoplasm are based on
Anamnesis: patient with pathological history of psoriasis vulgaris, Breast cancer; Arterial
Hypertension; Chronic Ischemic Disease, Obesity; Clinical evaluation: BMI=35.9, psoriasis
lesions;
Recommen ded treatment: Systemic treatment: Hepatoprotectors, Folic acid, Methotrexare,
Diazepam, NSAIDs, gastroprotectors; Topical treatment: 5% salicylic acid ointment.
Evolution: improvement of the cutaneous lesions
Prognosis: good prognosis if adherence to the treatment is ensured
Complications: the general complications of vulgar psoriasis plus those of the comorbidities
Recommendations: salt r estriction, hypocaloric, low fat diet; avoidance of alcohol consumption and
smoking; avoidance of psychological stres s; Sun exposure; Systemic treatment with Methorexate 3
tablets/week and folic acid 2 tablets/week; Management of the comorbidities; Rheumatology
consultation; Dermatological reevaluation in 2 weeks.

Conclusion
1. Psoriasis is a chronic inflammatory disea se of the skin, noninfectious and non -sensitive. This
Pathology affects more than 100 million people around the globe.
2. Gravity and prolonged progression of psoriasis, which, by its complications, can put in
Danger to the patient's life, if not therapeut ically.
3. From a total of 1,598 patients admitted to the Department of Dermatology of the Arad County
Hospital
In the period 01.01.2014 – 31.12.2015, respectively 859 in 2014 and 739 in 2015, they boarded

In a percentage of 7%, 128 patients diagnosed with psoriasis.
4. The prevalence of the majority of patients with psoriasis in the examined group is that of the groups
Between 50 -60 and 60 -70 years of age.
5. From the study of patients suffering from psoriasis pathology in Arad County between 2014 –
2015 is a 77% male, with a net higher than females,
This being only 23%.
6. The incidence of affection according to the environment of origin showed that the difference is quite
high
Of rural and urban patients is a percentage of those in the urban area
Of 62%.
7. A fairly high percentage of patients who have been diagnosed with o
Ages 1 -5 years, chronic and recurrent, influence on quality of life, not affected
Labor, but emotional changes such as embarrassment, frustration, depression can occur.
8. The study show s that in an exacerbation episode with psoriasis pathology, a patient
It takes an incremental number of 7 -11 days to blur the climax of
exacerbation.
9. From the study carried out on patients admitted to the Department of Dermatology of the Arad
County Hos pital,
All types of psoriasis known in the medical literature were highlighted, but in different percentages
Compared to those in the world. In ascending order were: psoriasis gut 2%, psoriasis
Pustulous 5%, reversed psoriasis 7%, erythrodermic psoriasis 2 0%, vulgar psoriasis 66%.
10. Generalized localization of lesions, occupies a majority percentage in the study.
11. A high number of patients experience pruritus as manifestations of this pathology, this aspect
Greatly influencing the quality of life and s ocial aspects.
12. Cardiac pathologies are most often associated with the psoriasis, but the liver pathology also
occupies
An important place among sufferers of psoriasis due to high alcohol consumption. diabetes
And psychiatric pathologies and orthopedic pathologies are at the forefront of the study
performed.
13. Food habits are a very important factor in triggering and exacerbating
Psoriasis pathology.
14. The most frequently favored factors were the consumption of alcohol and tobacco with a
74% of all p atients with psoriasis.

15. In psoriasis treatment, combination therapy, local and systemic therapy is used successfully.
Bibliography
1 Brian R. Walker et.al Nicki R Colledge et. al Stuart H. Ralston (2010) Davidson’ s Principles and
Practice of medicine, 21 st edition.
2 http://obiettivobenessere.tgcom24.it/2013/10/01/la -psoriasi -come -si-sviluppa -il-perche -e-le-
cure/
3 Mariella Fassino,Anna G. Burroni ,Michele Ruggiero (2010 ),La Psoriasi un male antico
Viaggio nella malattia della pelle
4 http://psoriasi.corriere.it/2015/04/16/quali -sono -le-cause -della -psoriasi/
5 http://www.corriere.it/salute/speciali/2014/psoriasi/notizie/psoriasi -stress -elemento -rischio –
fattore -scatenante -98d43c8a -49cc -11e6 -ab2a -a1fe125e6334.shtml
7 Lionel Fry MD FRCP, An Atlas of Psoriasis , The Encyclopedia of visual medicines series, 2th edition
Taylor and Francis group
8 Telfer NR, Chalmers RJ, Whale K, Coleman G. The role of streptococcal infection in the initiation of
guttate psoriasis. Arch De rmatol 1992;128:39 –42
9 Baker BS, Powles AV, Garioch JJ, et al. Differential T cell reactivity to round and oval forms of
Pityrosporum in the skin of patients with psoriasis.Br J Dermatol 1997;136:319 –25
10 Fortes C et al: Relationship between smoking an d the clinical severity of psoriasis. Arch
Dermatol 141(12):1580 -1584, 2005
11 Herron MD et al: Impact of obesity and smoking on psoriasis presentation and management.
Arch Dermatol 141(12):1527 -1534, 2005
12 Lowell A. Goldsmith, Stephen I.Katz, Barbara A Gilchest, Amy S. Paller, David J. Leffell, Klaus
Wolff (2011 ), Fitzpatrick’ s Dermatology in General Medicine , 8th edition.
13 http://www.sitri.it/psoriasi/psoriasi.html
14 http://www.pharmamedix.com/patologiavoce.php?pat=Psoriasi+&vo=Diagnosi
15 Floare folescu Victor Neamtiu,(2008 ) Dermato -Venerologie, Editura “CONCORDIA”Arad,
16 http://www.medicinalive.com/mala ttia/psoriasi -guttata/
17 http://bastapsoriasi.com/psoriasi -unghie/
18 http://psoriasicure.org/sintomi -psoriasi/sintomi -e-cause -psoriasi -pustolosa/
19http://bastapsoriasi.com/psoriasi -pustolosa -tutto-cio-che-devi-sapere/
20 http://bastapsoriasi.com/psoriasi -inversa/
21 http://psoriasicure.org/cure -psoriasi/come -curare -la-psoriasi -eritrodermica/
22 http://www.farmacoecura.it/malattie/psoriasi -sintomi -cura-cause/#steps_3
23 Erythrodermic psoriasis: pathophysiology and current treatment perspectives (Singh RK, Lee)
KM, Ucmak D, Brodsky M, Atanelov Z, Farahnik B, Abrouk M, Nakamura M, Zhu TH, Liao W )
24 Global report on psoriasis. WHO
25 Psoriasis and Streptococci: the Natural Selection of Psoriasis Revisited
26 J.P. McFadden; B.S. Baker; A.V . Powles; L. Fry
27 http://www.psoria siscouncil.org/docs/1._epidemiology___classification.pdf
28 Seasonal variation of acne and psoriasis: A 3 -year study using the Physician Global Assessment
severity scale Vanessa Lindsay Pascoe , MD, Alexandra Boer Kimball , MD, MPH
29 Psoriasis and the Metabolic Syndrome
Arnon D. COHEN1,2, Harel GILuTz3, Yaakov HENkIN3, Doron zAHGer3, Jonathan SHAPIRO1,
Dan Y . BONNEH1,2 and Daniel A. V ARDY1,2

30 https://www.agerpres.ro/comunicate/2015/07 /03/comunicat -de-presa -studiul -oro-13-39-08
31Epidemiology, pathophysiology, clinical manifestations, and diagnosis of psoriasis, Steven R
Feldman, MD, PhD
32 http://ec.europa.eu/commfrontoffice/publicopinion/archives/ebs/ebs_429_fact_ro_en.pdf
33 https://www.ncbi.nlm.nih.gov/pubmed/16365261
34 The role of inflammatory markers in assessing disease severity and response to treatment in patients
with psoriasis tre ated with etanercept . Kanelleas A 1, Liapi C .