Management of post-infectious olfactory dysfunction: a nationwide survey of UK ENT consultants.

OBJECTIVE: To determine the current practice of UK ENT consultants in investigating cases of suspected post-infectious olfactory dysfunction. METHOD: We prepared questionnaires and posted these to every consultant ENT surgeon registered with the British Association of Otolaryngologists Head and Neck Surgeons (BAO-HNS). Questions included preferred radiological investigation, smelling test and follow up. RESULTS: A total of 510 questionnaires were sent, with a response rate of 51%. Most UK consultant ENT surgeons investigated suspected post-infectious olfactory dysfunction by performing either a CT (44%) or an MRI (29%) scan, but only 37% performed formal smell tests. Most consultant ENT surgeons (76%) decide not to follow up post-infectious olfactory dysfunction. CONCLUSION: This study gives an indication that suspected post-infectious olfactory dysfunction is not investigated thoroughly in the United Kingdom, with only a minority of clinicians performing formal smell tests and a lack of consensus as to radiological investigation. Standardisation of investigations is key to adequately managing suspected post-infectious olfactory dysfunction.

Psoriasis. A review of recent advances in treatment.

Current concepts in the treatment of psoriasis are reviewed, including: traditional modalities of dithranol (anthralin), tar, and corticosteroids alone or in combination with other agents; phototherapy and photochemotherapy; experimental studies with the aromatic retinoid etretinate and related analogues; dialysis; and the potential use of hyperthermia. Prudent administration of agents that are known to have serious side effects should be the concern of all clinicians. Many regimens that have beneficial short term results may have the potential for long term sequelae that may not only affect the patient but the offspring as well. Two of the most promising innovative concepts in the therapeutic armamentarium for psoriasis are psoriasis 'day care centres', and prevention and self-care. With the ever-increasing costs of medical care throughout the world, ways and means of reducing costs should be initiated by the clinician when considering a treatment programme. The clinician has the responsibility of determining whether the severity of the disease warrants ambulatory outpatient regimens or hospitalisation. If the patient would benefit from daily attention, then the psoriasis day care centre approach provides an appropriate clinical setting. However, in addition to administering appropriate medication, it is incumbent upon the clinician to educate patients regarding their disease and the triggering factors to prevent exacerbations. 'Disability prevention' means extending the services of clinicians and others to deal systematically with 2 areas involved in disease development; one is recognising the genetic component of psoriasis; the other, environmental triggering factors, e.g. infection, trauma to the skin, low humidity, and stress. Until recently, dermatology has focused on diseases and repairing the damage they cause. Now, the significance of genetic and environmental influences in multifactorial diseases like psoriasis has been realised, as has the importance of educating psoriasis patients to understand their disease and to encourage them to take responsibility for self-care so that the morbidity will be lessened.

Psoriasis in the tropics. Epidemiologic, genetic, clinical, and therapeutic aspects.

There is a dearth of information on psoriasis in the tropics. Psoriasis occurs more frequently in northern geographic regions than in tropical climates. Its prevalence varies not only within the ethnic groups of a country but from country to country. A review of published studies on the natural history of psoriasis in the tropics is presented in this article.

The action and safety of ketoconazole: a brief literature review.

A great number of human diseases can be attributed in some way to the effects of fungi, and consequently have long been recognized as important to the dermatologist and mycologist. However, not in all spheres of medicine are fungi significant in the diagnosis and treatment of disease. Fungi are biochemically similar to the host since they are eukaryotic. Thus, it is difficult to synthesize agents that will destroy the pathogenic organism and not harm the patient. Ketoconazole, an imidazole, was the first broad-spectrum, oral antifungal drug to be used in clinical medicine. Selected publications on the pharmacology, comparative efficacy in treatment, toxicity and safety of ketoconazole are briefly reviewed. In addition, new areas of research being undertaken for the azole derivatives are surveyed.

Nonpustular palmoplantar psoriasis.

Nonpustular palmoplantar psoriasis can be disabling in causing painful fissuring and scaling. Preventive measures in avoiding friction and irritants can reduce the morbidity of this variant. Lubricants, anthralin, and corticosteroids form the mainstay of therapy in mild and moderate psoriasis of the palms and soles. Topical PUVA therapy and use of cytotoxic agents should be reserved for refractory cases.

Nail psoriasis.

Psoriatic nail involvement is common and accompanies skin lesions on the body surface. The occurrence of nail psoriasis has been reported in up to 50 percent of patients, including children, adults, and the elderly. The characteristics of psoriatic nails are pitting, discoloration, onycholysis, subungual hyperkeratosis, as well as crumbling and grooving of nails and splinter hemorrhages. There is no consistently effective treatment for psoriatic nail involvement; nails are difficult to treat and respond slowly to therapy. Corticosteroids, 5-fluorouracil, systemic agents such as photochemotherapy, oral retinoids, and methotrexate, and nail avulsion are among the therapeutic approaches utilized. We offer suggested measures whereby patients may benefit in the prevention and control of their nail psoriasis.

Genital psoriasis.

Psoriasis of the genitalia occurs in all age groups from infancy to the elderly. Approximately one-quarter to one-half of various epidemiologic studies report that genital psoriasis occurs with a higher frequency in males than in females. Therapeutic modalities for management of psoriasis in this site underscore the need for caution in not irritating the sensitive genital skin. Preventive measures include avoiding tight under- and outer-garments that provoke penile or vulvar psoriasis as well as maintaining cleanliness of the genital area.

Natural history and treatment of scalp psoriasis.

The scalp is a common site of involvement at onset and throughout the course of psoriasis. Worldwide census studies report that approximately half of the psoriasis population are afflicted with psoriasis of the scalp. We describe the frequency, clinical aspects, and treatment of scalp psoriasis in childhood, adulthood, and in the geriatric age groups. Measures of prevention and control are reviewed.

Psoriasis and ultraviolet radiation.

Prevention and detection screening programs as a public health service in curtailing the ever-increasing incidence of all forms of skin cancer are reviewed. The effect of solar and artificial ultraviolet radiation on the general population and persons with psoriasis is examined.

Systemic antifungals.

The administration, effectiveness, action, adverse reactions, and commentary are presented in Table I for a selected number of systemic antifungal agents.

Psoriasis and alcoholism.

The association of psoriasis and alcoholism is controversial. Early studies negate a relationship of psoriasis and alcohol intake, whereas more recent studies demonstrate a positive correlation between the two. Results of investigations of familial aggregation, adoption studies, twin concordance, marker gene associations, and biochemical and genetic evidence suggest that alcoholism is a multifactorial disorder with both genetics and environmental factors playing a role. Selected studies on the occurrence of psoriasis and alcoholism are presented.

Perianal and intergluteal psoriasis.

Psoriasis of the perianal and intergluteal areas can cause pain and discomfort. Individualized therapeutic programs will reduce the morbidity. It is essential that optimal hygienic conditions be maintained in these regions to avoid itching and inflammation.

Guttate psoriasis.

Prevention and early treatment with appropriate antibiotics administered at the onset of upper respiratory infections in children with psoriasis may be able to block the appearance of acute guttate psoriasis. A careful screening for a focus of infection is also indicated, especially in children.

Psoriasis associated with human immunodeficiency virus/acquired immunodeficiency syndrome.

Since the prevalence of psoriasis is between 1.5 to 2 percent, it would be expected to occur by chance in a person infected with HIV who is genetically predisposed to psoriasis. Several studies in the literature on HIV/AIDS-associated psoriasis have reported such percentages of frequency. Although psoriasis is a low priority for a patient with HIV/AIDS who is coping with many other cutaneous conditions and cancers, when treating the HIV/AIDS-infected psoriatic patient, immunosuppressive drugs are contraindicated because of their serious impact on an already immunodeficient person.

Pustular psoriasis.

Pustular psoriasis may appear as localized pustular psoriasis, which runs a chronic course, or, in a more severe state, generalized pustular psoriasis. Precipitating factors influencing both local and generalized forms include various drugs (eg, lithium, hydrochloroquine), irritative topical therapy (eg, coal tar), dental and upper respiratory infections, pregnancy, and solar irradiation. Both adults and children are affected, but infantile and juvenile pustular psoriasis is rare. It is recommended that provoking factors be eliminated as the first line of management. Short-contact anthralin therapy and topical psoralen/ultraviolet A can be used in treating localized pustular psoriasis. Methotrexate, hydroxyurea, etretinate, dapsone, cyclosporin A, as well as systemic corticosteroids may be needed in life-threatening cases.

Erythrodermic (exfoliative) psoriasis.

Erythrodermic (exfoliative) psoriasis represents a manifestation of psoriasis that is difficult to treat and requires the execution of consummate clinical skills. Careful analysis of precipitating factors may prevent recurrences. Systemic as well as topical therapy are essential for a favorable outcome.

Psoriasis: a stress-related disease.

Stress is a well-known triggering factor in the appearance or exacerbation of psoriasis. The concept of psychoneuroimmunology in relation to stress is described. As part of the total care of the psoriasis patient, physicians are urged to augment traditional psoriasis treatment regimens with stress-reduction strategies, such as biofeedback, meditation, and self-help approaches.

The office visit and the self-help concept in treating the patient with psoriasis: a strategy revisited.

All dermatologists and physicians who care for patients with psoriasis should be aware that their patients may have an insufficient understanding of their disease. Every effort should be made to help patients fully comprehend their condition: to become aware of factors that can improve self-care and environmental events that can exacerbate the disorder. Strategies for self-help instructions can be modified from the highly structured approach in a university setting to the more informal atmosphere of a physician's office using the abundant patient educational resources available today. Improving communication between patient and physician will benefit the patient, by providing knowledge about psoriasis, encouraging the patient to acquire specific skills in dealing with the disease, and instilling a sense of responsibility for the patient's involvement in self-care.

Childhood psoriasis.

Psoriasis is a common skin disease in infants, children, and adolescents. A review of the clinical, epidemiologic, genetic, and therapeutic aspects of childhood psoriasis is presented. Population studies indicate that the first signs of psoriatic lesions occur in the pediatric age group, birth to 18 years of age, and that both genetic and environmental factors interact to precipitate the development of psoriasis. Koebner reactions are the result of external or internal triggering factors, such as physical injury to the skin, low humidity, and certain drugs. The most frequently observed variant to psoriasis is the plaque type, followed by guttate psoriasis, and juvenile psoriatic arthritis. Pustular psoriasis and erythrodermic psoriasis are rare forms of the disease, but are seen in children from infancy to adolescence. The scalp is the most frequently affected site of involvement in pediatric psoriasis, followed by the appearance of lesions on the extensor surfaces of the extremities, trunk, and nails. Although not common in adult psoriasis, the face and ears are often involved. Topical medications such as corticosteroids, calcipotriol, coal tar preparations, anthralin formulations, and ultraviolet B are recommended in monotherapy or in combination therapy, whereas psoralen plus ultraviolet A, methotrexate, and retinoids should only be administered in crisis situations. The treatment objectives in childhood psoriasis are to preserve skin surfaces, to afford physical relief from the disease, and to employ treatments that do not endanger the health or future development of the child.

Search for the psoriasis susceptibility gene: the Newfoundland Study.

The authors review early pioneering research on the genetics of psoriasis and recently published independent and collaborative investigations searching for the psoriasis susceptibility genes. We describe the research design and current plans for a joint pursuit between the Psoriasis Research Institute, the Memorial University of Newfoundland, and Chiroscience R&D, Inc., for susceptibility genes. A unique study sample from Newfoundland, drawn from affected and unaffected members of multiplex families and relatives, provides a nearly homogeneous isolated population. Families reflect English, Scottish, and Irish ancestry, and have been in residence in Newfoundland for over 300 years. The prevalence of psoriasis is estimated to be 2 to 3%. Familial psoriasis occurs in over 85% of families, with at least one affected member. The experimental strategy using linkage analysis and linkage disequilibrium analysis of the collected tissue bank are discussed, emphasizing prospects for the future outcome of the research findings.