Psoriasis: Recognition and Management Strategies.

Psoriasis is an inflammatory skin and systemic disorder that affects 3.2% of the U.S. population, including 1% of children. It is an immune-mediated process triggered by an interplay of genetic, environmental, physical (e.g., skin trauma), and infectious factors. Associated comorbidities include cardiovascular disease, obesity, metabolic syndrome, diabetes mellitus, and inflammatory bowel disease. Psoriasis presents in various forms, including plaque, guttate, erythrodermic, pustular, inverse, nail, and psoriatic arthritis. The most common form is plaque psoriasis, which affects 90% of adults with psoriasis. Psoriasis is diagnosed clinically based on the presence of characteristic erythematous, scaly skin plaques in typical locations, with associated history and systemic symptoms. Treatment strategies are similar for most forms of psoriasis and based on body surface area involved. Topical corticosteroids, vitamin D analogues, and tazarotene are used to treat mild to moderate disease. Systemic treatment with nonbiologic and biologic agents and ultraviolet B phototherapy are used for moderate to severe disease, with the exception of apremilast, a systemic agent approved for mild psoriasis. Disease management is improved with maintaining ideal body weight, avoiding tobacco products, limiting alcohol, and practicing stress reduction techniques. The Psoriasis Area and Severity Index is a tool to assess severity and monitor treatment effectiveness over time. Special consideration is needed for treatment of children and patients who are pregnant, breastfeeding, or trying to conceive.

Exercise Stress Testing: Indications and Common Questions.

Exercise stress testing is a validated diagnostic test for coronary artery disease in symptomatic patients, and is used in the evaluation of patients with known cardiac disease. Testing of asymptomatic patients is generally not indicated. It may be performed in select deconditioned adults before starting a vigorous exercise program, but no studies have compared outcomes from preexercise testing vs. encouraging light exercise with gradual increases in exertion. Preoperative exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery or who have active cardiac symptoms before undergoing nonemergent noncardiac surgery. Exercise stress testing without imaging is the preferred initial choice for risk stratification in most women. Sensitivity and specificity increase with the use of adjunctive imaging such as echocardiography or myocardial perfusion imaging with single-photon emission computed tomography. Exercise stress testing is rarely an appropriate option to evaluate persons with known coronary artery disease who have no new symptoms less than two years after percutaneous intervention or less than five years after coronary artery bypass grafting. The Duke treadmill score has excellent prognostic value for exercise stress testing. Imaging is not necessary if patients are able to achieve more than 10 metabolic equivalents on exercise stress testing. Exercise stress testing is not indicated before noncardiac surgeries in patients who can achieve 4 metabolic equivalents without symptoms.