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Background: Topical corticosteroids are the primary treatment for scalp psoriasis. Keratolytic agents are promoted as adjunctive treatments.  However, complex treatment regimens may result in poor adherence and outcomes.Objective: To evaluate the evidence for the need for use of topical keratolytic agents as opposed to topical corticosteroid monotherapy in the treatment of scalp psoriasis.Methods: A review of the literature was performed seeking clinical trials using topical keratolytics, topical corticosteroids or the combination for treatment of scalp psoriasis.Results: Complete clearance of scalp psoriasis can be achieved in 10-78% of patients using topical corticosteroids alone, in 3% of patients using topical keratolytics alone, and in up to 84% using a combination of topical keratolytics and topical steroids. Clinical trials comparing the combination of keratolytics and topical corticosteroids versus topical corticosteroids alone found marginally more efficacy using combination regimens.Limitations: We could not find any long term study evaluating the efficacy of combination therapy in scalp psoriasis and its effect on the patients’ adherence.Conclusion: High potency topical corticosteroids are usually effective in treating scalp psoriasis in clinical trials.  Poor efficacy in clinical practice may be owing to poor adherence to the treatment regimen. Using a keratolytic agent in conjunction with a topical corticosteroid may provide marginal additional benefit in clinical trials, but that benefit is likely outweighed by the downside of complicating treatment and reducing adherence in the clinical setting, unless a single product containing both medications were used.

Background: Although some skin conditions predominate in patients of certain ages, little data exists about the relative prevalence of dermatologic conditions by age.Objectives: To determine the common skin conditions by age group in the United States, both in dermatologist samples and for all specialties.Methods: The National Ambulatory Medical Care Survey (NAMCS) was queried for top diagnoses at dermatologist and all skin disease visits from 1993-2010. ICD-9 coding was used for diagnoses.Results: There were 588 million estimated visits to dermatologists in the US from 1993-2010. Atopic dermatitis, acne, and actinic keratosis were the top diagnoses in all age groups. Common diagnoses in all groups included contact dermatitis and benign neoplasm. There were 740 million estimated skin disease visits to all physicians; more of these were acute or infectious. The percent of skin diseases seen by dermatologists gradually increased with age to a maximum of 55% in the 75-84 year age group.Conclusion: Dermatologic conditions seen in different age groups and between dermatologists and non-dermatologists vary. With advancing age, Americans increasingly seek a dermatologist rather than a non-dermatologist physician for skin conditions.

Background: Common belief holds that as topical glucocorticoids are used over time the less effective they become, a phenomenon called tolerance or tachyphylaxis.Objective: To determine what evidence supports the concept of tachyphylaxis to glucocorticoids.Methods: We searched Medline and Google Scholar for articles on tachyphylaxis to glucocorticoids published through October 2012. Results: Rapid tolerance, tachyphylaxis, to non-clinical effects of glucocorticoids has been reported in literature. However, clinically significant tolerance to topical glucocorticoids has not been identified in clinical trials. We did not identify any evidence that clinical efficacy of glucocorticoids in inflammatory skin diseases significantly diminishes during long term continuous use.Limitations: Tachyphylaxis or tolerance to clinical effects of topical glucocorticoids in inflammatory skin diseases is not fully characterized or well studied.Conclusion: Based on available data in literature, there is no clinical trial supporting the concept that topical glucocorticoids lose effectiveness over time, nor that intermittent use of topical glucocorticoids is more effective than continuous use.

Background: Skin inflammation causes vasodilation and increased vascular permeability, which may result in decreased blood pressure and peripheral edema. Patients with erythroderma usually compensate for low blood pressure with fluid retention and increased cardiac output. However, if the heart cannot support increased cardiac output, blood pressure will stay low, resulting in severe compensatory fluid retention, which leads to decompensated congestive heart failure, and pulmonary edema. Treatment for high-output congestive heart failure focuses on the primary pathology, which is skin inflammation. However, aggressive treatment of the inflammation with glucocorticoids may result in rapid resorption of extravascular fluid into the intravascular space and occurrence or aggravation of pulmonary edema. Erythrodermic patients with no clinical heart failure are also at risk for developing pulmonary edema if they receive glucocorticoids and/or intravascular fluids. Most hospitalists and dermatologists are not familiar with fluid administration and ways to manage cardiovascular function and blood pressure in patients with skin inflammation. Objectives and methods: In this article, we discuss the pathophysiology of vascular and fluid changes in the context of diffuse skin inflammation and provide some basic guidelines that can be presented to hospitalists by dermatologists. Limitations: Most of the recommendations and guidelines in the article are based on basic science and on the personal experience of the authors and are not supported by controlled trials. Diffuse skin inflammation causes major changes in the cardiovascular system and in the perfusion of internal organs. We provide guidelines for management of fluid status and cardiovascular function in patients with diffuse skin inflammation. Dermatologists can provide hospitalists or primary care providers with these guidelines to help them with creating better treatment plans. [ABSTRACT FROM AUTHOR]

Background:Scalp psoriasis can have a considerable impact on patients’ quality of life and is considered difficult to treat. Treatment failure may, however, be due to poor adherence, as application of topical treatments to hair bearing areas is difficult and time consuming and also poor communication between physician and patient. Objective:To assess the efficacy of short-term treatment of scalp psoriasis with topical clobetasol lotion. Materials and methods:Twelve patients with mild to severe scalp psoriasis were recruited for this study. Patients applied clobetasol 0.05% lotion twice daily for seven days. They were followed up with phone calls three days after starting the treatment. Skin hydration, transepidermal water loss (TEWL) and skin erythema were assessed noninvasively at baseline and end of study. Results:One week after treatment, median PSI score decreased significantly (p = .002). There was also a significant decrease in median TEWL (p = .012) and increase in skin hydration one week after treatment (p = .010). Eighty three percent of patients were satisfied with treatment result and felt convenient with applying clobetasol lotion. Limitations:Lack of a long-term follow-up. Conclusions:Psoriasis is a long-term disease, and improving adherence in the short time could improve patient’s adherence to treatment in long time. [ABSTRACT FROM PUBLISHER]