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Any written notes made by the clinical supervisor generic indapamide 1.5 mg line heart attack recovery, or discussions with their own supervisor will be anonymous and non-identifiable 6 buy generic indapamide 2.5 mg on line pulse pressure in aortic regurgitation. The clinical supervision provided will be evaluated at appropriate intervals to be decided between all parties order 2.5mg indapamide mastercard arrhythmia fatigue. Any reports prepared for management on the basis of such evaluations will be about appraisal of the supervision provided and not about the performance of the supervisees 8 indapamide 1.5 mg discount hypertension harmony of darkness. The relationship between the line manager, professional manager and Supervisor should be made explicit to all concerned before any supervision begins (for example the supervisor might be involved in assessment of the supervisee) 9. In the event of cancellations due to holidays or sickness as much notice as possible should be given. These arrangements can be changed by mutual negotiation, and can be terminated with a reasonable period of notice: (number of months) Additionally, research already referred to has identified key questions to ask when initiatives that support the professional functioning of staff (clinical supervision is an example) are being planned. Thorough planning, open negotiation and rigorous evaluation is essential to successful initiatives. Single session therapy: maximising the effect of the first (and often only) therapeutic encounter. Brief psychotherapy in war neuroses, Psychosomatic Medicine 1944; 6: 123-31 13 Golan N. Love s executioner and other tales of psychotherapy London: Penguin 1991 17 Erikson E. Treatment choice in psychological therapies and counselling; Evidence based clinical practice guideline. Maslach, Christina (Ed) Professional burnout: Recent developments in theory and research. Leicester national youth bureau and council for education and training in youth and community work. New York: Basic Books 1958 46 British Association for Counselling and Psychotherapy. There has also been an increase in the rates of infection of other sexually transmitted infections, in particular chlamydia, gonorrhoea and syphilis. Several studies have shown this aspect of the work covers3 * a significant proportion of the health adviser workload. A combined system of line management supervision and independent counselling supervision is recommended. To establish informed consent three conditions need to be met: The individual must be competent to consent The individual needs to understand the purpose, risks, harms and benefits of being tested and those of not being tested The individual must consent voluntarily However informed consent is only one of the purposes of the discussion. Other issues such as risk reduction and health promotion also need to be addressed. It is recommended that the health adviser goes through the pre-test discussion checklist and covers the following issues: 1. Providing details of the test and how the result will be provided, including a brief discussion regarding positive, negative and equivocal results and information about follow up 8. Ensure that results are given in private, and patient details checked to ensure the right person receives the correct result. It is important to bear the practicalities in mind when organising appointments for results and ensure there is adequate access to medical assessment and care if necessary. Each clinic will have its own policy and some health advisers have separate clinics for giving results, but generally it is recommended the health adviser give negative results to those most at risk, or within the 3 month window period, or to those who require further support around safer sexual practices and behaviour change. Given that this is an unusual result to give, it is important that lots of time and support are given to the patient if necessary. An equivocal result is where the tests taken in the laboratory from a patient s first blood sample are neither positive nor negative. The tests have differing cut off points so it is essential the consultant/senior doctor/health adviser discuss with the virologist which tests have been taken and what the virologist s opinion is on the likely outcome of the result, given the patient s risk and health issues, for example, the possibility of recent sero-conversion. It is important that the health care worker documents the outcome of the discussion and probability of the result within the patient notes. Ensure the patient is informed of the nature of the equivocal result as clearly as is possible Give the patient the opportunity to read the result, pointing out the clinic number and date of birth Clarify the patient s understanding of the result Discuss the need for the patient s initial blood sample to be tested further at the reference laboratory for a more definitive result Give clear guidance based on the laboratories information of when results will be available and arrange the patient s re-attendance Explain the need for a further blood specimen on the day of receiving the result for repeat testing, which may provide a more conclusive result Address the patient s immediate reactions. Most equivocal results do turn out to be negative, but it is important to check the history and nature of risk, and the timing of the last risk activity. Remember that it is a medical diagnosis and the doctor has responsibility in interpreting that result. It is essential that positive results are not dealt with single-handedly, and require a multidisciplinary approach so that the patient is seen promptly and the service is responsive to the needs of the individual. Find out what the patient will be doing in the next 24-48 hours Carry out a risk assessment for suicidal thoughts or other mental health issues Clarify the patient s understanding of the result Discuss the need for a repeat test for confirmation. It is preferable to take the second blood sample on the same day as receiving the result Refer for specialist management, including treatment where appropriate. If the relevant doctor is available introduce the patient to him/her Check if the patient has any immediate medical problems. It may be appropriate to address partner notification issues in the immediate post-test session. It is important to remember that this is the patient s result and if the clinic has the means of contacting the patient it is recommended that an attempt be made to do so. Explain why this is not usually encouraged, in that it is not a free from infection certificate, and only relates to a specific time period. For those wanting written confirmation (some people attend simply for this), for example, for insurance purposes or to meet visa requirements, it is preferable to have a written letter rather than a photocopy of the result. This would clearly state the patient details, the date of the test and the date of last risk, to indicate whether the patient is in the window period. It is recommended that there be a written policy to clarify which patients receive written results, how much to charge and the procedure for financial transactions within the clinic. There is an increase in the use of communication technology, and patients are making more use of mobile phones, text messaging and email facilities, and often wish to be contacted by these methods. Services need to keep pace with these developments to ensure choice and accessibility, whilst considering confidentiality and data protection. Some clinics use a risk assessment to determine which patients are referred to the health adviser (see above). Those patients deemed to be at low risk are often seen by the medical or nursing staff. Therefore there may be different routes by which the patient receives their result - from the health adviser, the nurse or the doctor. Co-ordination of service It is important to identify who will co-ordinate the service to ensure adequate resources, consistency, and evaluation. Times of service This will obviously depend on clinic times and resources so it is essential to provide a service that is accessible but manageable, and to ensure the patient is fully aware of the date, time and person they need to ring.

If dissecting cellulitis is seen unaccompanied purchase 1.5mg indapamide with visa pulse pressure greater than 80, or if there is a strong suppurative component with growth of S indapamide 2.5mg low cost arteria bulbi vestibuli. If the predominant morphology is that of pustules crusting and sinus tracts then topical and/or oral antibiotics should be emphasized in the treatment regimen indapamide 2.5mg generic blood pressure medication ramipril. Antibiotics are often combined with intralesional corticosteroids for treatment of concomitant inammatory papules or hypertrophic scars 2.5 mg indapamide amex blood pressure chart by race. Current surgical treatments consist of scalp aps, reduc- tion procedures with or without prior tissue expansion, and autologous hair transplantation; these procedures are often combined or done serially (58). Patients with traumatic types of alopecia are generally seen to be the most appropriate candidates for surgery since there is little likelihood for progression of hair loss. There are no studies to determine the optimal period of quiescence before undertak- ing surgery; some have advocated 6 9 months, while others have waited 3 years (58,59). Other limitations to surgical hair restoration include the lack of appropriate donor sites and atrophy of the recipient area. The future of Cicatricial Alopecia 147 surgical hair restoration may lie in cloning hair follicles, thus providing an unlimited supply of donor grafts; technological advances will likely make this a reality in the next decade. Surgical treatment may also play a role in providing symptomatic relief for patients with suppurative, boggy, pus-lled lesions, or sinus tracts. Incision and drainage of these types of lesions may relieve symptoms and hasten healing. Surgical removal of hypertrophic scars can be an option in folliculitis keloidalis for improved cosmesis. Study of these disorders on a molecular level will no doubt provide much needed insight into the pathophysiology and provide targeted treatment options as well. Possible role of the bulge region in the pathogenesis of inammatory scarring alopecia: lichen planopilaris as the prototype. Folliculitis decalvans including tufted folliculitis: clinical, histological and therapeutic ndings. Postmenopausalfrontal brosing alopecia: a frontal variant of lichen planopilaris. Immunouorescent ndings and clinical overlap in two cases of follicular lichen planus. Successful treatment regime for folliculitis decalvans despite uncertainty of all aetiological factors. The normal hair shaft has a consistent diameter throughout its length, with the most common shape in cross section being oval. Signicant variations exist particularly in different racial groups from straight to woolly hair as well as in thickness of the hair shaft. The medulla is a normal feature of the hair shaft and is character- ized by a central cavity, but is only present in some individuals. Its appearance can vary from a continuous cavity throughout the hair shaft to being only intermittently present. Weathering Hairs grow, on average, 1 cm per month, so the tip of a hair ber that is 35 cm long has been exposed to environmental insults for approximately 3 years. These include damage to the hair cuticle leading to fraying or loss of cuticular cells from the distal hair shaft. Other features of weathering include longitudinal splits and trichorrhexis nodes (Fig. If weathering is seen in the proximal hair shaft (particularly within the rst 2 cm from the scalp) this is considered pathological and may either be present nonspecically or be related to a characteristic hair-shaft anomaly. Examination of the Hair Shaft Most disorders (perhaps apart from disorders leading to uncombable hair, which is better diag- nosed with electron microscopy) can be diagnosed on light microscopy of hair samples. It is important to take hair samples from multiple sites as pathology can be of intermittent severity and it is helpful in noting which is the proximal end of the hair to determine if weathering changes are pathological. It is only when considering a disorder such as loose anagen syndrome that hairs need to be obtained by hair pull. Classication of Hair-Shaft Disorders A major division of hair-shaft disorders is into those associated with hair fragility and those that do not affect the integrity of the hair shaft. Within each of these categories for each specic hair abnormality consideration should be given to whether the hair-shaft disorder is occurring as an isolated phenomenon, in association with other cutaneous or noncutaneous abnormali- ties, or as a syndrome. It is important to note that hair-shaft disorders can have signicant variations in severity from barely noticeable even subclinical anomalies to severe effects (particularly in the hair-shaft 150 Dinh et al. These variations can even occur between patients with the same genetic mutation in the same family. The condition may be present throughout the entire scalp or maybe patchy or even localized. Patients with fragility disorders usually present with short hair that breaks easily. For these patients, haircare advice is required to minimize the impact of grooming habits (Table 1). When shampooing, always use a conditioner, and leave it on the scalp for at least ve minutes before rinsing. Protect the hair from excessive exposure to sunlight, by wearing a loose-tting hat or scarf. If a fracture occurs transversely through the node, the end of the hair resembles a small paintbrush. However an assessment of what is pathological needs to also consider the patient s racial background. Vigorous attempts to straighten curly hair may cause nodes to occur sooner and closer to the root. In contrast, Caucasian and Asian hair is stronger than African hair and even the most vigorous abuse tends to produce distal rather than proximal acquired trichorrhexis nodosa. Trichorrhexis nodosa is the most common defect of the hair shaft leading to hair breakage (1). Treatment of trichorrhexis nodosa (congenital or acquired) involves the avoidance of mechanical or chemical injury to hair. When severe, the entire scalp is affected and patients are totally bald or more often have a sparse covering of short, twisted, broken and lusterless hairs. Follicular keratosis and abnormal hairs are found most frequently on the nape and occiput but may affect the entire scalp. Occasionally there is no keratosis pilaris, suggesting that the follicular hyperkeratosis is not important in the genesis of the beaded hairs. The most pathogenic mutations in hHb6 affect either the start of the rod domain at the helix initiation motif or the end of the rod domain at the helix termination motif (2). Both these sites in the rod domain contain a sequence that is very susceptible to point mutation. In fact, patients with autosomal recessive monilethrix appear to have more severe disease than those with an autosomal dominant aetiology with more extensive alopecia and papular rash.

As many as two-thirds of treated individuals do not achieve or maintain complete virologic sup- pression (147) 2.5 mg indapamide overnight delivery hypertension 6 months pregnant. Transmission of resistant virus is increasing (148) indapamide 1.5 mg hypertension lifestyle modifications, which limits the medica- tions that individuals infected with resistant strains may receive quality 1.5mg indapamide arteria iliaca comun. Treatment of human immunodeficiency virus infection with saquinavir discount 1.5mg indapamide otc hypertension 34 weeks pregnant, zidovudine, and zalcitabine. Treatment with indinavir, zidovudine, and lamivudine in adults with human immunodeficiency virus infection and prior antiretrovi- ral therapy. Treatment with amprenavir alone or ampre- navir with zidovudine and lamivudine in adults with human immunodeficiency virus infection. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. Regression of progressive multifocal leukoen- cephalopathy with highly active antiretroviral therapy [Letter]. Remission of progressive multifocal leukoencephalopathy after antiretroviral therapy. Remission of progressive multifocal leukoen- cephalopathy after antiretroviral therapy. In: Abstracts of the 37th Inter- science Conference on Antimicrobial Agents and Chemotherapy. Resolution of azole-resistant oropharyngeal candidiasis after initiation of potent combination antiretroviral therapy [Letter]. Resolution of intractable molluscum contagiosum in a human immunodeficiency virus infected patient after institution of antiretroviral therapy with ritonavir. Cytomegalovirus retinitis after initiation of highly active antiretroviral therapy. Discontinuing anticytomegalovirus therapy in patients with immune reconstitution after combination antiretroviral therapy. Discontinuing or withholding primary pro- phylaxis against Mycobacterium avium in patients on successful antiretroviral combina- tion therapy. Immune recovery vit- ritis associated with inactive cytomegalovirus retinitis: a new syndrome. Progressive multifocal leukoencephalopathy following initiation of highly active antiretroviral therapy. Enhancing progressive multifocal leukoen- cephalopathy: an indicator of improved immune status? Recurrence of cytomegalovirus retinitis in a human immunodeficiency virus-infected patient, despite potent antiretroviral therapy and apparent immune reconstitution. Immune reconstitution in the first year of potent antiretroviral therapy and its relationship to virologic response. Immune reconstitution after 2 years of suc- cessful potent antiretroviral therapy in previously untreated human immunodeficiency virus type 1-infected adults. Functional T cell reconstitution and human immunodeficiency virus-1-specific cell-mediated immunity during highly active antiretroviral therapy. Response of recent human immunodeficiency virus seroconverters to the penumococcal polysaccharide vaccine and Haemophilus influenzae type b conjugate vaccine. Progressive human immunodeficiency virus- specific immune recovery with prolonged viral suppression. Characteristics of the cell-mediated immune response in human immunodeficiency virus infection. Lymphocyte proliferative responses to human immun- odeficiency virus antigens in vitro. Decay kinetics of human immunodeficiency virus- specific effector cytotoxic T lymphocytes after combination antiretroviral therapy. Levels of human immunodeficiency virus type 1-specific cytotoxic T-lymphocyte effector and memory responses decline after suppres- sion of viremia with highly active antiretroviral therapy. Neutralizing antibody responses to autologous and heterologous isolates of human immunodeficiency virus. Evolution of cytotoxic T lymphocyte responses to human immunodeficiency virus type 1 in patients with symptomatic primary infection receiving antiretroviral triple therapy. The effect of commencing combination antiretroviral therapy soon after human immunodeficiency virus type 1 infection on viral replication and antiviral immune responses. Highly active antiretroviral therapy in a large urban clinic: risk factors for virologic failure and adverse drug reactions. In the presence of an intact immune response, viremia is contained, and disease does not recur. Another important component of immune control is the virus-specific T-helper cell response. These studies suggest that in this From: Immunotherapy for Infectious Diseases Edited by: J. Factors that can contribute to a persistently low viral load and a benign disease course include infection with attenuated viruses (8 10), and host genetic factors (11,12). One limitation of neutralizing antibodies is that they typically recognize three-dimensional conformations of their epitopes, meaning that they are highly type-specific (15 17). This high degree of specificity may also lead to rapid escape from an initially effective neutralizing anti- body response. The heavy degree of glycosylation of the viral envelope protein may be another factor that allows the virus to resist antibody-mediated inactivation (24,25). These factors are formidable hurdles to immune-based therapies meant to augment antibody responses. This occurs prior to the assembly of progeny virions, a process that takes approximately 2. In fact, these factors are released concurrently with the mobilization of the cell s cytolytic machinery when an infected cell is recognized (28), and this prob- ably has an important effect on the microenvironment of the infected cell. However, a substantial fraction of sub- jects don t recognize this epitope, and other epitopes are less frequently recognized. Over the past few years, newer technologies have been developed that allow for eas- ier measurement of immune responses. It is not known exactly what con- stitutes help, but it is probably composed of released lymphokines and a series of direct cell-cell interactions. The critical role of T-helper cells in response to chronic viral infection has been firmly demonstrated in animal models. Alternatively, these cells may undergo activation-induced cell death owing to overstimulation at the time of maximum virus load (57). Immune-based therapy may be much more successful in subjects identified shortly after acute infection, when the viral qua- sispecies diversity is much more limited (66), but this would limit the number of sub- jects that could be treated. The immune recovery inflammatory syndromes that have been described reflect the restoration of immunity against opportunistic infections. Lymph node biopsies showed focal lymphadenitis caused by unsuspected Mycobacterium avium complex infection, which was probably 186 Kalams caused by an increase in memory cells specific for the organism (68). This was based on observa- tions in humans and animal models showing that the volume of thymic tissue decreased with age and that the production of naive T-cells after myeloablative chemotherapy was delayed in adults versus children (86,87). Despite the rela- tively preserved thymic function in adulthood, there are age-related declines in thymic function.

Even though the decision to operate on a An incomplete cataract might permit a visual cataract must be made by the ophthalmic acuity of 6/12 or 6/18 and yet the child could be surgeon buy indapamide 2.5mg with mastercard heart attack feeling, optometrists and the nonspecialist able to read small print by exercising the large general practitioner need to understand the rea- amount of available focusing power order indapamide 2.5mg line heart attack 5 hour energy. Elderly patients child could undergo normal schooling cheap indapamide 2.5mg fast delivery hypertension reading chart, and tend to forget what they have been told in the cataract surgery might never be required 2.5mg indapamide with visa hypertension 120 80. A clinic and might not, for example, understand complete cataract in both eyes demands early why cataract surgery is being delayed when surgery and this can be undertaken during the macular degeneration is the main cause of visual rst few months of life. An operation is usually not required if the one eye could become amblyopic in these young patient has not noticed any problem, although patients, even after cataract surgery. The require- Traumatic Cataract ments of the patient need to be considered; those of the chairbound arthritic 80-year-old subject This is usually a unilateral problem in a younger who can still read small print quite easily are dif- patient and sometimes the nature of the damage ferent from the younger business person who to the eye prevents the insertion of an intra- needs to be able to see a car number plate at ocular lens. Some patients Vision can be restored by a strong convex who have marked glare might need surgery with spectacle lens but the difference between the 88 Common Eye Diseases and their Management two eyes makes it impossible to wear glasses. This is partly because everything looks much bigger with the corrected aphakic eye; the image on the retina is abnormally large. By wearing a contact lens on the cornea, the optical problems might be solved,but it is an unfortunate fact that patients with traumatic cataracts usually have working conditions that are unsuited to the wearing of a contact lens. It is an example of a classical pro- ferent designs to suit different surgical techniques. This entailed pushing the lens back into the vitreous, where it was complete lens within its capsule and, by this allowed to sink back into the fundus of the eye. Initially, they Modern cataract surgery was founded by the were mostly employed with intracapsular French surgeon Jacques Daviel in the eighteenth surgery, but a new technique for extracapsular century. The operation that he devised involved surgery was then developed and found to be seating the patient in a chair and making an successful with implants. The trend is now considering the technical difculties that he towards smaller incision surgery and the use of must have encountered. Subsequently, the pro- foldable or injectable implants, which unfold cedure was facilitated by lying the patient down into position as they are being inserted into the and making the incision around the upper part eye. An important and widely used technique is of the cornea where, in the postoperative phakoemulsication. By the beginning of the twentieth century, two methods had evolved for the actual removal of the lens. The safest way was to incise the anterior lens capsule and then wash out or express the opaque nucleus, pre- serving the posterior lens capsule as a protec- tive wall against the bulging vitreous face. Cataract 89 case work, dictated partly by economic reasons, but also by safer surgery. Convalescence It is a fair generalisation to say that an eye requires about four to six weeks for full healing to take place following a cataract operation. After phakoe- mulsication, glasses can be prescribed at this point but after larger incision surgery the pre- scription of new glasses is usually done after a month. The visual recovery is undoubtedly quicker after small incision surgery but the ulti- mate visual result is probably no better than when a larger incision is used. General anaes- usual to instill antibiotic drops combined with a thesia is preferred in younger patients and esp- steroid (usually in one bottle) four times daily ecially where there is a risk of straining or for three to four weeks. An overnight stay is and this is usually heralded by pain, redness, needed after a general anaesthetic in many discharge and deterioration of vision. The elderly patient living alone with no tion might be acquired from the patient s own relatives is also usually kept overnight in hospi- commensal eyelid ora or from contamination tal but the trend is towards more and more day- at the time of surgery. The commonest types of bacterial infection are streptococcal and staphy- lococcal species. About 10 20% of patients develop opacication of the posterior lens capsule behind the implant after months or years. This is simply cured by making an opening in the capsule with a special type of laser. This is a day-case procedure, which requires no anaesthetic and takes two or three minutes. When corneal sutures have been used, these can sometimes need to be removed and this can also be done on a while-you-wait basis in the outpatient department. An understanding of the meaning of aphakia and the optical consequences of an implant are also useful. Most patients who present with cataracts are diagnosed as having age-related cataracts and investigations as to the cause are limited to tests to exclude diabetes and to conrm that the patient is t for surgery. An understanding of the symptoms of cataract is helped by under- standing the meaning of index myopia. An elderly woman would not normally be able to read small print without glasses and this lady s eyes must be abnormal. She might have inherited myopia,allowing her to see near objects without the need for a presbyopic lens, but the myopia could also be index myopia, which in turn could be caused by early cataract formation. Now- Intraocular Pressure adays the term has come to cover a group of eye diseases characterised by raised intraocular If the eye is to function as an effective optical pressure. These diseases are quite distinct and instrument, it is clear that the intraocular pres- the treatment in each case is quite different. At Glaucoma might be dened as a pathological the same time, an active circulation of uid rise in the intraocular pressure sufcient through the globe is essential if the structures enough to damage vision. Here, we unyielding envelope and within this an even consider what is meant by the normal intra- pressure is maintained by a balance between the ocular pressure. Aqueous is produced by the ciliary epi- thelium by active secretion and ultraltration. A Normal Intraocular Pressure continuous ow is maintained through the pupil, where it reaches the angle of the anterior Measurement of the intraocular pressure in a chamber. The pattern of as the trabecular meshwork and then reaches a distribution ts a Gaussian curve, so that the circular canal embedded in the sclera known as majority of subjects have a pressure of about Schlemm s canal. For clinical purposes, it is necessary around the limbus (corneoscleral junction) and to set an arbitrary upper limit of normal. By from it, minute channels radiate outwards and large, the eye can stand low pressures through the sclera to reach the episcleral circ- remarkably well, but when the pressure is ulation. These channels are known as aqueous abnormally high, the circulation of blood veins and they transmit clear aqueous to the through the eye becomes jeopardised and episcleral veins, which lie in the connective serious damage can ensue. In actual fact, poses, an upper level of 21 mmHg is often the proof of the route of drainage of aqueous accepted. Above this level, suspicions are raised can be veried by any medical student it and further investigations undertaken. After a a basic requirement in any eye clinic, attempts time, one can sometimes detect that some of the have been made to introduce even more rapid deeper veins convey parallel halves of blood and and efcient devices. Perhaps the most ingen- aqueous in the region beyond the junction of ious to date is the tonometer, which measures aqueous and episcleral vein. This air- and trabecular meshwork in maintaining what puff tonometer is less accurate than applan- is a remarkably constant intraocular pressure ation, but it is useful for screening, although throughout life are not fully understood. It abnormal results should be conrmed by would appear that the production of aqueous is Goldmann tonometry. In Clinical Types of Glaucoma normal subjects, the intraocular pressure does not differ in the two eyes by more than about It has been mentioned above that the word 3 mmHg. For suspect early glaucoma, especially if there is a clinical purposes, these can be subdivided into family history of the disease.

They work by inuencing vitamin D it is better to become familiar with a few remedies receptors in keratinocytes indapamide 1.5mg with amex arrhythmia test questions, reducing epidermal pro- than dabble with many indapamide 2.5mg with amex blood pressure readings by age. They with psoriasis is an art as well as a science and few also inhibit the synthesis of polyamines (p purchase indapamide 2.5mg on-line arrhythmia course certification. It seldom clears plaques of psoriasis completely effective 2.5 mg indapamide blood pressure chart during the day, but does reduce their scaling and Vitamin D analogues thickness. Local and usually transient irritation may Ultraviolet radiation helps many patients with psoriasis occur with the recommended twice-daily application. Up to 100 g/week calcipotriol may be used but the manufacturer s recommendations should be con- sulted when it is used in children over 6 years old. Our current practice, which may be unnecessary, is still to check the blood calcium and phosphate levels every 6 months, especially if the psoriasis is widespread or the patient has had calcied renal stones in the past. The drug should not be used for longer than a year at a time and is not yet recommended for children. Like the vitamin D analogues, its main side- prescriber to keep the patient under regular clinical effect is irritation. If this occurs, the strength should review is especially important if more than 50 g/week be reduced to 0. The drug should not 1 In limited choice areas such as the face, ears, gen- be used in pregnancy or during lactation. Females of itals and exures where tar and dithranol are seldom childbearing age should use adequate contraception tolerated (mildly potent steroid preparations should during therapy. Crude coal tar and its distillation products have been 4 For patients with minor localized psoriasis (moder- used to treat psoriasis for many years. The less rened tars are dose should not exceed 15g/day or 100g/week and the smelly, messy and stain clothes, but are more effective ointment should not be applied for longer than 4 weeks. It has Ultraviolet radiation to be applied carefully, to the plaques only; and, if left on for more than 30 min, must be covered with gauze Most patients improve with natural sunlight and dressings. The initial dose is calculated either by discoloration peels off after a few days. One popular regimen is to apply dithranol daily for 5 days in the week; after 1 month many patients will be clear. Short contact therapy, in which dithranol is applied for no longer than 30 min, is also effective. If there is no undue reaction, the application can be extended the next day and, if tolerated, can be left on for 30 min. After the cream is washed off, a bland application such as soft white parafn or emulsifying ointment is applied. Dithranol is too irritant to apply to the face, the inner thighs, genital region or skin folds. Recent research has shown that applying triethanolamine after the dithranol has been removed reduces inam- mation and staining without diminishing the thera- peutic effect. The initial small dose is increased incrementally after each exposure providing In this ingenious therapy, a drug is photo-activated it is well tolerated. Salicylic acid and tar com- by determining the patient s minimal phototoxic dose binations are also effective. Suitable preparations include depending on erythema production and the therapeutic emulsifying ointment and zinc and ichthammol cream. Protective goggles are worn during radiation Tar steroid preparations are reasonable alternatives. All phototherapy equipment should be serviced and calibrated regularly by trained personnel. An accurate record of each patient s cumulative dosage Eruptive/unstable psoriasis and number of treatments should be kept. A systemic approach should be considered if extensive psoriasis (more than 20% of the body surface) fails to Side effects Painful erythema is the most common improve with prolonged courses of tar or dithranol. This often controls even aggressive (see above) for 24 h after each treatment should pro- psoriasis. Aspirin and sulphonamides displace the drug this must be recorded and kept as low as possible, from binding with plasma albumin, and frusemide without denying treatment when it is clearly needed. Minor and temporary side-effects, such as nausea Acitretin (10 25 mg daily; Formulary 2, p. It is also used to thin hepatic brosis, the risk of which is greatly increased down thick hyperkeratotic plaques. All exclude active liver disease is advised for those with settle on stopping or reducing the dosage of the drug, risk factors. Exceptions are made for patients over but the use of emollients and articial tears is often 70 years old and when only short-term treatment recommended. Liver biopsy before Acitretin can be used on its own for long periods, but treatment, or early in the course of therapy, should regular blood tests are needed to exclude abnormal be repeated after every cumulative dose of 1. Children, and interval being slowly increased to monthly or every those with persistently abnormal liver function tests other month depending on when stable maintenance or hyperlipidaemia, should not be treated. The most important side-effect is teratogenicity and The drug is teratogenic and should not be given acitretin should not normally be prescribed to women of to females in their reproductive years. Folic acid, 5 mg daily, half-life of its metabolite, these should continue for taken on days when the patient does not have 2 years after treatment has ceased. Blood donation methotrexate, can lessen nausea and reduce marrow should be avoided for a similar period. Methotrexate Cyclosporin is effective in severe psoriasis, but pati- This folic acid antagonist (Formulary 2, p. Treatment with often be reduced but the side-effects of long-term cyclosporin should not continue for longer than 1 year treatment include hypertension, kidney damage and without careful assessment and close monitoring. Blood pressure and renal function should be assessed care- Other systemic drugs fully before starting treatment. The serum creatinine should be measured two or three times before starting Antimetabolites such as mycophenolate mofetil, 6- therapy to be sure of the baseline and then every other tioguanine, azathioprine and hydroxyurea help psori- week for the rst 3 months of therapy. Thereafter, asis, but less than methotrexate; they tend to damage if the results are stable, the frequency of testing will the marrow rather than the liver. If these changes do not reverse them- selves when the dosage has been reduced for 1 month, If psoriasis is resistant to one treatment, a combina- then the drug should be stopped. Hypertension is a common side-effect of cyclosporin: Combination treatments can even prevent side-effects nearly 50% of patients develop a systolic blood pres- by allowing less of each drug to be used. Common sure over 160 mmHg and/or a diastolic blood pressure combinations include topical vitamin D analogues over 95 mmHg. It is also advisable to watch levels of cholesterol, The development of retinoids and vitamin D analogues triglycerides, potassium and magnesium, and advise over the last decade has heralded a resurgence of patients that they will become hirsute and that they interest in new treatments for psoriasis.

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