Introduction:
Psoriatic arthritis(psoriatic arthritis, PsA) is seen in 3% to 5% of patients with psoriasis. Although most occur in patients with confirmed active skin diseases, some patients (especially children) develop joint disease before psoriasis. The degree of skin damage in psoriasis, although not related to the occurrence of arthritis, but the risk of psoriatic arthritis in people with a family history of spondyloodesis and generalized point-like concave changes in the nails. increase. The genetic relevance of psoriatic arthritis is heterogeneous.
Cause:
(1) Causes of the disease
The etiology of this disease varies from place to place, among which there are mainly hereditary, infection, metabolic disorders, endocrine effects, neuropsychiatric factors and immune disorders.
1. Genetic factors This disease often has a tendency to family aggregation. The prevalence of first-degree family members is as high as 30%, and the risk of single-oval twins is 72%. The domestic report has a family history of 10% to 23.8%, and foreign reports are 10% to 80%, which is generally considered to be around 30%. The disease is autosomal dominant, with incomplete penetrance, but some are considered autosomal recessive or sexually inherited.
2. Infectious factors
(1) Viral infection: Some people have been treated with antiviral therapy for patients with psoriasis and viral infection, and the condition of psoriatic arthritis has also been alleviated.
(2) Streptococcal infection: It is reported that about 6% of patients have a history of pharyngeal infection and upper respiratory tract, and their anti-"O" titer is also increased.
(3) Metabolic disorders: Some people believe that the three major metabolic disorders of fat, protein and sugar have pathogenic effects on this disease. Others believe that these three major metabolic abnormalities are following the discovery of the disease. Others believe that this disease and the three major substances It has nothing to do with metabolic disorders.
(4) Endocrine dysfunction The related role of psoriasis and endocrine gland function has long been paid attention to.
(5) Neuropsychiatric disorders: In the past, the literature often reported that mental factors are related to the disease. For example, trauma can sometimes cause the onset of the disease or aggravate the condition, and it is believed that this is due to the increase of vascular motor nerve tension after mental stimulation. However, during the Great Patriotic War of the former Soviet Union, there were many people with severe mental trauma, but the incidence of this disease was not seen.
(two) pathogenesis
1. Henseler et al. recommend that psoriasis be classified into type 2 type I as hereditary type (60% is autosomal dominant), and the onset age is light. The average male is 22 years old and the female is 16 years old. The course of the disease is irregular and can be generalized. The positive rate of HLA-CW6 is as high as 85% (relative risk 4.5). 50% of patients with this type have psoriasis. Type II is sporadic, with a peak age of 60 years, and 15% of patients are associated with HLA-CW6 (relative risk is 7.3). This type of patient has no parental disease. Recent studies suggest that HLA is closely related to the clinical type of psoriatic arthritis. For example, asymmetric peripheral arthritis is associated with HLA-B38, B17, B13, CW6, and spondylitis is associated with B27 or B39. It was also found that early onset of arthritis was associated with HLA-DR4 and DRW53, disease severity was associated with DQW3, joint space narrowing and erosion were associated with HLA-A9 and B5.
2. It has been confirmed that there are eosinophilic inclusion bodies in the nucleus of the spine, but some people also deny the existence of such inclusion bodies. Although there seems to be some basis for the pathogenic effect of viral infection, the specific virus causing the disease has not yet been isolated. Young children often have a history of acute tonsillitis or upper respiratory tract infection, and the symptoms are relieved after penicillin treatment and removal of the tonsils. These all indicate that the infectious factor has a pathogenic effect on the disease.
3. It has been reported that there are two types of lesions in patients with this disease, oxaloacetate dehydrogenase combined with coenzyme II, which are involved in skin maturation and keratinization. It has also been found that the activity of lactate dehydrogenase and cytochrome oxidase in the blood of patients increases, and succinate dehydrogenase decreases. The changes in these enzymes are not necessarily primary or secondary, but they are sure to have an effect on the metabolism of sugar. Studies have found that the patient's skin lesions lack acyclic adenosine monophosphate. Proliferation and division of the epidermis is caused by the lack of cyclic adenosine monophosphate. Cyclic adenosine also activates phosphorylase, which can affect the metabolism of sugar. If the content of cyclic adenosine monophosphate in the epidermis is decreased, the glycogen content is increased, the mitosis of epidermal cells is enhanced, and the conversion rate is accelerated. The normal epidermal cell transformation time is 4 weeks, and the psoriasis conversion time can be reduced to 3 to 4 days, which indicates that the reduction of cyclic adenosine monophosphate content in the skin lesion has a certain pathogenic effect.
4. Farber pointed out that about one-third of patients with psoriasis during pregnancy can be relieved, and the condition deteriorates after delivery. It has also been reported in the country that the treatment of this disease with pregnancy urinary tract has achieved good results. Some patients may also have pituitary-adrenal dysfunction. Urine 17-ketosteroids are reduced. Clinically, treatment with glucocorticoids can achieve better results.
5. Pathology
(1) Skin pathology: According to the characteristics of skin lesions, it is generally classified into vulgaris, pustular and erythrodermic.
1 vulgaris type: the epidermis changes earlier, there is horny hyperplasia in the epidermis, mainly keratinization. The keratinized cells can be combined into a sheet, which is filled with air and refraction, so it is observed by the naked eye as silvery white scales. In the quiescent period, hyperkeratosis may be more pronounced than parakeratosis. Under the keratinized layer or keratinized layer, small abscesses composed of neutrophils are sometimes seen. This neutrophil is caused by the upper capillaries of the dermal papilla to swim to the surface, which is more common in early damage. Seen in old damage. The granular layer becomes thin or disappears, the spinous layer is thickened, accompanied by epidermal protrusion, and the ends are often thickened, sometimes connected to adjacent epidermal processes. There may be significant interstitial edema in the spinous cell layer at the top of the nipple. In early lesions, neutrophils and lymphocytes are scattered in the layer of spine cells. The dermal capillaries of the dermis are distorted and the wall is slightly thickened with mild to moderate inflammatory cell infiltration. In old damage, its infiltration is composed of lymphocytes and plasma cells. The infiltration of plasma cells is most prominent in the nipple. The nipple can be elongated upwards and edema, often extending to the surface keratinized layer. The spinous cell layer at the top is thinned, leaving only 2 to 3 layers of cells. There are often no granulosa cells, so it is easier to scratch the small blood vessels at the top of the nipple and cause clinical punctiform bleeding. Due to the extension and widening of the epidermal process, the dermal papilla grows and narrows accordingly, and is in the shape of a rod or a finger.
2 pustular type: its pathological changes are basically the same as the vulgaris, but there are large pustules in the keratinized layer, mainly neutrophils in the blister. The thickness of the spinous cell layer and the change of the rod-shaped nipple were not obvious. The inflammatory infiltration of the dermis is more serious, mainly lymphocytes, tissue cells and a small number of neutrophils.
3 erythrodermic type: except for the pathological features of psoriasis, other changes are similar to dermatitis, showing significant parakeratosis, thinning and disappearing of the granular layer, hypertrophy of the spinous cell layer, prolongation of the epidermal process, and obvious intracellular and extracellular Edema, but does not form blisters. Upper dermis of the dermis, vasodilatation and hyperemia, lymphocytes and neutrophils infiltrated around the blood vessels, sometimes eosinophils. Late infiltration is mostly lymphocytes, tissue cells and plasma cells.
(2) Arthritis pathology: Basically similar to rheumatoid arthritis, but lacks typical rheumatoid arteritis. In the early stage, there may be synovial edema and hyperemia. Later, the synovial cells are slightly hyperplasia and villi are formed. Lymphocytes and plasma cells infiltrate around the synovial blood vessels. In the elderly, fibroblasts proliferate and synovial fibrosis occurs. A typical change is to cause osteolysis of the toe, which is caused by non-inflammatory hyperplasia of the periosteum and intermittent loss of cortical bone. At the same time, it may be accompanied by mild new bone formation caused by enhanced osteoblast activity, but the whole process is mainly related to osteolytic bone, and the change of the metatarsophalangeal joint is obvious.
symptom:
The ratio of male to female incidence is 1:1.04, the age of onset is 20 to 50 years old, and the peak is 40 years old. About 5% of patients with psoriasis develop psoriatic arthritis, most of whom have psoriasis, psoriatic arthritis occurs 5 to 10 years later, and about 1 in 5 patients have arthritis before Psoriasis, about 1 in 10 patients appear at the same time. One third of patients may have acute onset, with low or moderate fever or high fever, fatigue, poor appetite.
1. Arthritis is divided into peripheral arthritis and ankylosing spondylitis.
(1) Peripheral arthritis: manifested as acute gout-like episodes, large toe involvement and elevated uric acid, and good response to colchicine treatment. The distinguishing point between this disease and gout is the absence of birefringent urate crystals in the joint effusion. In addition, the distal and proximal interphalangeal joints are the most common sites of early involvement, except for the first toe of the big toe. Its performance ranges from mild single joint involvement to extensive disabling polyarthritis. Clinically, peripheral arthritis is divided into 5 types:
1 typical psoriatic arthritis type: mainly involving the distal interphalangeal joint. This type is rare, and once it appears, it can prompt the diagnosis of the disease (Figures 3, 4, 5).
2 disabling arthritis type: due to severe phalanges, metacarpal or humeral bones, the bones become sharp, and form a pencil-like shape with a pen-like pen, or a mushroom-like shape, often accompanied by ankle arthritis. . Joint stiffness and osteolysis can occur in severe cases.
3 symmetrical arthritis type: all aspects are similar to rheumatoid arthritis, most patients with negative serum rheumatoid factor, a few rheumatoid factors can be positive. Some people think that the latter belongs to both psoriasis and rheumatoid arthritis.
4 less arthritis type: is the most common type of psoriatic arthritis, accounting for more than 70%. For asymmetry, individual proximal and distal interphalangeal joints and metacarpophalangeal joints are usually involved. This type of "sausage finger" caused by arthritis between the fingers and the acral follicle of individual fingers or toe flexors, it is considered that the asymmetry is less (single) joint involvement, which is the most common psoriatic arthritis. Characteristic performance.
5 peripheral arthritis combined with ankylosing spondylitis. In addition to the typical changes in the hand and foot joints, it is not uncommon for large joints such as the wrist, knee, ankle, elbow and shoulder joints to be affected. These large joints can be affected alone without acromegaly. Major joint involvement often occurs in the joint cavity, pain, tenderness or dysfunction.
(2) Ankylosing spondylitis: about 40% of psoriatic arthritis, mainly involving the spine, more common in men, the ratio of male to female is about 6:1. Most patients with HLA-B27 genotype psoriasis can develop ankylosing spondylitis or ankle arthritis during the course of the disease. Also known as psoriatic spondylitis, but not necessarily clinical symptoms. Ankylosing spondylitis can involve any part of the spine, and cervical involvement is most common. It is also possible to directly involve a part of the spine without sputum arthritis (Fig. 6). Some patients may also have iritis.
2. Skin damage is also clinically divided into vulgaris, pustular and erythrodermic types.
(1) Vulgaris: Most of the vulgaris are acute onset, the most common skin lesion in the clinic. It is usually an inflammatory red papule from the beginning to the mung bean. It gradually enlarges or merges into a sheet. The boundary is clear, there is an inflammatory redness around it, the base is infiltrated, and the surface is covered with multiple layers of silver-white dry scales. In addition to the surface scales, a layer of light red shiny translucent film is exposed, which is the epidermal layer of the epidermis, called the film phenomenon. The film is scraped off, that is, the top of the dermal papilla layer is reached. Here, if the capillaries are scraped, a small bleeding point may occur, which is called a point bleeding phenomenon (Auspitz phenomenon). White scales, shiny film and spotted bleeding are the characteristics of this type. In the process of disease development, skin lesions can be expressed in a variety of forms, such as skin lesions ranging from miliary to mung bean-sized papules, which are dotted in the whole body, called psoriasis; lesions continue to expand and the center fades to form a ring It is a map-shaped person, called map-like psoriasis; the distribution of lesions is banded or like a snake, called banded psoriasis; the number of lesions is large, the distribution is wide, and even spread to the whole body, said Generalized psoriasis; lesions occur in the scalp, eyebrows and ears, and have characteristics of seborrheic dermatitis, called seborrheic dermatitis-like psoriasis; lesions with erosion and exudation, moisturizing eczema After drying, it forms dark brown scales and crusted, and overlaps and accumulates such as clam shells, which is called crustaceous psoriasis; the lesions develop and are lichen-like changes, similar to lichen planus, called lichen planus-like psoriasis; Repeated episodes of skin lesions, after multiple treatments, the lesions showed hypertrophic dark red scales, small and thin, and merged into each other, like chronic eczema, called chronic hypertrophic psoriasis; the surface of the lesions formed flat warts , called sputum psoriasis.
Skin lesions can occur anywhere in the body, but are most common in the scalp and extremities. A small number of patients can also be found in the axillary and inguinal folds, but rarely occur in the palmar and mucosa. Skin lesions are symmetrically distributed. In some cases, the patient's skin lesions are limited to a certain location, and thus their clinical characteristics may also be different.
About half of the patients may have a change in the nail, and the common deck is somewhat concave, uneven, and tarnished. Sometimes there are lateral grooves, mediastinum, turbidity, hypertrophy, rough surface white nails. The nail bed changed to rupture and bleeding, with erythema plaques and horns. Under the nail, the keratinization, yellow-green debris and nail peeling were changed.
The course of the disease is long and can last for decades. During this period, the patient's skin sensitivity is enhanced, such as trauma, friction, injection and acupuncture of normal skin, where lesions can often occur, a phenomenon known as "homotype reaction" (Kohner phenomenon). 2 quiescent period: the condition is stable in the stationary phase, basically no new skin lesions appear, but the old skin lesions do not fade. 3 regression period: inflammatory infiltration gradually subsided, scales decreased, rash shrink and flatten, there is a light red blush around, and finally the residual pigment can reduce white spots, and achieve clinical recovery. However, pigmentation can also occur. The extinction site usually begins with the trunk and upper limbs. The head and lower limbs tend to be more stubborn and often do not retreat.
(2) pustular type, this type is rare in clinical, and can be divided into two subtypes of generalized and palmar pustule.
1 generalized pustular onset is urgent, can be spread throughout the body within a few weeks, accompanied by high fever, joint and muscle pain, general malaise and other symptoms, leukocytosis. On the basis of psoriasis, dense, miliary superficial aseptic abscesses can be seen with atypical scales on the surface. The rash is more common in the flexion and wrinkles of the extremities, and often causes erosion, exudation, scarring and purulent sputum due to friction. Small patches of pustules can also form in the buccal mucosa of the mouth. The nails can be shrunk, shattered or loosened. Some decks are thick and turbid. There are layers of scales under the deck, and small pustules can also appear on the nail bed. Vulvar skin lesions can occur after the condition is relieved. The disease can last for several months or longer and is prone to recurrence.
2 palmoplantar pustular lesions are limited to the hands and feet, mostly in the palm of the hand, the damage is symmetric erythema. There are many miliary-sized pustules on the erythema. The blister wall is not easy to rupture. After one or two weeks, it can dry itself and brown. Small pieces of scales may appear after the cockroaches fall off, and small bleeding spots may occur when the scales are removed. Later, clusters of new pustules can appear under the scales, resulting in pustules and scars on the same erythema. Skin pain and itching. This type may also be accompanied by symptoms such as low fever, headache, loss of appetite and general malaise, deformation of the nail, turbidity, hypertrophy and irregular ridges. In severe cases, there may be pus accumulation under the armor. Psoriasis lesions can be seen in other parts of the body at the same time.
3 erythrodermic type: It is a serious skin lesion that is rare in this disease. It is more common in adults and rarely affects children. This type can be caused by the use of irritating drugs or the long-term use of glucocorticoids for sudden withdrawal. It can also be derived from vulgaris or pustular lesions. The clinical manifestation is exfoliative dermatitis. At the beginning, the original skin lesions were flushed and rapidly expanded. Later, the skin of the whole body was diffuse red or dark red, and the inflammatory infiltration was obvious. The surface had a lot of bran-like scales and continued to fall off. Occurred in the hands and feet, often have a whole piece of horny exfoliation. A turbid, hypertrophic, deformed, or exfoliated nail. The oral and pharyngeal mucosa are both congested and red, accompanied by systemic symptoms such as chills, fever, and headache. The lymph nodes of the whole body can be swollen. The condition is more stubborn, the constant month or years of unhealed, even if cured, often relapse.
3. Other manifestations of psoriatic arthritis include different degrees of fever, occasionally superficial lymphadenopathy, sometimes muscle loss and idiopathic consumption, extensor tendon effusion, gastrointestinal Amyloidosis, aortic regurgitation, myopathy, Sjogren's syndrome and ocular inflammatory changes. The disease can also overlap with other seronegative polyarthritis. According to reports, this disease can be combined with other seropositive polyarthritis diseases to constitute the following overlapping syndrome: 1 psoriatic arthritis - Behcet's disease; 2 psoriatic arthritis - Reiter syndrome; 3 silver shavings Sick arthritis - Crohn's disease; 4 psoriatic arthritis - ulcerative colitis.
Diagnosis is not difficult based on typical psoriatic lesions and clinical symptoms, particularly arthritis symptoms and typical X-ray findings. It must be determined that the patient has psoriasis or psoriasis nail disease, and then has joint damage and serum rheumatoid factor is negative, so that a diagnosis can be made. However, it is necessary to pay attention to the medical history and physical examination, especially the skin damage in the hidden parts, such as the scalp hair, navel, perineum and groin and other skin lesions are easily overlooked. Pay attention to distinguishing from other skin diseases.
diagnosis:
In the clinical care should be distinguished from the following diseases:
1. The skin lesions and nail changes of Reiter syndrome are quite similar, but there are urethritis and conjunctivitis in Reiter syndrome, and prostatitis in male patients. In terms of joints, although both of them show asymmetric arthritis, Reiter syndrome involves the lower extremity major joints, and this disease involves the distal or proximal interphalangeal joints. There are often diarrhea or urinary tract infections around 2 weeks before the onset of recurrent syndrome, and psoriatic arthritis has a history of skin psoriasis (Table 1).
2.Rheumatoid Arthritis The two not only have similar clinical manifestations, but also can coexist, and should pay attention to identification. If the serum rheumatoid factor is positive. And the high titer or subcutaneous nodules, mostly rheumatoid arthritis. If there is skin damage first, each subsequent joint symptom onset is related to the appearance of skin damage, which should be considered as psoriatic arthritis.
3. Patients with gout psoriasis active blood uric acid often increased. If the arthritis is characterized by acute single or less joint synovitis and hyperuricemia, it is easily misdiagnosed as gout. However, gout has a typical history of seizures. Patients often suffer from excessive fatigue, overeating, alcohol abuse, etc., and are effective in the treatment of colchicine. Chronic recurrent episodes often involve the formation of tophi.
4. Asymmetric osteoarthritis distal knuckle damage should be differentiated from osteoarthritis with Heberden nodules. Osteoarthritis is characterized by hyperosteogeny, no skin lesions, and normal erythrocyte sedimentation rate, while psoriatic arthritis has bone-like osteolytic lesions with skin lesions. X-rays are typically "pen-like" changes, and erythrocyte sedimentation rate is normal.
complication:
The disease can be complicated by muscle wasting consumption and idiopathic consumption, extensor tendon effusion, gastrointestinal amyloidosis, aortic regurgitation, myopathy, Sjogren's syndrome and ocular inflammatory changes. It can also overlap with other seronegative polyarthritis. According to reports, this disease can be combined with other seropositive polyarthritis diseases to constitute the following overlapping syndrome: 1 psoriatic arthritis - Behcet's disease; 2 psoriatic arthritis - Reiter syndrome; 3 silver shavings Sick arthritis - Crohn's disease; 4 psoriatic arthritis - ulcerative colitis. It can also cause fatal complications such as severe infections, peptic ulcers and perforations.
treatment:
(a) treatment
1. Western medicine treatment:
(1) Non-steroidal anti-inflammatory drugs have a rapid anti-inflammatory and analgesic effect and are effective for most psoriatic arthritis. Commonly usedaspirinIbuprofen,Indomethacin, non-Prazin, diclofenac, acemetacin and sulindac, etc., can be selected according to the patient's tolerance, clinical efficacy and economic conditions.
(2) Cytotoxic drugs: Because the disease has epidermal cell proliferation rate in skin histopathology, some cytotoxic drugs that inhibit DNA synthesis can be used to inhibit cell mitosis for therapeutic purposes. Although these drugs have a certain effect on the disease, they will produce toxic reactions and are prone to recurrence after stopping the drug. Liver, kidney function and white blood cells should be checked frequently during medication and the indications should be strictly selected.
1Methotrexate: It is a derivative of aminopterin, which has good curative effect on psoriasis, but the poisoning dose and therapeutic dose of the drug are very close, the safety range is narrow, and it can cause extensive liver fibrosis, so it should be strictly selected when using. Indications. This medicine is suitable for erythrodermic, pustular and extensive skin lesions. The contraindications are the same as those of aminopterin sodium (Bai Xuening). Sulfonamides, salicylic acids, tetracyclines, aminobenzoic acid andPhenytoinAnd other drugs. Because methotrexate is attached to plasma proteins, it can be replaced by the above drugs, interfering with its excretion in the renal tubules, thereby increasing its toxicity. Oral, intramuscular or intravenous injection, 20 ~ 25mg per week, or 2.5mg per day, even for 5 days, 2 days of withdrawal, 5 days, and then stopped for 7 days. Weinstein proposed 2.5 to 7.5 mg orally every 12 hours according to the principle of epidermal cell dynamics, and even served 3 times, and then administered the same method every week. The reason is that the period of normal epidermal cells is 457 hours, and the epidermal cell cycle of this disease is only 37.5 hours. The drug acts primarily on the DNA synthesis phase of the cell cycle, preventing DNA synthesis and inhibiting cell mitosis. After taking the drug once for 12 to 16 hours, and even taking 3 times, the lesions can be inhibited within 36 to 48 hours. The same is true for the action of tissue cells in joint lesions. Normal epidermal cells have a small cell cycle and have less DNA synthesis, so there are fewer side effects.
Other immunosuppressants such asAzathioprine,Hydroxyurea, 巯嘌呤, cyclosporine A, etc. are all effective, should be selected according to their respective advantages and disadvantages.
2D A acid (retinoic acid) This drug is effective for psoriatic lesions and arthritis. It is effective for all-trans retinoic acid, 0.5Mg/kg per oral administration. This medicine has teratogenic effects, it is forbidden in pregnant and lactating women, and it is best not to have liver and kidney dysfunction.
3 ethylimine which is commonly used is bismorpholine, although the effect is good, but it has the effect of inducing leukemia, it should not be used.
(3) Glucocorticoids: At present, it is generally not recommended to take such drugs, because of its side effects, and degeneration can occur after reduction or withdrawal.
2. Non-medication
(1) Photochemotherapy: Oral methicillin (8-methoxypsoralen), after 2 hours, irradiated with long-wave ultraviolet rays, has a good effect on psoriatic lesions, and it has been reported that the symptoms of arthritis can be correspondingly alleviated. .
(2) Physical therapy: short-wave electrotherapy, ultrasound therapy, whole body mineral hot water bathing method, whole body steam bath method.
(3) Anesthesia therapy: stellate ganglion block, knuckle synovial injection therapy, ankle joint synovial injection therapy, knee joint synovial injection therapy.
(4) Other treatments: psychotherapy and surgical arthroplasty.
3. Chinese medicine treatment
(1) Dialectical treatment:
1 wind cold block:
Main symptoms: more common in children or initial cases. The erythema of the skin lesions is not obvious, the scales are white and thick, and the skin lesions are scattered on the scalp or limbs. It is easy to aggravate or recur in winter, and the pain is more or less in summer. The joint pain is indefinite, and when it is cold, it is aggravated. Light red, thin white fur, tight pulse.
Governing Law: hurricane dispels cold, promotes blood circulation and collaterals.
Recipe: Huangqi Guizhi Wuwu Decoction combined with body pain and decoction.
Raw scutellariae 20g, cassia twig 12g, Gentiana 15g, scorpion 15g, angelica 15g, peach kernel 10g, safflower 10g, frankincense 10g, black-snake snake 15g, Sichuan achyranthes 20g, Kochia scoparia 12g, licorice 6g.
2 wind and blood dry:
Main symptoms: skin lesions throughout the trunk and limbs, and new skin lesions continue to appear. Skin lesions at the base of the lesions are bright red, scaly thickening, itching, increased in summer, often low fever, joint swelling and fever, pain is more fixed, heat pain increased, dry stool, yellow urine, red tongue, yellow tongue coating, pulse string Fine and counted.
Governing Law: Disperse the wind and heat, cool the blood and moisten.
Recipe: Xiaofeng Sanhe Jiedu Yangyin Decoction.
Honeysuckle 20g, dandelion 20g, raw land 30g, paeonol 20g, red peony 20g, salvia miltiorrhiza 20g, alfalfa 10g, sarcophagus 15g, matrine 12g, eliminary 15g, raw gypsum 30g, Kochia scoparia 20g.
3 wet heat accumulation:
Main symptoms: skin lesions occur mostly in the flexor and skin folds of the metacarpal joint, the skin lesions are red, the epidermis is wet or pustules, low fever, joint swelling, burning pain, lower extremity edema or joint effusion, and the symptoms are aggravated in rainy days. God is tired, poor appetite, lower limbs sore and heavy, dark red tongue, yellow greasy tongue coating, slippery pulse.
Governing Law: clearing away heat and dampness, phlegm and blood circulation.
Recipe: Si Miao San combined with pain and phlegm soup addition and subtraction.
Atractylodes 10g, Phellodendron 12g, raw coix seed 20g, Gentiana 15g, scorpion 15g, white fresh skin 20g, Sophora flavescens 12g, earthworm 30g, pork chop 15g, peach kernel 10g, safflower 10g, frankincense 10g, Sichuan achyranthes 20g.
4 hot poison blazing:
Main symptoms: the whole body is bright red or dark red, or there is exfoliation of the epidermis, or there are dense small pus points, skin fever, increased body temperature or high fever, thirst like cold drink, dry, yellow urine, severe joint pain in the limbs. Do not dare to bend, the tongue is red, the tongue is less, and the pulse is huge.
Governing Law: clearing away heat and detoxifying, cooling blood and promoting blood circulation.
Recipe: Detoxification Qingying Decoction.
30g of honeysuckle, 20g of forsythia, 20g of dandelion, 20g of Radix isatidis, 20g of raw land, 20g of Danpi, 15g of Zhimu, 60g of raw gypsum, 15g of sarcophagus, 20g of red peony, 20g of salvia miltiorrhiza, 30g of buffalo horn powder, 5g of glutinous rice powder.
5 liver and kidney deficiency:
Main symptoms: The disease course is prolonged and unhealed, the skin lesions are pale, and most of them are fused into pieces. The scales are not thick, the joints are painful, the torso is deformed, the backache is soft, the dizziness and tinnitus, the tongue is dark red, the tongue is white, and the pulse is slow. Two feet of weak pulse, men have more nocturnal emission, impotence, women's menstrual flow less color or menstrual error.
Governing Law: Replenishing liver and kidney, phlegm and blood circulation.
Recipe: Dabu Yuanjian and body pain are added to and subtracted from the soup.
20g of raw land, 20g of rehmannia, 15g of angelica, 12g of Eucommia, 12g of hawthorn, 15g of hazelnut, 15g of medlar, 10g of peach, 10g of safflower, 10g of frankincense, 12g of scorpion, 12g of Chuanxiong.
(2) Comprehensive treatment:
1 Chinese patent medicine:TripterygiumTablets, Xuefu Zhuyu Pills, Kunming Shanhai Tablets, Awei A Ester (Silver Chip) granules, Torch Flower Root Tablets, Compound Qinglan Pills.
2 single prescription: According to Zhao Bingnan's experience, using the peach leaf or arborvitae leaves to boil the water bath, it is effective for the treatment of skin lesions.
3 acupuncture therapy:
Body acupuncture: acupoints Zusanli, Fengchi, Hegu, Waiguan, Zuze, Yangxi, Dazhui, Shenshu, Yaoyangguan, Juyu, Hangzhong, Yanglingquan, Xuehai, Sanyinjiao, Shenmai, Zhao The sea, etc., each time 5 to 6 points, using the flat-filling method, leaving the needle for 20 to 30 minutes.
Triangular needle: suitable for the disease hot poison blazing certificate. Use a triangular needle to pick up the earlobe or the ear wheel and let out a small amount of blood, once a day or every other day.
4 lavatory therapy: phlegm and blood circulation medicine (Shandong College of Traditional Chinese Medicine Affiliated Hospital prescription: Cnidium, Kochia scoparia, Sophora flavescens, Phellodendron, sclerotium each 15g, rhubarb, white fresh skin, frankincense, myrrh, Sumu, Safflower and Dafeng decoction into 500ml, and wash the joints and skin lesions of the limbs once a day.
5 topical ointment: According to Zhao Bingnan's experience, psoriasis blood heat syndrome can be used externally with huanglian ointment, cooling cream, fragrant wax; for blood dry type can be used externally 10% ~ 20% Jinghong powder ointment, 2.5% ~ 25% black soybean oil ointment , 5% to 10% black red ointment, bean green cream and so on. Jinghong powder mercury preparations are prone to toxic reactions in large-area use. They should be transitioned from low to high concentrations. It is best to first select small pieces of skin lesions for trial use.
4. Nursing
(1) Nursing problems: mood anxiety, depression, fear; decreased ability to live; skin damage, possible infection; multiple joint pain, unfavorable activity; possible joint deformity.
(2) Nursing goal: eliminate the patient's bad mood; improve the ability to live; reduce skin damage, avoid infection; restore spontaneous activity, maintain limb function.
(3) Nursing measures:
1 The temperature of the hospital should be kept at around 20 °C, air circulation, and sufficient sunlight.
2 diet to low-fat food, avoid fish, sea hair products, avoid spicy and spicy food; fever patients, consumption is severe, need to enter high protein, high calorie, high vitamin diet.
3 Do a good job in psychological care, keep your mood comfortable, and make patients build confidence and actively cooperate with treatment.
4 closely observe the distribution of the rash, color, size, shape, scaly, skin itching degree, with or without bleeding, bleeding points, timely report to the physician.
5 Keep the bed clean, change the sheets and clean the dander in time. When applying the ointment during the treatment, the washed rags should be worn and the clean rags should be placed to avoid irritation to the skin caused by oil and chemical fiber, which makes the patient feel uncomfortable.
6 patients with erythrodermic psoriasis should stop all suspected pathogenic drugs. The body resistance of such patients is very low, which is easy to cause secondary infection. Therefore, the hospital should be disinfected frequently, keep warm, and prevent the patient from catching cold or causing respiratory infection.
7 strengthen oral care to prevent mucosal infections of fungi.
8 Patients should be encouraged to exercise appropriate joint activities every day. For patients with obvious morning stiffness, they should be encouraged and assisted in their activities.
9 For patients with joint movement disorders caused by narrowing of joint space or due to muscle contracture, it is necessary to assist them to perform passive exercise every day to promote functional improvement or recovery and avoid malformation.
10 Close observation of the side effects of non-steroidal anti-inflammatory drugs, gold preparations, penicillamine and immunosuppressive agents, once treated promptly.
(4) Discharge guidance:
1 Keep your mood comfortable, regular life, pay attention to hygiene, and prevent infection.
2 diet avoid spicy, fish and sea hair products.
3 adhere to appropriate functional exercise, enhance the body's immunity and prevent muscle atrophy and joint deformity.
4 If the recurrence is timely, see a doctor.
(two) prognosis
The disease has a long course and can last for decades. It can even be extended for life and easy to relapse. The prognosis of patients with psoriasis is generally better. A small number of patients have extensive joint involvement, severe skin lesions, and high disability. Acute arthritis itself rarely causes death, but glucocorticoids and cytotoxic drugs can cause fatal complications such as severe infections, peptic ulcers and perforations.
prevention:
Disability analysis
(1) The disease invades multiple small joints of the hands and feet and the spine and ankle joints. It is characterized by progressive para-articular erosion, resulting in osteolysis, which is characterized by redness, deformity and stiffness of the joint.
(2) may be associated with liver, kidney, cardiovascular and other organ diseases, affecting the patient's ability to resist disease, aggravating psoriasis-like damage.
(3) Psoriasis is stubborn and often relapses, and patients are prone to pessimistic negative emotions, which is not conducive to the clinical cure of this disease.
2. Personal prevention
(1) Primary prevention:
1 Remove all possible predisposing factors, such as prevention and treatment of tonsillitis or upper respiratory tract infection, avoid trauma and trauma, irritation, excessive tension and other mental factors, maintain good eating habits, avoid spicy, spicy food.
2 strengthen physical exercise and improve the body's immunity.
3 life rules, maintain a comfortable mood, pay attention to hygiene, prevent skin infections.
4 to improve the understanding of psoriasis, the disease is not contagious, can be alleviated by active treatment.
(2) Secondary prevention:
1 Early diagnosis: Psoriasis arthritis is characterized by both arthritis and psoriasis, and most patients have psoriasis first. In particular, about 80% of patients have deformed and damaged nails, such as hyperkeratosis, thickened deck, turbidity, tarnish, blood, and unevenness; this condition is simple psoriasis. Only 20% of patients. For those with only arthritis and no history of psoriasis, the scalp and elbow joints should be carefully examined for the presence of skin lesions, and whether there are lesions that are not easily found, it is meaningful for early diagnosis of this disease.
2 early treatment: the disease is a chronic recurrent, joint disease. The cause is not completely clear. So far, there are many treatments, but there are still no satisfactory treatments. Therefore, comprehensive therapy should be adopted, combining Chinese and Western medicine.
A. Internal drugs: such as methotrexate, vitamins A, E, C, D, etc., glucocorticoids, transfer factors, thymosin injection (thymosin), antibiotics, etc.
B. Topical drugs: 2% salicylic acid ointment, 5% coal tar ointment, etc.
C. Other methods: 1 bath therapy; 2 ultraviolet therapy; 3 photochemotherapy.
D. TCM syndrome differentiation and treatment.
(3) Level 3 prevention
1 Pay attention to clean skin and prevent recurrence of psoriasis.
2 Avoid mental stress and keep your mood comfortable.
3 Avoid feeling the wind, heat and cold.
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