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Shallow Hal

 

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Tony Robbins as himself a motivational tv guru

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Rosemarie Shanahan (Gwynneth Paltrow actress, singer, food writer and goop.com)  in  the perception of Hal (Jack Black).
Rosemarie Shanahan in her real form.

  

Hal (Jack Black) got stuck on an elevator with Tony Robbins and had the chance talk  whilst waiting. Hal is about to recieve the gift he never expected from Tony Robbins. He will have the chance to meet the love of his life in a different perspective. He will meet Rosemarie Shanahan’s inner beauty and will look different in his eyes. Hal will be able to defend Rosemarie Shanahan as he meets her family, friends and even her ex lover who happen to have a psoriasis.

PSORIASIS

is a disease that is rapid proliferation of epidermal cells and abnormal increase of keratin at the basal layer. There is no cure for this disease however the signs and symptoms can be manage with lifetime treatment an avoiding aggravating factors.

Signs and symptoms

  • red scaling papule with silvery plaque and pruritic or itchy
  • When the patches are scraped off they appear to bleed.
  • Scalp, lower back, genitalia, gluteal cleft, fingers, elbows and knees are prone to this signs in bilateral oval form.
  • It also appear in the nails (pitting discoloration, nail plate separated from nails, crumbling beneath the free edges)
  • palmar pustular psoriasis
  • adjacent skin – red smooth plaques with emacerated surface
  • Guttate psoriasis – 1 cm wide lesion similar to raindrops scattered to body caused by streptoccocal infection

Aggravating factors:

  • Stress
  • Anxiety
  • Trauma
  • Infection
  • Seasonal and hormonal changes
  • Unfavorable environment (cold weather)
  • Medications (lithium, beta blockers and indomethacin)
  • 15 to 50 years old

Presence of plaque type lesion confirms the diagnosis.

The treatment includes prevention of dryness

  1. removing of scales with warm water and
  • oil bath (olive oil, Aveeno oilated oatmeal bath and mineral oil)
  • coal tar preparations  (Balnetar)

Pat dry with towel and avoid rubbing ro scratching.

2. emolient creams are given after bath. It moisturizes the skin and provides occlussive film on skin. Normal water loss is halted. Traps water and hydrates the stratum corneum.

  • alpha-hydroxy acids (Lac-hydrin, Penederm)
  • Salicylic acid (softens thick skin)

Medications

  1. Topical Application
  • Tar Preparations -It is seldom use because it can irritate skin, difficult to apply and it is malodorous
  • Anthralin – need to inform the patient that it leaves a brownish purple stain on the skin but it will subside after the medication has stop. Cover with gauze, stockinette, soft covering to avoid furniture staining
  • Salicylic acid
  • Vitamin D preparation – Suppresses epidermopoeisis
  • Calcipotriene (Dovonex) – it is non steroidal anti inflamatory drugs and a Vitamin D2 Derivative available in cream or solutionIt acts by decreasing mitotic turnover. Local irritation of the skin is the most common side effect. Monitor for Hypercalcemia. Avoid application in the face and intertrigenous areas (skin that are prone to friction rub such as the axilla). Not given to elderly patients and pregnant women.
  • Tazarotene (Tazorac) – A retinod compound that  slough off scales/plaque. Increase sensitivity to sunlight or photosensitive. Avoid photosensitizers such as tetracyline or antihistamine medications when treated with Tazoratene. Contraindicated for pregnant women. Side effects include burning, erythema, irritation at the site for severe psoriasis but not applicable for face and areas prone to friction such as axilla.
  • Corticosteroid – High potency corticosteroids are given to severe psoriasis patients twice a day for four weeks with two weeks interval before reapplying. Not for face and intertrigenous areas. Moderate potency is recommended for long term use. Low potency is long term use for face and friction prone areas.

When the medication has been  applied cover with tubular plastic or vinyl jumpsuit and cover the hands with gloves      and feet with plastic bag and hair with a shower cap. Check flammability for plastic substances and avoid smoking.

Side effects of corticosteroids are cataract, striae, medication resistance, atrophy and telangiectasis which causes adrenal suppression.

2. Intralesional Agents – are given to patients who are resistant to treatment.

  • Triamcilidone Acetinode ( Aristocort, Kenalog-10, Trymex)

3. Systemic Agents – Increase risk for flare ups on withdrawal.

  • Methrotrexate – inhibits DNA synthesis in epidermal cells and reducing the turnover time of the psoriatic epidermis. Taken with food to avoid nausea.Side effects include bone marrow suppression and livr toxicity. Advise patient not to drink alcohol during treatment. Monitor for hepatic symptoms, hematopoiesis and renal system disorder.
  • Hydroxyurea – affects DNA synthesis. Side effects bone marrow suppresion.
  • Cyclosporine A – a cyclic peptide used to prevent the rejection of transplanted organs. Side effects include nephrotoxicity and hypertension
  • Oral retinoids – Vitamin A ( synthetic derivatives and its metabolites) modulates growth and differentiation of epithelial tissue
  • Etritinate – severe pustular/ eryhtrodermic psoriasis; teratogenic
  • Photochemotheraphy -Psorden medication with Ultraviolet A (PUVA) light treatment given for patients who are severely debilatated with psoriasis.

PUVA has elctromagnetic spectrum of 180 – 400 nm. It is given with 8- Methoxypsoralen (photosensitizing meds that effects for 6-8 hours. Advice patient to avoid exposure to sun or apply sunscreen protection and wear green or gray tinted glasses. Schedule a regular opthalmology examination). Psoralen with PUVA psoralen binds with DNA and dicrease cellular proliferation. Side effects include skin cancer, cataracts and premature aging. It has a chamber that contains high out black-light lamps and an external reflectance system. Exposure time will depend on the skins tolerance given for 2-3 times a week until cleared. There’s an interim peroid of 48 hours in between. When cleared of psoriasis, maintenance of less potent therapy is given to prevent minor flare ups.
Ultraviolet – B (UVB) treats generalized plaques. Ranging from 270 to 350 nm. It may be given alone or with topical coal tar.

Narrow band uvb has a spectrum of 311-312 nm. It lessens the epoxure to UV rays but increases specific theraphy.

If photochemotheraphy is not possible patient can have direct exposure to sunlight. However patient will be prone to acute sunburn, photosensitive disorders such as lupus, rosacea, polymorphic light and eruption. It can cause wrinkles, thickening of the skin and skin cancer.

Excimer lasers treats the scalp and hard to treat areas which aims directly on plaque. Spectrum light is 308 nm given in four to six treatments and clears  in nine months.

PSORIATIC ARTHRITIS

  • sacroiliac and distal joints of fingers
  • Mild joint discomfor and pitting of fingernails with cutaneous lessions
  • Treated with joint rest, heat and salicylates
  • Psoriatic arthropathy
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