Woman with 3 months of Flexural (Inverse) Psoriasis 皮褶型牛皮癣

A 45-year-old otherwise healthy female was presented with 3 months of flexural psoriasis. Initially, she reported rashes appearing on areas on the groin and submammary folds. GP prescribed Fobancort (Fusidic acid and Betamethasone dipropionate) cream and referred her to a dermatologist for final diagnosis and a treatment plan to help improve her condition. However, rashes developed on areas of her popliteal and chelidon. A diagnosis of flexural psoriasis was then made by a dermatologist and Triamcinolone acetonide cream (potent steroid) was further administrated. Her rash resolved intermittently but successively appeared on both retroauricular folds. She came to seek a third opinion.

Upon examination, there were glossy and sharp demarcated erythema presented on areas of the groin, submammary folds, preauricular area, retroauricular fold, popliteal and chelidon.  The scaling on shiny erythematous plaques of the skin folds is minimal (Fig.1,2,3). She was prescribed with herbal medicinal powder and was told to take it twice daily. She was then reviewed every 4 weeks with her progress tracked by photographs. The lesions improved considerably with herbal medicine within 8 weeks of starting the treatment. When there was complete resolution at month 5, prescription of herbal medication was ceased. We continued to follow-up the patient for an additional 12 months with no recurrence of lesions observed till date.

Inverse psoriasis-1

inverse psoriasis-2

inverse psoriasis-3
Fig. 1-3 Inverse (flexural) Psoriasis. Shiny erythematous plaques of the skin-to-skin folds that lack scaling. There is much less scaling than in untreated chronic plaque psoriasis. Flexural lesions are characterized by shiny, pink to red, sharply demarcated thin plaques.

Discussion

Due to the moist nature of the skin folds, the appearance of the psoriasis is slightly different from untreated chronic plaque psorisis. Many clinicians would make the diagnois of Candida infection, intertrigo or seborrhoeic dermatitis. The inverse psoriasis tends not to have silvery scale, but is shiny and smooth. There may be a crack (fissure) in the depth of the skin crease. The deep red colour and well-defined borders characteristic of psoriasis may still be obvious. The most common sites of involvements are the retroauricular fold, intergluteal cleft, inguinal crease, axilla, and inframammary region, skin-to-skin contact area. Sweating is impaired in affected areas.

When flexural areas are the only sites of involvement, the term “inverse” psoriasis is sometimes used. Localized dermatophyte, candidal or bacterial infections can be a trigger for flexural psoriasis.

My Thoughts and Self-Reflection

With an autoimmune skin disease, like psoriasis, the immune system attacks the body’s own tissue, skin. Immunosuppressant drugs, a class of drugs that suppress or weaken the body’s immune system, are administrated conventionally to reduce the impact of the autoimmune disease on the body.

However we take the initiative NOT to use conventional or herbal steroids or immunosuppressants to treat non-life-threatening skin diseases. Tangs herbal medication helps the body balance and revitalize its immune system to treat skin disorders in a natural and safe way.

Such unorthodox methods are the polar opposite of what modern medical treatments preaches.

This then begs the question of whether the example mentioned above an anecdotal evidence, a single person’s story being used to support a claim? Indeed we do need a large sample size of prospective cohort studies to further test the hypothesis. We have been continually presented with a series of cases reporting of disconfirming evidence for the conventional immunosuppressant treatment theories of autoimmune skin diseases, that our treatment results are in direct opposition to the guidelines of the conventional skin disease treatments.

However, certain beliefs about conventional treatment that we hold – beliefs that seem obvious to us, to be empirical facts – have turned out, in light of numerous disconfirming evidence, to be mistaken philosophical “beliefs”. We are then, in a sense, in a similar situation to that of our predecessors, Aristotle, Newton and Einstein on the 2000, 400 and 100 years ago respectively. Maybe our entire way of looking at the world might turn out to be the wrong way of looking at the world? Just as new discoveries forced them to rethink core beliefs they had long taken as apparent facts, the recent scientific discoveries force us to rethink some of our most fundamental beliefs about the sort of medical treatments we accept to be the panacea.

病例报告

一名 45 岁其他方面健康的女性罹患皮褶型银屑病 3 个月。她称最初在腹股沟和双乳下褶皱区域出现皮疹。全科医生开了Fobancort(夫西地酸和二丙酸倍他米松)乳膏,并将她转介给皮肤专科医生进行最终确诊和治疗。随后皮疹出现在她的腘窝和肘窝区域,皮肤专科医生诊断为皮褶型牛皮癣,并处方曲安奈德乳膏(强效类固醇)涂药皮疹间歇性消退,但随即又在两耳后褶皱处出现皮疹。她前来我处寻求第三方意见。

经检查,腹股沟、乳房下褶皱、耳前区域、耳后褶皱、腘窝和颊部区域出现光泽清晰的红斑。 皮肤褶皱的闪亮红斑块上的鳞屑很小(图1,2,3)。处方草药药粉每日两次,每四周对她进行一次检查,并拍照记录。在开始治疗后的8周内,皮疹病变显着改善。牛皮癣疹在第五个月完全消退,因此停止服用草药。随后我们继续对患者进行12个月的随访,迄今为止没有观察到病变复发。

讨论

由于皮肤褶皱的湿润性质,牛皮癣的外观与未经治疗的慢性斑块型银屑病略有不同。许多临床医生会诊断念珠菌感染、擦烂红斑或脂溢性皮炎。反向牛皮癣往往没有银色鳞片,但有光泽并且比较光滑。皮肤褶皱的深度可能有裂缝。牛皮癣的深红色和清晰的边界特征仍然很明显。最常见的受累部位是耳后褶皱、臀沟、腹股沟、腋窝和乳下区域、皮肤与皮肤接触区域。受影响区域出汗受损。

当皮肤褶皱区域是唯一受累部位时,有时使用术语”反向”银屑病。局部皮肤癣菌、念珠菌或细菌感染可引发反向型(皮褶)银屑病。

我的想法与反思

对于自身免疫性皮肤病,如牛皮癣,免疫系统攻击身体自身的皮肤。免疫抑制剂药物是常规疗法,它一类抑制或削弱身体免疫系统的药物。但是我们主张不使用常规或草药类固醇或免疫抑制剂来治疗非危及生命的皮肤病!我们使用唐氏草药帮助身体平衡免疫系统,以自然和安全的方式治疗皮肤病。

那么问题来了,一个个别医案轶事证据可以被用来支持一个主张吗?事实上,我们需要大量的前瞻性队列研究样本量来更深入地测试假设。我们已经正在持续写出一系列病例报告,对阵自身免疫性皮肤病的常规免疫抑制剂治疗理论的不确凿证据,我们的治疗结果与常规皮肤病治疗指南的结论直接相反。

我们多年以来所持有的某些常规治疗信念 – 在我们看来是显而易见的、经验性的事实 – 会慢慢地在越来越多的证据下,被证明是错误的哲学”信念”。因此,从某种意义上就我们的当前医学理念而言,我们所处的情况与我们的前辈亚里士多德,牛顿和爱因斯坦分别在2000年前,400年前和100年前所遇到的境况极其相似:也许我们曾经自以为看待世界的正确观念是否后来会被证明是看待世界的错误观念?正如新的发现迫使过去的前辈们重新思考他们长期以来一直认为是明显事实的核心信念一样,最新的医疗发现也迫使当前的我们重新思考关于我们所传承下来的一些疾病治疗信念是否是一场错误的哲学”信念”。