My sister has huge red raised patches on her body, including on the tops of her legs. She says the itching is unbearable. Her doctor called psoriasis guttata and suggested applying E45 cream. She is 78 and has been under a lot of stress. Your advice would be appreciated.
Name and address provided.
Guttate psoriasis is a skin condition usually caused by a bacterial infection such as strep throat or a sinus infection, but some people are also genetically more prone to it.
Within weeks of infection, numerous red spots, usually between 2 mm and 15 mm in size, suddenly appear on the trunk and upper parts of the arms and legs and sometimes on the face, hands and feet. In some cases, these spots can itch.
Guttate psoriasis is the result of the immune response, which had fought the infection and mistakenly focused its attention on the skin. Stress can also play a role.
In about 60 percent of cases, guttate psoriasis resolves spontaneously within weeks or months.
If they can’t help, gentle sun exposure in the afternoon (here in the UK) for up to ten minutes can provide significant improvement, but it’s essential that your sister doesn’t stay outside any longer than this to avoid sunburn
However, in about a third of cases, it leads to chronic plaque psoriasis, which typically causes larger patches of scaly, itchy, raised skin due to an overproduction of skin cells. This is also caused by an overreaction of the immune system.
Plaque psoriasis has a strong genetic element. You say in your longer letter that you have this specific form and I suspect your sister has this too.
E45 is an emollient – a medical moisturizer that can help soothe the skin, but won’t address the cause of the symptoms. However, corticosteroids (applied as a cream or ointment) or calcipotriol, a vitamin D-based ointment, can help reduce the underlying inflammation of both guttate psoriasis and plaque psoriasis.
There is also a combination topical medication containing the steroid betamethasone and calcipotriol called Dovobet, which studies have confirmed to be highly effective.
The difficulty with this type of treatment is that the rash tends to be widespread throughout the body, making daily applications relatively impractical.
An alternative treatment is phototherapy, which exposes the skin to a specific wavelength of ultraviolet light that slows the conversion of skin cells. This requires a referral from your general practitioner to a specialized dermatology department.
If they can’t help, gentle sun exposure in the afternoon (here in the UK) for up to ten minutes can provide significant improvement, but it’s essential that your sister doesn’t stay outside any longer than this to avoid sunburn. Using sunscreens is said to block the beneficial UVB light.
If your sister shows no signs of improvement, another visit to the GP is necessary.
Guttate psoriasis is the result of the immune response, which had fought the infection and mistakenly focused its attention on the skin. Stress can also play a role
In recent years, if I get water in my ear while showering, I get a foul-smelling, yellow discharge. Ofloxacin drops clear the infection, but I want to know what is causing this.
Ken Mace, Nottinghamshire.
You say in your longer letter that the problems with your ear go back 50 years to an infection that eventually required surgery.
There are two features in your history that point to a probable diagnosis. The first is that if water gets in your ear, an infection is likely to follow, and the second is that you said you also have a perforated eardrum.
I think you have silent mastoiditis, a chronic infection of the mastoid air cells, which only occasionally causes symptoms.
The mastoid bone (the area of the skull immediately behind the ear) has a spongy honeycomb structure made up of mastoid air cells — small cavities that contain air that protect the ear and regulate pressure in the middle ear.
Normally, a small perforation of the eardrum will heal, but not if there is an ongoing infection in the middle ear cavity or the mastoid air cells.
In that case, water in the ear will pass through the perforation and cause a flare-up of a low-grade infection in the mastoid (leftover from that original infection 50 years ago).
There are no ear drops for this type of infection, which is why Ofloxacin eye drops are used. These contain a potent antibiotic that suppresses the infection when it occurs, but it is insufficient to fully penetrate the spongy mastoid air cells and so the low-grade infection is never completely eradicated.
I suggest that you discuss your medical history with your new doctor, as you have just moved, and are seeking a referral to an ear specialist.
The most likely outcome is that you will be referred for a CT scan of the mastoid bone to confirm or rule out silent chronic mastoiditis.
If my suggested diagnosis is correct, you may need another surgery. Years ago, the surgery may not have been invasive enough to remove all the infected bone. I hope this helps.
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