How to diagnose psoriatic arthritis. Psoriatic arthritis - symptoms, photos, treatment and drugs

About 10% of people with psoriasis have an additional condition called psoriatic arthritis. Moreover, joint pain can manifest itself even without obvious problems. skin. That is, the patient comes to the doctor with complaints of joint pain, and a form of psoriasis is diagnosed. Treatment of psoriatic arthritis remains one of the most difficult tasks of dermatology.

Causes of malaise

Like any other disease, psoriatic arthritis has specific causes and symptoms. It has been clinically proven that, as in the case of psoriasis, psoriatic arthritis (the second name is psoriatic arthropathy) can occur against the background of regular stress conditions. At the same time, due to the peculiarities of psychology, women are more susceptible to this complex of diseases than men.

Injuries that directly affect the joint - dislocations, fractures - are the main causes. Against the background of the current inflammatory process (psoriasis), arthropathy develops much faster and more aggressively.

The following pathologies provoke purulent arthritis:

• tuberculosis;
• syphilis;
• osteomyelitis.

Chronic and rheumatoid forms of psoriatic polyarthritis can develop against the background of increased activity of the immune system with in large numbers in the blood of autoimmune complexes. Allergy is often the cause.

• medicinal;
• food;
• vegetable;
• "household" and other types of allergies.

As you can see, the causes of psoriatic arthritis are no different from the causes of other types of this disease. But if in all cases such causes are the cause of the disease, then in the case of psoriatic polyarthritis, these factors act as a "trigger", because arthritis, or rather a predisposition to it, is already present in the patient's body.

Important! The etiology of this type of disease is not fully understood. Doctors continue to disagree about the nature of the disease. Therefore, psoriatic arthritis (psoriatic polyarthritis) remains one of the most intractable in its series.

Clinical features

Due to the specific etiology of the disease, its course is not typical for other types of the disease. On the other hand, it is the specific signs of psoriatic arthritis that make it possible to quickly diagnose it, with a timely visit to a doctor:

1. Joint pain.
2. The defeat of the interphalangeal areas of the fingers.
3. Various subluxations of small joints.
4. Stiffness and little mobility of the limbs after long sleep and in the morning.
5. Also, the disease is characterized by the following symptoms:
6. Destruction of the bone tissue of the body of the joint.
7. Local increase in temperature of the skin around the joint.
8. Finger modification.
9. Simultaneous damage to several joints on one finger.
10. Psoriatic manifestations in the area of ​​the diseased joint.

An experienced doctor can accurately diagnose the disease based on the symptoms of psoriatic arthritis. Wherein clinical picture joint pain almost identical to any other type of arthritis.

How to treat, medicines or traditional medicine?

As with the treatment of any disease and its symptoms, the question arises - how to treat psoriatic arthritis? There are always representatives of two paradigms - classical medical and folk. As practice shows, with the right selection of medicines, some folk methods quite beneficially complement the treatment.

Medical treatment

Based on the diagnosis of the patient, his predisposition or intolerance to drugs, an individual course of treatment is developed. Its goal is step-by-step inhibition of the disease:

1. Removal of acute symptoms.
2. Decrease in immune-inflammatory reactions throughout the body.
3. Slowing down the course of pathological processes in damaged joints.
4. Stabilization of the functionality of the musculoskeletal system.

An integrated approach to solving the problem makes it possible to treat psoriatic arthritis as effectively as possible in this sequence. The complex of medicines used is slightly different from that for non-surgical treatment of other types of arthritis:

1. Anti-inflammatory non-steroids - Diclofenac, Ibuprofen.
2. Glucocorticosteroids (directed against psoriasis symptoms).
3. Sulfasalazine is an anti-inflammatory antibiotic.
4. Cyclosporine, Leflunomide, tumor growth inhibitors - are prescribed according to the specific decision of the attending physician.

Any drugs, except for anti-inflammatory creams and ointments, are taken only on the instructions of a doctor and in the indicated dosages.

Important! Self-medication and self-prescription of drugs is strictly unacceptable. Aggressive drugs with the wrong dosage can catastrophically aggravate psoriatic arthritis.

Traditional medicine in the treatment of psoriatic arthritis

One of the leading dermatologists using folk recipes is Svetlana Mikhailovna Ogneva, a doctor with 40 years of experience. The traditional medical community has always been quite wary of the use of non-pharmacological agents. But practice shows that some of them give a positive effect in combination with drug therapy.

Svetlana Mikhailovna offers several folk recipes, which help relieve painful symptoms at home. These recipes will definitely not bring harm and will help to cope with the painful manifestations of psoriatic arthritis.

1. When the joint swells, make a compress from raw carrots, passed through a grater or meat grinder. For 30 g of the pureed mass, 5 drops of any vegetable oil and 5 drops of pharmacy turpentine are added. The procedure is done in a day. On the second day, compresses from aloe are placed.
2. If you are prone to swelling of the joints, you should drink juice squeezed from burdock leaves. 30 g 3 times a day 40 minutes before meals and eaten with a small amount of honey (provided that there is no diabetes or allergies to such products). The juice is prepared for 3-4 days from a fresh plant and stored in the refrigerator. This tool Dr. Ogneva Svetlana Mikhailovna recommends taking during the entire course of treatment.
3. It has been noticed that with psoriatic arthritis, pain in the small joints of the legs often occurs. In this case, the grass woodlice gives a positive effect. The soles of shoes or socks are lined with this grass (the main thing is that when walking there is direct contact with the skin of the legs to absorb the juices of the plant). No contraindications other than personal intolerance have been identified.

Also Ogneva Svetlana Mikhailovna recommends herbal baths 2-3 times a week to relieve swelling and pain in the joints. But in this case, you need to consult with your doctor. Contraindications are possible due to problems with pressure, blood vessels, or a negative reaction of the skin to decoctions of any of the herbs.

Home alternative treatment of psoriatic arthritis will not harm and even help in the fight against psoriatic arthritis, if it is chosen correctly in combination with medication.

For reference! Svetlana Ogneva insists on an integrated approach to solving the problem. Whether or not to use her recommendations is up to the patient to decide. But it's still worth listening to them.

Recovery prognosis

Unfortunately, there is no cure for psoriatic arthritis (psoriatic arthritis). This fact must be accepted. But this does not mean that the patient is doomed to suffer because of painful symptoms. With the right complex treatment(I use both medicines and folk remedies) the symptoms of the disease are minimized:

1. On average, 50% of patients show a stable remission for about 2 years.
2. Disability or persistent disability manifests itself in the case of reactive development of the disease, insufficient treatment or late diagnosis. Irreversible consequences are possible already during the first year of the disease.
3. Increased mortality due to the high risk of cardiovascular pathology and amyloid kidney damage.

The presented data are based on long-term studies of the disease. As practice has shown, it is currently impossible to completely cure psoriatic arthritis due to the unclear etiology of the disease.

As the name implies, psoriatic arthritis combines two diseases at once - rheumatoid arthritis and psoriasis. The inflammatory process affects the human joints and is currently the most severe form of psoriasis. The prevalence of the disease among the world's population is low. According to experts, psoriatic arthritis, the symptoms of which may appear only in the later stages, is common mainly among patients with psoriasis (from 7 to 47%). Ordinary people suffer from the inflammatory process much less frequently (the disease is recorded in 2-3% of the population).

The insidiousness of psoriatic arthritis is manifested in the fact that it can proceed absolutely painlessly. As a result, in the vast majority of cases, the disease is detected too late, when adverse changes in the joints are already irreversible. This means that with a timely diagnosis of psoriatic arthritis, treatment should be prescribed as early as possible, which will avoid serious consequences and complications. Methods for early detection of the inflammatory process are standard: careful monitoring of the body, responding to known symptoms, regular examination at the rheumatologist.

All standard preventive actions, which are important in other orthopedic diseases, have no effect in the case of psoriatic arthritis, because doctors do not know the exact cause of the inflammation. This means that the main way to combat the disease remains the so-called secondary prevention, which is aimed at slowing down the spread of pathology and maintaining the basic functions of the joints.

Unfortunately, no clinic in the world still guarantees a 100% cure for this unpleasant disease. At this point in time, researchers are just beginning to understand how the body's immune system works. It is possible that in a few years an effective cure will be found, but so far, with a diagnosis of psoriatic arthritis, treatment continues to rely on ineffective medicines overwhelming too strong immune reactions organism. Accordingly, sick people continue to suffer from the gradual destruction of soft tissues and joints. Many of the patients become disabled for life.

Psoriatic arthritis - symptoms and clinical picture

Most characteristics inflammation is the appearance of red, scaly spots on the skin, a change in the pigmentation of the nails on the legs and hands, the formation of small scars resembling pockmarks. Psoriatic plaques are small in size, but they quickly spread throughout the body, and this process is accompanied by unpleasant itching and constant feeling discomfort. As mentioned above, when psoriatic arthritis is diagnosed, symptoms can appear very late, so each person needs to be regularly examined by a rheumatologist and monitor the state of his body. An indirect sign of the presence of an inflammatory process is pain in the joints and their swelling, however, they are also characteristic of the usual rheumatoid arthritis, so for any unpleasant sensations it is necessary to consult a specialist to exclude the risk of serious complications.

Psoriatic arthritis - treatment and prognosis

There is no specific method for treating inflammation of the joints, so all the efforts of doctors are aimed at restoring lost functions and relieving severe pain. For this, the following groups of drugs are used:

• non-steroidal anti-inflammatory drugs, in particular ibuprofen. Such drugs reduce joint stiffness, relieve pain, and suppress the development of inflammation. However, they have a negative effect on the intestines, kidneys, heart and gastric mucosa, so they should be taken with caution;
• glucocorticoids - used in cases where psoriatic arthritis is accompanied by strong, sharp pains in the joints;
• basic preparations - reduce pain and inflammation, prevent the spread of the disease to other joints. The drugs of this group act very slowly, so the effect of their use becomes noticeable a few weeks after the start of the course of treatment;
• immunosuppressive agents - partly suppress immune system, but relieve healthy tissues from the “attack” of our own body, which, in fact, happens with psoriatic arthritis. The best known immunosuppressive drugs are cyclosporine and azathioprine.

Surgical intervention in the treatment of psoriatic arthritis is practically not used. It is resorted to only in cases where the disease continues to spread despite medication, and threatens to move to healthy joints.

Video from YouTube on the topic of the article:

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The degree of activity characterizes inflammatory process both in the area of ​​the joints and from other organs and systems and is determined according to the criteria proposed for rheumatoid arthritis.

I. The minimum degree of activity is manifested by minor pain during movement. Morning stiffness is absent or its duration does not exceed 30 minutes. ESR is not increased (no more than 20 mm/h), body temperature is normal. Exudative manifestations in the area of ​​the joints are absent or slightly pronounced. Other inflammatory symptoms are not detected.

II. Moderate activity suggests pain at rest and on movement. Morning stiffness lasts up to 3 hours. Moderate, unstable exudative symptoms are determined in the area of ​​\u200b\u200bthe joints. ESR within 20-40 mm/h, significant leukocytosis and stab shift. Body temperature is often subfebrile.

III. The maximum degree of activity is characterized severe pain at rest and while moving. Morning stiffness lasts more than 3 hours. Pronounced exudative phenomena are observed in the area of ​​periarticular tissues. ESR above 40 mm/h. Heat body. A significant increase in the level of biochemical laboratory parameters (sialic acids, SRV, fibrinogen, etc.). It is possible to develop a remission of the inflammatory process, especially in the mono-oligoarthritic variant of the articular syndrome and limited psoriasis vulgaris.

Laboratory indicators. Laboratory changes at psoriatic arthritis are nonspecific and reflect the degree of activity of the inflammatory process. With a moderate and maximum degree of inflammation activity, anemia, accelerated ESR, leukocytosis are determined, the appearance of CRV, dysproteinemia with an increase in globulins due to α- and γ-fractions, etc. skin changes and almost never accompanied clinical symptoms gout. In 5-10% of cases of psoriatic arthritis, a positive test for RF is detected in small (not higher than 1/64) titers.

In patients with osteolytic variant of joint damage a violation of the aggregation properties of erythrocytes is detected, leading to an increase in blood viscosity, a decrease in hematocrit).

When malignant form of psoriatic arthritis very pronounced deviations from the norm of nonspecific signs of inflammation and significant changes in immunological parameters are revealed: hypergammaglobulinemia above 30%, an increase in the concentration of immunoglobulins of classes A, G and E, circulating immune complexes, the appearance of nonspecific (antinuclear factor, rheumatoid factor) and specific (to the cells of the horny and granular layers of the epidermis) antibodies, etc. In the study synovial fluid find high cytosis (up to 15-20 x 104/ml) with a predominance of neutrophils. The mucin clot is loose, decaying.

X-ray signs psoriatic arthritis. The radiological picture of psoriatic arthritis has a number of features. Thus, osteoporosis, which is characteristic of many diseases of the joints, in the case of psoriatic arthritis is detected only in the mutilating form. Psoriatic arthritis is characterized by the development of erosive changes in the area of ​​the distal interphalangeal joints. Erosions, formed along the edges of the joint, further spread to its center. In this case, the tops of the terminal and middle phalanges are grinded off with simultaneous thinning of the diaphysis of the middle phalanges, and the second articular surface is deformed in the form of a concavity, which creates an x-ray symptom of “pencils in a glass”, or “a cup and a saucer”.

X-ray of the fingers in psoriatic arthritis

1. Psoriatic arthritis, polyarthritic variant with systemic manifestations (renal amyloidosis, terminal kidney failure), severe form. Widespread psoriasis vulgaris, progressive stage. Activity III. Stage III. Functional insufficiency of joints II degree.
2. Psoriatic arthritis, spondyloarthritic variant with systemic manifestations (aortitis, left-sided anterior uveitis), severe form. Palmar-plantar pustular psoriasis, progressive stage. Activity III. Stage II B. Bilateral sacroiliitis stage IV, multiple syndesmophytosis. Functional insufficiency of joints III degree. Palmar-plantar pustular psoriasis, progressive stage.
3. Psoriatic arthritis, distal variant, without systemic manifestations, common form. Activity II. Stage III. Functional insufficiency of the joints of the 1st degree. Limited psoriasis vulgaris, stationary stage.

Diagnostics. Psoriatic arthritis has a number hallmarks, which in 1974 were grouped by D. Mathies into diagnostic criteria and remain relevant to this day.

Diagnostic criteria psoriatic arthritis (Mathies D., 1974):

1. Damage to the distal interphalangeal joints of the fingers.
2. Simultaneous lesion of the metacarpophalangeal (metasophalangeal), proximal and distal interphalangeal joints, "axial lesion".
3. Early damage to the joints of the feet, including the big toe.
4. Pain in the heels (heel bursitis).
5. The presence of psoriatic plaques on the skin or a change in the nails typical of psoriasis (confirmed by a dermatologist).
6. Psoriasis in next of kin.
7. Negative reactions to RF.
8. Characteristic radiographic findings: osteolysis, periosteal overlays. No epiphyseal osteoporosis.
9. Clinical (usually X-ray) symptoms of unilateral sacroiliitis.
10. X-ray signs of spondylitis are gross paravertebral ossifications.

Diagnostic rule: the diagnosis is reliable in the presence of three criteria, one of which must be 5th, 6th or 8th. In the presence of the RF, five criteria are required, among which there must be the 9th and 10th.

Joint diseases
IN AND. Mazurov

Psoriasis is a chronic relapsing disease that manifests itself mainly in the form of rashes of abundantly scaly plaques on the skin, but which can be accompanied by damage to other organs, primarily joints, as well as bones, muscles, pancreas, lymph nodes, kidneys. , various neurological and psychiatric symptoms. Therefore, modern scientists sometimes prefer the term: psoriatic disease.

For example, on III International Symposium on psoriasis in 1987 prof. Novotny from Czechoslovakia made a presentation called "Visceral psoriasis" and presented a classification in which such forms as psoriatic nephritis, endocrinopathic form of psoriasis, etc. are highlighted. And of course, in our time, it is no longer possible to consider psoriasis only as a dermatosis limited to lesions of the skin and nails. It follows that it is necessary to take a critical look at the definition of psoriasis, made in most textbooks, where it is considered as an isolated lesion of the skin.

Exploring the state internal organs autopsy of patients with psoriasis revealed alterative changes in the walls of the vessels of the main substance, depolymerization of fibrillar structures of the connective tissue, the appearance of perivascular cell infiltrates and macrophage nodules in the myocardium, kidneys, etc. Changes of the reversible and irreversible type in nerve cells were also revealed (Bukharovich MN et al. - in the collection: Systemic dermatoses. - Gorky, 1990).

It should be emphasized that the etiology and pathogenesis of psoriasis are still poorly understood, and that the most likely causes of psoriasis are a complex relationship of genetic and many other influences. But this definition still says little about the pattern of articular and visceral lesions in psoriasis.

What psoriatic skin rashes look like, what psoriatic nail changes look like, what methods are used to confirm the diagnosis of skin psoriasis, what purely morphological changes in the skin underlie the so-called “psoriatic triad”, how psoriasis flows, what complications there are - you studied all this in detail or you will study in practical classes, and we will not touch on this issue at the lecture.

I will only say why you need these, at first glance, purely dermatological knowledge and diagnostic techniques. The fact is that a family doctor, a district therapist, a surgeon, a traumatologist in their practical work often encountered with patients with psoriatic arthritis. And in order to recognize this form of joint damage, you need to be able to recognize the skin manifestations of psoriasis. By the way, the ability to diagnose psoriatic arthritis is provided for by the qualification characteristic of a general practitioner, approved by the Ministry of Health.

Joint diseases are one of the most frequent types of human pathology, and there are up to 100 of their nosological forms. Apparently, at least 20 million people in the world suffer from these diseases. Among patients with various forms of chronic inflammatory diseases of the joints, rheumatoid arthritis is undoubtedly in the first place in frequency at the present time. However, due to the incidence rate, resistance to therapy, the complexity of diagnosis and often poor prognosis, psoriatic arthritis also occupies an important place, which, according to modern classification belong to the group of rheumatoid diseases.

According to the All-Union Arthrological Center (Abasov E.M., Pavlov V.M., 1985), in patients with chronic monoarthritis, psoriatic arthritis is more common (7.1%) than Bechterew's disease - ankylosing spondylitis (5.3%), yersiniosis arthropathy (2.7), tuberculous synovitis (3.1) and other diseases of the joints. The actual frequency of psoriatic arthritis is undoubtedly much higher, since many patients, especially those with widespread skin rashes, are treated in dermatological hospitals and are not taken into account by statistics. In addition, often psoriatic arthritis is not recognized and registered in a timely manner, since it can occur for a long time without characteristic skin rashes. And then, as noted by many well-known rheumatologists at the All-Union Conference in 1988, patients are mistakenly diagnosed with rheumatoid arthritis, infectious-allergic polyarthritis, etc.

It is believed that psoriatic arthritis develops on average in 7% (according to the American rheumatologist Rodnan G.P., 1973) or even in 13.5% of patients with psoriasis (according to Moscow rheumatologists). But psoriasis itself is a very common disease. With the help of mathematical analysis, it was found that the probability of getting psoriasis during a lifetime is 2.2% (Mordovtsev V.N. et al., 1985). Thus, the probability of developing psoriatic arthritis during a person's life (up to 75 years) is approximately equal to 0.1-0.15 (i.e. 100-150 per 100,000 population). This is a fairly high frequency: according to this calculation, in the city of Chelyabinsk with a population of 1 million people, from 1000 to 1500 patients with psoriatic arthritis can be expected. This calculation is confirmed by the data of employees of the Institute of Rheumatology of the Academy of Medical Sciences Erdes and Benevolenskaya, who in 1987 cited a figure of 0.1% as an indicator of the incidence of psoriatic arthritis among the population of Moscow.

Since we will talk about diseases of the joints today, we need to get acquainted with some general information.

Firstly, articular syndrome refers to a combination of pain in the joint(s), swelling, stiffness, and limited function. Joint swelling can be caused by intra-articular effusion (increased volume of synovial fluid), thickening of the synovial membrane of the joint, thickening of the periarticular (extra-articular) soft tissues, intra-articular fatty growths, etc. Therefore, articular syndrome may be due to both intra-articular and peri-articular changes.

term arthritis(synovitis) are inflammatory lesions of the synovial membrane, accompanied by its hypertrophy and effusion into the joint.

term arthrosis(or osteoarthritis) refers to a degenerative lesion of cartilage in the underlying bone, primary or secondary, associated with inflammation and other factors.

Psoriatic arthritis belongs to the so-called seronegative arthritis: rheumatoid factor, as a rule, is not detected in patients with psoriatic arthritis RF - rheumatoid factor is antibodies to the Fc fragment of IgG that are found in the blood serum of most patients with rheumatoid arthritis and some other diseases). But what exactly is psoriatic arthritis? Ailbert, who first described arthritis in a patient with psoriasis in 1882, believed that this was a random combination. However, it has now been proven that psoriatic arthritis is a special nosological form that naturally occurs in patients with psoriasis.

On the etiology and pathogenesis psoriatic arthritis makes no sense to stop, since it is simply not known as the etiology and pathogenesis of psoriasis. Those who wish can look at the collection "PSORIASIS" (M., 1980). They will find different assumptions about the role of the CIC and cellular immunity, cyclic nucleotypes and lipid metabolism disorders, changes in the intestinal mucosa and nervous system etc. The viral theory of the etiology of psoriasis will not be forgotten either. But in the end it turns out that psoriasis is a multifactorial disease and the disclosure of its pathogenesis is a matter of the future.

True, it is of interest that in patients with psoriasis vulgaris and psoriatic erythroderma, HLA B13 and B17 antigens occur approximately 4 times more often than in the population. It is estimated that carriers of the B13 antigen have a risk of developing psoriasis almost 9 times greater than those who do not have this antigen (Erdes Sh. et al., 1986). But in patients with psoriatic arthritis, the frequency of detection of the HLA B27 antigen is 2-3 times higher than in the population: in patients with psoriatic arthritis, this antigen occurs in about 20-25%, and among the population in 7-10%. In patients with uncomplicated psoriasis (without arthritis), the B27 antigen occurs with the same frequency as in healthy individuals, i.e. in 7-10%. The diagnostic significance of the HLA B27 antigen in psoriatic arthritis is associated with the fact that it is found in 80-90% of patients with psoriatic arthritis with lesions of the spine (“central arthritis”) and sacroiliac joints, but when only peripheral joints are affected, this antigen occurs with such the same frequency as in healthy individuals (Brewerton et. al. 1974; Lambert et. al. 1976).

Psoriatic arthritis is an inflammatory disease that affects the joints. Its leading clinical manifestations are pain in the spine and muscles, plaque formation on the skin, subsequent deformation of the vertebral bodies, bone, cartilage articular structures. Treatment of psoriatic arthritis is conservative with the use of drugs of various clinical and pharmacological groups, physiotherapy, exercise therapy.

General description of the disease

Psoriatic arthritis is one of the forms of psoriasis, diagnosed in 5-7% of patients. and spine usually occur after severe skin lesions. Nodules of bright pink color, covered with silvery scales, form on it. It is this specific symptom that allows you to quickly diagnose the pathology.

Small interphalangeal joints are the first to be involved in the inflammatory process, and then large joints and the spinal column are damaged. In the absence of medical intervention, after a few years, the patient may become disabled due to destructive changes in cartilage, bones, and development.

Classification of pathology

Psoriatic arthritis is characterized by various variants of the course. The forms of the disease differ in the severity of symptoms, the number of those involved in the process, and the sequence of their defeat.

Asymmetrical shape

This is the most common clinical form diseases. Oligoarthritis affects no more than four asymmetrically located joints of the feet or hands. There is a strong swelling of the fingers, purple-bluish coloration of the skin in the area of ​​inflammation. Often the course of the pathology is complicated. This is the name of the inflammation of the flexor tendons, equipped with soft tunnels from connective tissues (sheaths).

Arthritis of the distal interphalangeal joints

Arthritis affecting the distal interphalangeal joints is characterized by the most typical clinical picture for this pathology. and swell, the skin turns red and becomes hot to the touch. Painful sensations occur not only in the daytime, but also at night, further worsening the psycho-emotional state of a person.

symmetrical shape

With this form of the course of psoriatic arthritis, five or more interphalangeal, metacarpophalangeal small joints are involved in the inflammatory process. Symptoms of pathology are similar to clinical manifestations rheumatoid diseases, which greatly complicates the diagnosis. With arthritis of a symmetrical form, chaotic deformity of the joints and multidirectional axes of the fingers are often observed.

Mutilating

The disease, which proceeds in a mutilating form, often causes subluxations, irreversible deformity, shortening of the toes and hands. Such destructive-degenerative changes are provoked by osteolysis - complete resorption of bone tissue without the formation of fibrous foci. Mutilating psoriatic arthritis often accompanies spondyloarthritis and severe skin symptoms.

Psoriatic spondylitis

Adequate assessment of stressful situations

In group sessions with a psychotherapist, patients are taught to adequately respond to conflict situations in order to prevent stressful or depressive states. It is they who most often act as factors provoking relapses of psoriasis.