Cold weather

6. Trauma: Local trauma to the skin of any sort sufficient to injure the epidermis and upper dermis can induce active lesions at the site of injury. This is known as the Koebner phenomenon and is common in cases of eruptive exanthematic PV. It is considered a supporting diagnostic feature.

7. Sunlight: Sunlight improves most cases, but 5% of patients are worsened and this must be taken into account prior to starting treatment. Severe sunburn can dramatically flare PV even in patients who have been responding to heliotherapy.

8. Pregnancy: Most psoriatics improve during pregnancy, and then flare during the postpartum period. There are many exceptions and the effect of pregnancy is erratic, even during succeeding pregnancies in the same patient.

9. Intercurrent infections: Streptococcal pharyngitis has been recognized as a specific trigger factor for the onset of eruptive exanthematic PV. Upper respiratory infections frequently precipitate intercurrent flares. Staphylococcal infections have been documented in association with rare pustular forms. When suspected, these infections should be documented and treated. Preexisting PV has been noted to flare when seen in conjunction with HIV infection.

10. Medications: Many modern medications have been reported to aggravate PV. The most frequently implicated are lithium, quinine derivatives, 4- and 8-amino-quionolone compounds, ^-adrenergic blocking agents, and systemic corticos-teroids. These drugs can exacerbate existing disease or provoke latent cases into activity. The flares following withdrawal of systemic steroids can be so severe as to be life-threatening, and use of these agents in a psoriatic for treatment of PV or other conditions must be weighed very carefully as to the potential benefits. Less severe flaring of PV has been documented after withdrawal of potent group I topical steroids and with ocular administration of ^-blockers for glaucoma.

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been variously reported to flare or improve psoriasis. Because of their extensive use, a decision should be made in each case based on history of disease activity relative to the indication for the NSAID. A psoriatic patient starting one of these agents should be warned to report flaring promptly.

Self-Medication

Self-treatment is seldom a problem in PV.

Supplemental Review From General History

When PV occurs in an explosive fashion, becomes refractory to therapy, or occurs in the context of opportunistic infection, an in-depth history for high-risk behavior and other signs and symptoms of HIV infection is indicated.

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