**10. Conclusion**

Nail psoriasis is frequent in psoriatic subjects with about 50% of psoriasis patients presenting with nail changes at any time and a life-time prevalence of up to 90%. Nail psoriasis has a strong genetic background and a frequent association with psoriatic arthritis. The most frequent signs of nail matrix involvement are pitting, leukonychia, crumbling and red spots in the lunula, whereas salmon or oil spots, subungual hyperkeratosis, onycholysis and splinter haemorrages represent changes of nail bed involvement. Understanding the mechanism of psoriatic nail sign development requires some basic knowledge of the nail organ, its specific reaction patterns and of nail histopathology. Nail psoriasis has a serious impact on the quality of life interfering particularly with manual work but also being cosmetically embarrassing. Treatment of nail psoriasis is difficult as the matrix pathology is hidden by the proximal nail fold and the nail bed changes are protected against treatment by the overlying nail plate and nail bed hyperkeratosis. Progress has been made with the new biologic drugs, which are however, usually only administered for skin plus nail involvement.

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**10** 

 *Iran* 

**Psoriasis and Stress – Psoriasis Aspect of** 

Nowadays stress is a normal part of everyday living and the physiological and behavioral consequences of exposure to stressful situations have been extensively studied for decades. The neuroendocrine stress response is a necessary mechanism but disrupts homeostatic process and it is subserved by a complex system located in both the central nervous system (CNS) and the periphery. Stressor-induced activation of the hypothalamus–pituitary– adrenal (HPA) axis and the sympathetic nervous system (SNS) results in a series of neural and endocrine adaptations known as the "stress response" or "stress cascade." The stress cascade is responsible for allowing the body to make the necessary physiological and metabolic changes required to cope with the demands of a homeostatic challenge. In recent years, evidence has suggested that stress responses are not only under control of the CNS but are influenced by peripheral tissue, outside of the classical HPA axis. Corticotrophinreleasing hormone (CRH) is a central component of the HPA axis and is an important coordinator of the systemic stress response with subsequent modulation of the inflammatory response. In peripheral sites, cutaneous CRH and CRH-receptor1 (CRH-R1) is believed to regulate various functions of the skin that are important for local homeostasis. Common inflammatory skin disorders such as atopic dermatitis and psoriasis exhibit decreased barrier function and recent studies suggest that the complex response of epidermal cells to barrier disruption may aggravate, maintain, or even initiate such

The concept of stress is as old as medical history itself, dating back at least to the time of Hippocrates who referred both to the suffering associated with disease (pathos) and to the toil (ponos) — the fight of the body to restore itself to normalcy (Hippocrates, 1923) . In more recent history, both Walter Cannon (Cannon, 1939) and Claude Bernard (Bernard, 1949) described the ability of all organisms to maintain a constancy of their internal milieu or homeostasis. 70 years ago Hans Selye, the pioneer of contemporary stress research, first described the General Adaptation Syndrome (GAS) as a chronological development of the

**1. Introduction** 

conditions.

**2.1 Historical context** 

**2. Overview of the stress system** 

**Psychoneuroendocrinology** 

F.Z. Zangeneh, A. Fazeli and F.S. Shooshtary *Vali-e-Asr, Reproductive Health Research Center, Tehran University of Medical Sciences, Tehran,* 

from the literature including a series of 6 new cases. Am J Clin Dermatol 2008;9:1- 14

