How Psoriasis Affects Joints

From miragenews.com

Approximately 20 to 30 percent of all people who suffer from psoriasis also develop painful inflammation in their joints over time. If left untreated, this condition known as psoriatic arthritis can lead to permanent damage to bones and joints. Until now, it was a mystery why the disease progressed this way in some patients and not in others. A team of researchers from the Department of Medicine 3 – Rheumatology and Immunology at Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), have now discovered which cells migrate from the skin of psoriasis patients to the joints and how they trigger inflammation there. These findings pave the way for new approaches for preventing psoriatic arthritis before it takes hold. The team has now published their findings in Nature Immunology.*

Firstly: How inflammatory cells travel from the skin to the joints

Psoriasis triggers the production of special precursor cells from the immune system in the inflamed skin. "These cells can migrate from the skin to the bloodstream and from there to the joints," explains Dr. Simon Rauber, head of the working group at Department of Medicine 3. "It is interesting that the mere migration of immune cells into the joint is not sufficient to trigger inflammation there."

Secondly: How inflammatory cells infiltrate the joint

It is crucial to examine the processes that take place in the joint. Here, the migratory immune cells encounter connective tissue cells known as fibroblasts that are usually less than pleased to encounter these new arrivals. "The protective function of these connective tissue cells is usually considerably reduced in people who develop psoriatic arthritis," says Prof. Dr. Andreas Ramming, team leader and deputy head of department at Department of Medicine 3. "As a result, the inflammatory cells that enter the joint cannot be brought into check, and go on to trigger an inflammatory reaction in the joint." The results provide an explanation for why some psoriasis patients go on to develop joint disease as well.

Early detection and prevention before the disease affects the joints

As the migratory immune cells can already be detected in the blood before triggering inflammation in the joints, this could act as an early warning signal in future, allowing patients at risk to be identified in time. In future, treatment strategies could be aimed specifically at intercepting these inflammatory cells and preventing them from triggering inflammation in the joints.

The research is being funded by the German Research Foundation (DFG) within the framework of the CRC/TRR 369 – "DIONE: Degeneration of bone due to inflammation", by the European Research Council (ERC) as part of the project "Barrier Break", and by the Interdisciplinary Center for Clinical Research in Erlangen (IZKF) as part of the project "Tissue imprinting of skin-derived immune cells in psoriatic arthritis"

https://www.miragenews.com/how-psoriasis-affects-joints-1601960/

How Does Diet Affect Your Psoriasis?

From everydayhealth.com

If you have psoriasis, you may have wondered whether certain foods are making your symptoms worse — or whether changing your diet can help.

The answer isn’t straightforward: While psoriasis isn’t caused by what you eat, your diet may still play a role in how the condition — and your symptoms — show up day to day.

“Your diet impacts your health, including your psoriasis. Because the foods we eat can help our immune system function better, or they can trigger more inflammation, it's important to make good choices,” says Steven Daveluy, MD, a professor and the program director in the dermatology department at Wayne State University’s School of Medicine in Dearborn, Michigan. Dr. Daveluy specializes in treating patients with skin diseases, such as psoriasis and eczema. 

Psoriasis is an autoimmune disease that causes inflammation in your skin. Plaque psoriasis, the most common type, looks like thick, scaly patches called plaques. Some foods can “feed the fire of psoriasis,” while anti-inflammatory ones will do the opposite, Daveluy says.

Research on diet and psoriasis is still limited; however, it suggests people with psoriasis report fewer flares when they follow an anti-inflammatory eating pattern, such as the Mediterranean diet, while exercise and losing excess weight have also been effective in combating symptom severity.

That said, dietary triggers are highly individual. What worsens symptoms for one person may have no effect on another. That’s why it’s crucial to work with your dermatologist and wider healthcare team to figure out a personalized approach.

                                                                                                                                 Adobe Stock

The Mediterranean Diet for Psoriasis

The Mediterranean diet has long been hailed as helpful in the management of many chronic diseases, psoriasis included. It’s an eating pattern that emphasizes:

• Fruits and vegetables
• Whole grains like whole-wheat bread and brown rice
• Healthy fats from olive oil and nuts
• Fish rich in omega-3 fatty acids
• Poultry and fish over red meat, which is limited

A key selling point for the Mediterranean diet is that it limits ingredients that typically cause inflammation in the body like red meat, fried foods, sugary drinks and ultra-processed snacks. At the same time, it encourages fresh produce, salmon, tuna, chicken and turkey, beans and legumes — all of which are anti-inflammatory and aid in lessening psoriasis symptoms, says Daveluy.

“There are several studies that show if psoriasis patients stick to an anti-inflammatory diet, such as the Mediterranean-style diet or intermittent fasting, their psoriasis is less severe and medications actually work better,” he says.

In one study, Spanish researchers conducting a randomized clinical trial with 38 psoriasis patients found that those who followed a Mediterranean diet for 16 weeks saw a 75 percent reduction in psoriasis severity compared with no change in their counterparts who were advised to follow a low-fat diet.

The diet is high in antioxidants, omega-3 fatty acids, and fibre — a combination that counters oxidative stress and fights inflammation in the body by suppressing pro-inflammatory pathways, says Chris Adigun, MD, a board-certified dermatologist in private practice in Chapel Hill, North Carolina.

Because psoriasis is often linked with other health conditions like heart disease, type 2 diabetes, and obesity, the Mediterranean diet can be helpful by targeting the underlying inflammation that connects both skin symptoms and these comorbidities, she says.

Vegetarian Diets for Psoriasis

While there’s currently little direct research on vegetarian diets and psoriasis, like the Mediterranean diet it’s been tied to less-severe psoriasis symptoms.

In a study of adults with psoriasis, researchers found that people who followed a predominantly plant-based diet — emphasizing fruits, vegetables, legumes, and nuts — tended to report less-severe psoriasis symptoms, while poorer-quality diets and higher intakes of red and processed meat were linked to greater symptom severity.

An earlier review looked at studies on the effects of a plant-based diet on a range of inflammatory skin diseases. It noted that a vegetarian diet is low in saturated and trans fat and high in antioxidants and omega-3s, which reduce inflammation and promote weight loss. Simply adding vegetables into their daily diet led to a “favourable” skin response in 43 percent of people with psoriasis.

Think carefully about constructing a healthy vegetarian diet if you decide to take this route, says Caylee Clay, RDN, a registered dietitian-nutritionist in Brooklyn, New York, who has psoriasis and specializes in helping clients manage autoimmune diseases.

Not all vegetarian diets are inherently anti-inflammatory. “Vegetarian” foods can include fruits and vegetables or french fries and highly processed meat substitutes, Clay notes. But if it’s planned thoughtfully — packed with Mediterranean diet and anti-inflammatory diet staples — you should reap the same benefits, including supporting the gut microbiome via eating a range of plants.

“A clear theme is emerging: eating plenty of plants is likely to improve our health. This is true whether the goal is preventing cancer or reducing psoriasis,” Clay says.

Gluten-Free Diets and Psoriasis

People with psoriasis are twice as likely to have celiac disease as people without the skin condition.

In diagnosed cases of celiac disease, a gluten-free diet is medically necessary and may improve both gastrointestinal and skin symptoms, Dr. Adigun says. But you shouldn’t adopt a gluten-free diet if you don’t have celiac disease as there’s no strong evidence that eliminating gluten benefits people with psoriasis who do not have celiac disease or a non-celiac gluten sensitivity.

You may want to talk to your doctor about gluten testing if you have:

• Digestive symptoms such as chronic bloating, diarrhoea, or abdominal pain
• Iron-deficiency or unexplained nutrient deficiencies
• A personal or family history of celiac disease

But whether you have a gluten-sensitivity or not, it’s important to notice if eating certain foods is regularly followed by worsening symptoms. “For me, my psoriasis and joint pain significantly increase if I consume wheat products regularly,” Clay says. If this applies to you, keep a food journal and talk to your doctor or registered dietitian about ways to edit your daily diet.

Weight Loss and Psoriasis

If you have psoriasis and are overweight, losing weight can help to:

• Manage psoriasis symptoms
• Reduce flares
• Decrease the need for psoriasis medications
• Improve psoriasis treatment outcomes

Fat — or adipose tissue — releases pro-inflammatory cytokines, which are communication signals in the body that trigger inflammation. Cytokines can worsen psoriasis and even block medications that treat psoriasis, Daveluy says.

“This is why studies show that obesity is associated with more severe psoriasis and a higher chance that medications won't work as well to treat it. If a patient is overweight or obese, losing 5 to 10 percent of your body weight often produces benefits,” he says.

Focusing on healthy eating, regular exercise, and getting enough sleep can help you with your weight loss goals. 

These habits will also create a sustainable lifestyle, supporting psoriasis management that complements any medication you're taking, Adigun says. “Psoriasis is a complicated disease, and treatment outcomes are often best with a multifaceted approach.”

The Takeaway

• Your diet doesn’t cause psoriasis, but it can influence how the condition appears day to day and may affect the severity of symptoms.
• The Mediterranean diet may help, as it’s rich in anti-inflammatory foods like fruits, vegetables, whole grains, lean protein sources, and healthy fats that support your immune system while limiting foods that promote inflammation, such as ultra-processed snacks, red meat, sugary drinks, and refined carbohydrates.
• Weight loss can improve psoriasis severity, especially for those who are overweight or obese. A 5 to 10 percent loss of body weight may reduce flares, enhance medication effectiveness, and support long-term overall health, including risk of comorbidities like cardiovascular disease and type 2 diabetes.

https://www.everydayhealth.com/skin-conditions/how-diet-affects-your-psoriasis/

Winter Can Worsen Eczema, Psoriasis And Dry Skin: Expert Tips To Prevent Flare-Ups

From news18.com

Cold weather and low humidity can trigger eczema, psoriasis, and dry skin. A dermatologist shares essential winter skincare tips to prevent flare-ups

Winter dryness can trigger skin flare-ups. Gentle care and regular moisturising make all the difference.

Did you know that cold weather, low humidity, and indoor heating can severely dry out the skin, triggering eczema flare-ups, worsening psoriasis, and increasing overall dryness during winter? Seasonal changes can have a significant impact on skin health, making it essential to take preventive measures. Here, an expert shares important tips to help prevent flare-ups during winter and protect your skin. Staying in regular touch with a dermatologist can also help you make informed decisions about your skin health.

Dr Shareefa Chause, Dermatologist, Mumbai, shares what you need to know.

Winter can quickly turn from a pleasant season into a challenging one for people with sensitive skin conditions. Skin problems are particularly common during colder months and can significantly affect quality of life. Winter weather can be harsh on skin health, especially for individuals diagnosed with eczema, psoriasis, and chronic dry skin.

During winter, the air holds less moisture, which leads to increased water loss from the skin. This strips away natural oils, weakens the skin barrier, and makes the skin more sensitive and inflamed. As a result, many people experience symptoms such as itching, redness, scaling, and frequent flare-ups. Reduced sun exposure during winter can also worsen psoriasis, as sunlight helps slow excessive skin cell growth. Those with eczema and psoriasis may experience severe dryness, itching, cracked skin, flaking, redness, and painful fissures during this time.

It is always better to be proactive and follow expert-recommended guidelines to prevent complications.

Adhere to These Tips

Choose moisturisers and emollients as advised by your dermatologist to lock in moisture, restore the skin barrier, and maintain healthy skin.

Creams and ointments are preferred over lotions, as they provide deeper and longer-lasting hydration.

Use medicated creams prescribed by your doctor strictly as directed to control inflammation and prevent flare-ups. Avoid using any product without medical advice.

Avoid hot water showers, as they can further dry out the skin.

Use gentle, fragrance-free cleansers to minimise irritation.

Wear soft, breathable fabrics like cotton and avoid synthetic materials that can irritate sensitive skin.

Never ignore persistent skin symptoms taking skin health lightly is a strict no-no.

Regular check-ups and follow-ups with a dermatologist are especially important during winter for individuals prone to skin conditions. Staying vigilant and adopting the right skincare habits can go a long way in keeping winter-related skin problems under control.

Stay alert, stay safe, and take care of your skin this winter.

https://www.news18.com/lifestyle/health-and-fitness/winter-can-worsen-eczema-psoriasis-and-dry-skin-expert-tips-to-prevent-flare-ups-9823621.html

Does Collagen Have Any Benefits for Psoriasis?

From everydayhealth.com

Psoriasis is a chronic autoimmune skin condition that causes inflammation in the skin, resulting in red, scaly, and often itchy or painful patches on different parts of the body.

Symptoms flare up when an overactive immune system speeds up the life cycle of skin cells, leading to build-up on the surface. Common treatments include topical steroids, oral medications, light therapy, and biologic drugs that target specific parts of the immune system. While these treatments can be highly effective, many people with psoriasis are also interested in complementary treatments to help manage symptoms or improve their skin health. 

Collagen, a key protein in skin, muscles, tendons, and more, is one supplement that often comes up in conversations. But does collagen actually have any benefits for psoriasis that are backed by science? 

What Is Collagen?

Collagen is a protein found throughout the body, helping with the formation of skin, muscles, tendons, ligaments, and connective tissues. But collagen levels in our bodies naturally decline as we get older, which is why collagen supplements are often marketed to improve skin firmness and elasticity.

                                                                                                                  iStock

“Collagen is the protein that fills the deeper layers of skin, and decreases in collagen with age cause us to look older, with more wrinkles. The concept of collagen supplementation is that you want your body to make more collagen in your skin, so you eat collagen, since it has all the ingredients necessary to make more collagen,” says Steven Daveluy, MD, a professor and the program director at Wayne State University’s School of Medicine in Detroit, where he specializes in treating patients with skin diseases, such as psoriasis and eczema.

Collagen can be consumed or used in several ways.

Orally as a supplement: Collagen supplements are sold in the form of powders, pills, or liquids. Most are made up of collagen peptides or hydrolyzed collagen, which are broken-down forms of the protein that are easier to absorb. They’re sometimes paired with additional nutrients related to skin and hair health, like biotin, vitamin C, or zinc. 

Topically: Collagen is also included in many creams and serums, but it’s effectiveness in boosting collagen production is questionable, says Steven Feldman, MD, PhD, a professor of dermatology at Wake Forest University in Winston-Salem, North Carolina. That’s because topical collagen is too large to seep through the skin and into the body, so it only works on the outside like a moisturizer. “If you're putting it on the skin, it wouldn't be absorbed. It would just sit on the surface,” Dr. Feldman says. 

Through food: Foods high in collagen, such as bone broth, won’t directly raise your collagen level, because your body can’t absorb whole collagen; it has to break it down into amino acids first. But it is thought that eating foods rich in the amino acids that make collagen — glycine, proline, and hydroxyproline — as well as foods containing vitamin C, zinc, and copper, which are necessary for collagen production, can boost collagen production in the body.

This is the preferred route for building collagen and supporting the collagen production process from within, Dr. Daveluy says. “A healthy diet already has those same amino acids and vitamins [as a collagen pill]. I'm a big fan of getting your nutrients from a healthy diet instead of supplements.”

What Is Collagen Used For?

One of the primary uses of collagen is to counter the changes associated with skin aging. As we age, collagen production naturally declines, contributing to wrinkles, sagging, and dryness. Some studies suggest that oral collagen may help to improve skin elasticity, hydration, and fine lines.

Collagen is also used in medicinal and cosmetic purposes including: Collagen injections and collagen-stimulating fillers are used to fill in lines and wrinkles in the skin.

Collagen wound dressings stimulate wound healing.

Oral collagen supplements may reduce joint pain and improve joint function, especially when paired with exercise.

Vascular prosthetics, using donor collagen tissue grafts, are used to reconstruct arteries and make blood vessel prostheses.

• Why Collagen Might Have Benefits for Psoriasis

  There is no strong evidence that collagen has any positive effect on psoriasis — and there isn’t an obvious link between the two, says Chris Adigun, MD, a board-certified dermatologist in private practice in Chapel Hill, North Carolina.

  “There is currently no clinical evidence to support taking a collagen supplement to improve psoriasis severity,” Dr. Adigun says.

  “Psoriasis is an inflammatory disease — it’s a disorder of the immune system that leads to [a rapid buildup of skin cells], but it’s also a systemic inflammation that leads to joint pain. Collagen has no place in any of that. They’re just not connected,” she says.

  There are theoretical reasons collagen might offer support for some people with psoriasis; but these benefits aren’t related to treating the autoimmune condition directly, Daveluy says.

  “Studies have shown that collagen peptides can have an anti-inflammatory effect on the skin, but it hasn't been shown if this is helpful in psoriasis or other skin diseases,” he says.

  It can help with moisturizing skin and healing the skin barrier, which are important if psoriatic skin is cracking and damaged, too, for example, Adigun says. But other treatment options yield better, evidence-based, results, such as topical steroids and systemic medications.

  “That's where we should focus our efforts. However, if [people are] interested in improving the appearance of their skin, its hydration and elasticity, and potentially improving wrinkles over a long period, then that would be the only place that oral collagen would have any role in their treatment plan,” Adigun says.

  What the Research Shows About Collagen and Psoriasis

  Research specifically testing collagen as a treatment for psoriasis is limited.

  In a small study published in 2012, researchers tested a bovine-based collagen added to petroleum jelly — or Vaseline — for four to six weeks on 12 patients with plaque psoriasis. The study reported improvements in scaling, redness, and the overall appearance of plaques on participants’ skin.

  But the study had several limitations, according to Feldman: a very small sample size, no control group, and a short duration. “If you just put Vaseline on the skin, scales can disappear, psoriasis can improve, and the itch could get better. Without a control, there's no way to know if this is any better than just plain Vaseline,” he says.

  The study was also open label, which means participants knew what treatment they were receiving, unlike blinded studies where this information is hidden to prevent biases. “The improvement may be due to the placebo effect: if you believe a treatment will work, it actually will,” Daveluy says.

  A review published in 2019 that included 11 studies and 805 study participants looked at whether oral collagen supplementation was effective across skin aging, wound healing, and medical dermatology. While the review found some evidence that collagen boosts skin elasticity, hydration, and dermal density, the authors said further research is needed to figure out if collagen plays a role in medical uses for skin diseases, such as atopic dermatitis and psoriasis.

  It’s an area that requires far more high-quality research — and clinical trials in people with psoriasis. “The collagen studies have focused on the anti-aging effects,” Daveluy says.

  Talk to Your Doctor About Collagen Supplements

  If you’re considering collagen — either orally or topically — it’s important to discuss it with your dermatologist, says Adigun. 

  Helpful questions to ask include:

  • Is topical collagen safe to apply to my skin? 
  • Can collagen — oral or topical — interfere with my current 
  • psoriasis medications?
  • Is oral collagen safe for me, given my medical history?
  • Are there specific ingredients I should avoid in collagen products?

  Adigun says some people’s skin may be hypersensitive to new topical products. Daveluy also warns that patients with food allergies, especially to fish or shellfish, should check the source of any collagen product.

  It’s important to note that the U.S. Food and Drug Administration (FDA) doesn’t regulate supplements, including collagen, which means they do not need to be proven safe or effective before they go on sale. You should do your research and consult with your healthcare team to choose a high-quality supplement from a trusted brand, Feldman says.

  Ask your healthcare team about other complementary treatment options aside from collagen, too. “Talk to your dermatologists about treatments that actually have evidence that they are beneficial for psoriasis. Your skin and your wallet will thank you,” Daveluy says.

  The Takeaway

  • Psoriasis is a chronic autoimmune condition that causes skin cells to grow faster, leading to itchy, inflamed, scaly patches. It’s typically treated with topical steroids, light therapy, oral medications, or biologics that target immune system pathways.
  • Collagen piques people’s curiosity because it’s marketed as a supplement to boost skin health. But research showing benefits of collagen for psoriasis management is limited. Dermatologists note there’s no clear or direct connection between collagen supplementation and improving psoriasis itself.
  • Talk to your doctor before trying collagen, whether oral or topical, to avoid potential adverse effects from allergies, interactions with current treatments, or products that may irritate already inflamed skin.

  https://www.everydayhealth.com/skin-conditions/does-collagen-have-any-benefits-for-psoriasis/

Psoriatic arthritis medications: A comprehensive guide

From krdo.com

Psoriatic arthritis is an autoimmune condition that causes joint inflammation, skin symptoms, and pain. People searching for psoriatic arthritis prescriptions are often looking for detailed information about medication options, their effectiveness, potential side effects, and ways to manage costs.

This guide from SaveHealth, a prescription discount/savings card website, explores the most commonly prescribed medications for psoriatic arthritis, including DMARDs, biologics, and NSAIDs, while highlighting considerations for effectiveness, safety, and cost.

                                                                                              Ray Geiger // Shutterstock

How Psoriatic Arthritis Medications Work

Medications for psoriatic arthritis aim to reduce inflammation, slow disease progression, and relieve pain. They work through different mechanisms depending on the drug class.

Major medication categories:

• DMARDs (Disease-Modifying Anti-Rheumatic Drugs): These slow disease progression and prevent joint damage. Examples include methotrexate and leflunomide.
• Biologics: Target specific components of the immune system to control inflammation. Examples include Skyrizi and Humira.
• NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Provide temporary relief from pain and stiffness without altering disease progression. Examples include naproxen and celecoxib.
• Corticosteroids: Offer rapid symptom relief during flare-ups but are generally used short term.
• PDE-4 Inhibitors: Commonly known as phosphodiesterase-4 inhibitors, these drugs work by blocking the PDE-4 enzyme which ultimately helps to lower inflammation in the body. A frequent used example is Otezla.

Top Psoriatic Arthritis Medications

The following medications are among the most commonly prescribed for psoriatic arthritis. They include both traditional and newer therapies.

DMARDs

• Methotrexate: Often first-line therapy for psoriatic arthritis. It slows joint damage and inflammation.
• Leflunomide: Useful for patients who cannot tolerate methotrexate.
• Sulfasalazine: Reduces joint inflammation and can improve skin symptoms.

Biologics

• Skyrizi (risankizumab): Targets interleukin-23, reducing inflammation and improving both joint and skin symptoms.
• Humira (adalimumab): TNF inhibitor that helps reduce pain and swelling.
• Enbrel (etanercept):TNF inhibitor that can slow joint damage and improve quality of life.
• Stelera, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Steqeyma (ustekinumab): Targets IL-12 and IL-23 to control inflammation.

NSAIDs

• Naproxen: Reduces pain and stiffness.
• Celecoxib: Offers pain relief with reduced gastrointestinal risk compared to traditional NSAIDs.

Corticosteroids

• Prednisone: Provides rapid relief during flares but is not intended for long-term use due to side effects.

Psoriatic Arthritis Medication Comparison

SaveHealth

Otezla PDE-4 inhibitor Oral Significant joint relief Nausea, decreased in 16 weeks appetite, weight loss, anxiety, insomnia.

Common Side Effects of Psoriatic Arthritis Medications

Side effects vary depending on the type of medication and individual response.

DMARDs

• Nausea
• Fatigue
• Liver enzyme elevation

Biologics

• Increased risk of infections
• Injection site reactions
• Upper respiratory infections

NSAIDs

• Stomach upset
• Kidney issues
• Increased bleeding risk

Corticosteroids

• Bone loss
• Weight gain
• Mood changes

PDE-4 inhibitors

• Gi side effects (Nausea, diarrhea, decreased appetite, abdominal pain, weight loss)
• Headache, dizziness, insomnia, anxiety, nervousness
• Infections (upper respiratory infections)

Choosing A Psoriatic Arthritis Medication

Selecting the appropriate psoriatic arthritis medication requires balancing effectiveness, side effect tolerance, convenience, and cost.

Factors to consider:

• Severity of joint and skin symptoms
• Past medication response
• Risk of side effects
• Administration preference (oral vs injection)
• Insurance coverage and out-of-pocket cost

Tips for Managing Psoriatic Arthritis Medication Costs

Psoriatic arthritis medications, particularly biologics and DMARDs, can be costly. Patients can reduce expenses by:

• Comparing pharmacy prices
• Considering generic options for DMARDs
• Exploring manufacturer savings programs
• Reviewing insurance co-pay assistance
• Planning prescriptions to avoid gaps in therapy

Even small monthly savings can make a significant difference for long-term disease management.

Psoriatic Arthritis Medications & Prescriptions

Psoriatic arthritis management involves a range of medications, including DMARDs, biologics, NSAIDs, and corticosteroids. Understanding options like Methotrexate, Leflunomide, Sulfasalazine, Skyrizi, Humira, Enbrel, Stelara, Naproxen, Celecoxib, and Prednisone helps patients select effective therapies for their condition. Working closely with a healthcare provider while considering effectiveness, safety, and affordability can optimize long-term outcomes.

https://krdo.com/stacker-science/2025/12/31/psoriatic-arthritis-medications-a-comprehensive-guide/#google_vignette