Psoriasis

Seminar presentation

1. . seminar Presentation on psoriasis Ms Jinumol Jacob First year Msc Nsg student NUINS

2. INTRODUCTION Psoriasis is a chronic skin disease result in patches of thick red skin covered with the silvery scales. These patches are referred as plaque which usually occur on the elbow, knees, legs, scalp, lower back, face, palm and sole of the feet, nails too

3. HISTORY The word psoriasis is derive from greek word ‘psora’ means ‘itching’. The greek physician Galen of perganon (130-200 BC) use the term Psoriasis vulgaris to refer all dermo and epidermopathies accompanied by pruiritis. Since 1950 local application and systemic medications are used for the psoriasis.

4. DEFINITION Psoriasis is a chronic , non infectious inflammatory disease of the skin in which the production of epidermal cells occur at a rate that is about 6 to 9 times faster than normal . ( B.T Basuvanthappa)

5. . “ Psoriasis is defined as a persistent skin disease causes cell to build rapidly on the surface of the skin, forming thick silvery scales, itchy, dry and red patches.” ( Lewis)

6. INCIDENCE 1 to 3% of world population Affects 7.5 million of Americans Onset may occur at any age Median onset is at 28 years More prevalent women, Caucasians,& obese people.

7. ETIOLOGY idiopathic Genetic Disorder Autoimmune reaction Infection Injury to skin

8. RISK FACTORS Climatic change Stress & anxiety Trauma Smoking Drugs such as propranolol, lithium

9. PATHOPHYSIOLOGY . Due to etiological and risk factor such as stress, genetic factors and autoimmune disorder Hyperactive of T Cell

10. . . Epidermis infiltration & keratinocytes proliferation. Deregulated Inflammatory process Large production of various cytokines (interferon & Interleukin 12)

11. . . Superficial blood vessel dilated and vascular engorgement Epidermal hyperplasia and improper cell maturation Fails to release adequate lipids which lead to flaking, scaling presentation of psoriasis lesion Silver scaling of skin

12. CLINICAL FEATURES The symptoms ranges from cosmetic annoyance to physically disabling and disfiguring affliction. The lesions appears as red, raised, patches of skin covered with silvery scales. Dry patching, itching

13. . Nail pitting, discoloration Separation of nail plates. If psoriasis occurs on the palms and soles , pustular lesions may develop. Fever, chills Electrolyte imbalance Despair and Frustration

14. TYPES There are mainly 4 types of psoriasis . They are Psoriasis vulgaris or plaque psoriasis Generalised pustular psoriasis Guttate psoriasis Generalised erythodermic psoriasis

15. . PSORIASIS VULGARIS ( PLAQUE PSORIASIS ) Also known as chronic stationary psoriasis Most common form Affect 85% to 90% of people Appears on inflamed skin with silvery white scaly skin. Most commonly found on the elbows, knees, scalp and back.

16. . Generalized Pustular psoriasis Rare form of psoriasis Also called as zumbusch’s psoriasis The Erythema suddenly appears in flexural areas and migrate to other body surface. Patient become toxic , febrile and develop leucocytosis.

17. . GUTTATE PSORIASIS Characterized by eruption of small (0.5 to 1.5 cm in diameter) papules over the upper trunk and proximal extremities • Manifests at an early age • Streptococcal throat infection frequently precedes . First episode before the age of 20 May resolve spontaneously in weeks or month

18. . GENERALIZED ERYTHODERMIC PSORIASIS Severe , unstable highly liabile manifestation of psoriasis. Usually comes in patients with previous history of psoriasis Precipitating factors include administration of systematic corticosteroid, topical steroid etc.

19. . Other types include Light sensitive psoriasis Psoriasis of scalp Psoriasis of nail Psoriasis over palms and soles Pustular psoriasis of the digits

20. DIAGNOSTIC MEASURES History collection Physical examinations Skin biopsy : under local anaesthesia Blood and radiography test was done to rule out psoriatic arthritis

21. MANAGEMENT The goal of Management are to slow the rapid turn over of epidermis to promote to promote resolution of psoriatic lesion and to control natural cycle of disease Remove scales and smooth skin, which is particularly remove by topical treatment.

22. MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY Topical corticosteroids Topical calcineurine inhibitor Vitamin D analogue's Coal tar Non medicated topical moisture

23. . TOPICAL CORTICOSTEROID • These are commonly first-line therapy in mild to moderate psoriasis and in sites such as the flexures and genitalia, where other topical treatments can induce irritation and skin folds. • Improvement is usually achieved within 2 to 4 weeks . • They slows the cells turnover by suppressing the immune system which reduce inflammation and relieves associated itching • Strong corticosteroids use for smaller area of skin like hands and feet. • Long term use may cause thinning of skin and resistance too. • Low potency steroids are usually recommended for sensitive area and treating wide spread patches damage skin.

24. . ADVANTAGES Rapid response Control of inflammation and itching Best for intertriginous areas and face DISADVANTAGES Temporary relief Less effective Atropy, expensive

25. . TOPICAL CALCINEURIN INHIBITOR Topical Calcineurin inhibitor common side effects such as tacrolimus and pimecrolimbus block the synthesis of cytokines. These drugs do not cause atropy as topical corticosteroid The most common side effects includes burning sensation Contraindicated in pregnant and nursing mothers

26. . VITIMIN D ANALOGUES Vitamin D Analogues are effective , safe and well tolerated for the short and long term treatment of psoriasis. Up to 100gm/ week can be used. Example Calcipotriene, calcitrol, Tazarotene

27. . COAL TAR Coal tar is a thick dark liquid which is the by product of the production of coal. It is effective treatment for psoriasis According to National psoriasis foundation coal tar is a valuable , safe treatment option for people with psoriasis O.5 to 5% are considered safe and effective for psoriasis.

28. . Nonmedicated topical moisture Effective treatment Used as topical agents Used thrice times as daily

29. . SYSTEMIC THERAPY Systemic therapy is used for the treatment of psoriasis. Systemic drug therapy mainly include methotrexate, cyclosporine, and biological agents METHOTREXATE Methotrexate 2.5 mg tab & 50 mg/lm vial Action Blocks dihydrofolate reductase leading to inhibition of purine and pyrimidine synthesis. Leading to accumulation of anti-inflammatory adenosine Dosage Start with a test dose of 2.5 mg and then gradually increase dose until a therapeutic level is achieved (average range, 10-15 mg weekly; maximum, 25- 30 mg weekly)

30. . Cyclosporine c yclosporine , a cyclic peptide is used to prevent rejection of transplanted organs, has shown some success in treatment. Side effects includes Nephrotoxicity, Hypertension, Immuno-suppression Neurotoxicity Increased risk of malignancy Contraindication Pregnancy Lactation Renal abnormalities

31. . BIOLOGIC AGENTS The newest line of treatment These agents act by inhibiting & eliminating T -cell completely.

32. . PHOTOTHERAPY ULTRA VIOLET THERAPY Ultraviolet light therapy has been used for decades to successfully treat psoriasis. Ultraviolet light is a wavelength of light in a range too short for human eye to see. -When exposed to the UV light ,the activated t –cells in the skin are destroy which lead reduces scaling and inflammation.

33. . PHOTOTHERAPY PhotOtherapy involves taking light sensitizing medication (psoralen) before exposure to UVA light . -UVA light penetrate deeper in skin and psoralen make more responsive to UVA exposure Side effect: nausea, headache, burning and itching, wrinkle skin or skin cancer.

34. NURSING MANAGEMENT Assessment Health History Physical examination

35. NURSING DIAGNOSIS Impaired skin integrity r/t lesion and inflammatory response as evidence by itching all over body . Fear and anxiety related to change in appearance Anxiety related to changes in health status secondary to psoriasis. Impaired self concept related to the crisis of confidence Knowledge deficit Risk for infection

36. . Improving skin integrity Advice the patient not to pick or scratch areas Encourage the patient to prevent the skin from drying out Inform the patient that water should not be too hot and skin should be dried by patting with towel Teach the patient to use bath oil or emolinent cleansing agent for sore and scaling

37. . IMPROVING SELF CONCEPT AND BODYIMAGE Introduce coping strategies and suggestions for reducing with stressful situations, to facilitate positive outlook and acceptance of disease MONITORING AND MANAGING COMPLICATIONS Educate the patient about care and treatment Assist the patient o take rest

38. HEALTH EDUCATION Take daily bath Use moisturizer Expose small amount of skin to sunlight Cover the affected area over night Apply medication cream or ointment Avoid drinking alcohol and smoking Eat healthy diet

39. RESEARCH STUDIES A study to assess psychological distress in patients with psoriasis , low consensus between a dermatologist and patient

40. CONCLUSION Psoriasis is considered as one of the most common chronic non communicable skin disease , psoriasis is typically characterized by appearance of slivery plague that most commonly appears on the skin over elbow, knees, scalp, lower back and buttocks.

41. BIBLIOGRAPHY Suddarth and Brunner , text book of Medical surgical Nursing, wolter publication New Delhi; 13 th Edition;2013 page no 1782 – 1784. B.T Basuvanthapa textbook of Medical Surgical Nursing, Wolter and Jaypee Publication New Delhi; 3 rd Edition Page No : 1304 – 1306. Clinical dermatology , text book of Medcine ,Elsevier's publication New Delhi Page no 1203 -1204