Psoriasis and its management and treatment

Psoriasis is a common benign, chronic inflammatory skin disease with both a genetic basis and known environmental triggers. Injury or irritation of normal skin tends to induce lesions of psoriasis at the site (Koebner phenomenon) (Obesity worsens psoriasis, and significant weight loss may lead to substantial improvement.
Psoriasis has several variants—the most common is the plaque type and hand involvement is also common Eruptive (guttate) psoriasis consisting of numerous, smaller lesions 3–10 mm in diameter occurs occasionally after streptococcal pharyngitis. Rarely, life-threatening forms (generalized pustular and erythrodermic psoriasis) may occur.
here are many therapeutic options in psoriasis to be chosen according to the extent (body surface area [BSA] affected) and the presence of other findings (for example, arthritis). Certain medications, such as beta-blockers, antimalarials, statins, lithium, and prednisone taper may flare or worsen psoriasis. Patients with moderate to severe psoriasis should be managed by or in conjunction with a dermatologist.
A. Limited Disease

For patients with large plaques and less than 10% of the BSA involved, the easiest regimen is to use a high-potency to ultra–high-potency topical corticosteroid cream or ointment. It is best to restrict the ultra–high-potency corticosteroids to 2–3 weeks of twice-daily use and then use them in a pulse fashion three or four times on weekends or switch to a mid-potency corticosteroid. Topical corticosteroids rarely induce a lasting remission. Initially, patients may be treated with twice-daily topical corticosteroids plus a vitamin D analog (calcipotriene ointment 0.005% or calcitriol ointment 0.003%) twice daily. This rapidly clears the lesions; eventually, the topical corticosteroids are stopped, and once- or twice-daily application of the vitamin D analog is continued long-term. Calcipotriene usually cannot be applied to the groin or face because of irritation. Treatment of extensive psoriasis with vitamin D analogs may result in hypercalcemia, so that the maximum dose for calcipotriene is 100 g/week and for calcitriol it is 200 g/week. Calcipotriene is incompatible with many topical corticosteroids (but not halobetasol), so if used concurrently, it must be applied at a different time. Tar preparations, such as Fototar cream and liquor carbonis detergens 10% in Nutraderm lotion, alone or mixed directly with triamcinolone 0.1%, are useful adjuncts when applied twice daily. Occlusion alone has been shown to clear isolated plaques in 30–40% of patients. Thin, occlusive hydrocolloid dressings are placed on the lesions and left undisturbed for as long as possible (a minimum of 5 days, up to 7 days) and then replaced. Responses may be seen within several weeks. For patients with numerous small papules and plaques, such as guttate psoriasis, phototherapy is the best therapy.

1. PSORIASIS Mr. Sachin dwivedi Tutor/Clinical Instructor College of NURSING, AIIMS RISHIKESH

2. INTRODUCTION

3. Definition The word psoriasis is derive from greek word ‘psora’ means ‘itching’. Psoriasis is a chronic non-infectious, inflammatory disease of the skin in which epidermal cells are produced at a rate that is about six to nine times faster than normal.

4. Contd. The cells in the basal layer of the skin divide too quickly, and the newly formed cells move so rapidly to the skin surface that they become evident as profuse scales or plaques of epidermal tissue. The psoriatic epidermal cell may travel from the basal cell layer of the epidermis to the stratum corneum ( ie , skin surface) and with in 3 to 4 days, which is in sharp contrast to the normal 26 to 28 days.

5. ETIOLOGY Idiopathic. Some of the factors that may trigger psoriasis are: Genetic: As per GWASs- HLA-C*06:02, TRAF3IP2 Involved in IL-17 Signaling. Autoimmune reaction: Crohn’s disease, Celiac Disease, Multiple sclerosis, SLE etc. Infection- Bacterial, Viral and Fungal. Injury to skin. Changes in climate

6. Contd … Medications: Lithium, Antimalarial Medications, Propronalol , Indomethacin.

7. Pathophysiology

8. CLINICAL MANIFESTATIONS Initially the first sign of psoriasis is often red spots on the body. Dry, swollen and inflamed patches Patches Covered with silver white flakes Raised and thick skin Other symptoms of psoriasis includes : Pain, itching and burning sensation

9. Contd … Restricted joint motion or pain, Arthritis Cracked and bleeding skin Dandruff on scalp Pus filled blisters Genital lesions in males. Pitting, small depression on the surface of the nail Yellow, discolored nail

10. Diagnostic Measures

11. Management:

12. Medical Management:

13. Pharmacological Management The standard treatment modalities includes: Topical therapy Intralesional therapy Systemic therapy photochemotherapy

14. Gentle removal of scales accomplished with baths . Oils ( eg , olive oil, mineral oil) can be added to the bath water and a soft brush used to scrub the psoriatic plaques gently. After bathing, the application of emollient creams containing alphahydroxy acids ( eg , Lac- Hydrin , Penederm ) or salicylic acid will continue to soften thick scales. Anthralin preparations ( Anthra-Derm , Dritho -Crème, Lasan ): for thick psoriatic plaques resistant to other steroid preparations. Topical corticosteroids: used for short periods because of their side effects. TOPICAL THERAPY

15. Methotrexate have been used in treating extensive psoriasis that fails to respond to other forms of therapy. It inhibits DNA synthesis in epidermal cells and thus reducing the epidermopoesis . Should monitor hepatic, haematopoietic and renal systems. Reinforce women of childbearing age that methotrexate are teratogenic; women must be using birth control. Oral retinoids (synthetic derivatives of Vitamin A and its metabolite, Vitamin A acid) Hydroxyurea ( Hydrea ). Monitor signs ands symptoms of bone marrow depression. Cyclosporine A SYSTEMIC THERAPY

16. A treatment for severely debilitating psoriasis is Psoralen and Ultraviolet A (PUVA) Therapy , which involves taking a photosensitizing drug (usually 8-methoxypsoralen) in a standard dose with subsequent exposure to long-wave ultraviolet light when peak drug plasma levels are obtained. UVB light is also used to treat generalized plaque. PHOTOCHEMOTHERAPY

17. Nursing Management Impaired skin integrity related to lesion and inflammatory response as evidence by itching all over body. Disturbed body image related to embarrassment over appearance and self-perception of uncleanliness Deficient knowledge about the disease process and treatment Risk for infection related to break in the integrity of the skin. Acute pain related to inflammation.

18. Complications

19. References