psoriasis kk 31.ppt

Physiotherapy in psoriasis

1. Psoriasis
Dr. Kaushik Patel, MPT
Assistant professor,
SPB Physiotherapy college

2. •Thisisoneofthecommonestandmostintractable
disorderoftheskin.
•Itisanautoimmunediseasethatappearsontheskin.
Definition
Itisachronicinflammatorydiseaseoftheskin
characterizedbyclearlydefinedry,roundedredpatches
withsilveryscalesonthesurface.

4. Etiology-
Age–Commonageoffirstoccurrenceis15-30years
Canoccurasyoungas2yearsandcanstartas
lateas80years.
Sex–Bothsexareequallyaffected.
Climate–Theconditionisworseindamp,cold
climates.

5. Predisposing factors
Heredity–Thereisaninheriteddefectintheskinwhich
resultinpsoriasisdevelopingincertain
circumstances
Infection-Ithasbeenknowntodevelopafter,
e.g.URTI
Trauma-Lesionstendtodevelopatsitesoftrauma,
e.g.mechanicalfriction,cuts,stings

6. Anxiety–psoriasis often appears in relation to mental
stress
Drugs-some drug, chloroquine may precipitate the
condition
Diabetes –some patients with diabetes develop the
condition
Arthropathy-

7. Causes –
•Themembraneoftheskincellsinpatientswho
developpsoriasiscontainabnormalproteinwhich
manifestasabnormalsurfaceantigen.
•Antibodyfrominresponsetothese‘foreign”bodies.
•Whenthisantibodylockontotheantigens,acomplex
reactiontakesplaceatthedermo-epidermaljunction
andpsoriasislesionareproduced

8. •Innormalskinthematuringofepidermalcellstakes
21-29days.
•Inpsoriasisthisisacceleratedto4days.
•whatcausestheabnormalproteintofromandwhat
triggerstheantibody–antigenreactionisnotknown
butitisprobablyrelatedtothepredisposingfactors
alreadylisted.

9. Pathological changes
Epidermis
•Thereisincreasedreproductioninthestratum
germinatum(growinglayer)
•Thestratumspinosumisthickerduetoanincrease
numberofcellplusoedema
•Thestratumgranulosumisabsent
•Thestratalucidumandcorneumarereplacedby
severallayersofnucleated,incompletelykeratinized,
softcells

10. •Thereisnotimeforthenormalchangestotakeplace
throughtheskinlayers.
•Theycellsurfacearestickyanddonotfalloflike
normalkeratin.
•Accumulationofthesecellformsscaleswhichover2-
3weeksdryoutandfalloffinbigflakes

11. Dermis
•Capillaries is dilated with increase blood flow
•Papillae are elongated
•There are changes of inflammation
Healing
•The center of the patch heals first causing circular
lesions.
•Normal recovery take place without scaring

12. Clinical features
1.Sharply defined red and pink areas termed plaques
2.Silvery scales due to light reflecting from the
swollen stratum spinosum
3.Distribution
Elbow, knee, scalp and sacrum are covered in
thickly scaled patches
Plaque of varying sizes appear anywhere on the
body

14. Nail become pitted, ridged or separated from the nail bed.
Skin contact areas can be badly affected –between fingers,
axilla, groin, between toes, under breast, behind ear.
The face is rarely affected
The size of plaques and distribution varies so that different
types are described
These are –1-Gutted 2-Pustular
3-Erythrodermic

16. 1-Gutted
•Commonestandleastseverewithgoodprognosis
•Smallmultipleplaquesarescatteredevenlyovertrunk
andlimbsandappearssuddenly
2-Pustular
•Affectthescalpandbodyfolds,althoughpalmand
solecanbadlyaffected
•Thereismoresevereinflammationandpustuleare
formed.
•Thefluidinsidethepustuleissterileandmustnotebe
confusedwiththeinfectedpustulesofacne

17. 3-Erythrodrmic
•The plaques join up and there is extensive erythema.
•The extensive distribution of blood to the skin can
cause cardiac failure and loss of temperature regulation

19. Treatment
This may be considered under
1.Generel management
2.Topical
3.Systemic
4.Physiotherapy

20. General management
•Asympatheticapproach
•Anyanxietyorworryshouldbeidentifiedandthe
patientencouragetorelaxorseekappropriatehelp
•Reassurancethatitisnotinfectiousordisfiguring
mustbegiventothepatientandfamily
•Dietingmaybetriedifthereappearstobeany
allergyfactor.

21. Topicaltreatment
•Simpleblandaqueouscream
•Coaltarapplicationwithsalicylicacidandzincoxide
inparaffinmaybeusedaloneorwithUVR
•Dithranolinlassar’spasteisusedforresistant
psoriasis.
•UVRwiththeraktinmaybegiveninconjunctionwith
dithranol
•Corticosteroidcream

22. Systemic
•Retinoid –A variant of vitamin A
-Side effect –dryness and cracking of mouth alopecia,
pruritisand not given in pregnancy
•Cytotoxic drugs-Methotrexate
Side effect –Damage to the bone marrow, intestinal and
liver tissue.

23. Physiotherapy
•Psoriasis can be treated successfully with UVR
•Two sources are used –
1.Theraktinand
2.PUVA

24. The Theraktin
•The spectrum of UVR emitted is 390-280 nm and peak
emission is around 313 nm therefore this constitute
UVB
•It may be used alone or in conjuction with coal tar or
diathranol
Treatment –
Suberythemal dose is given daily or three times a week

25. •Whenlesionstarttoflattenandhealthesametimeis
repeatedandfrequencyoftreatmentreducedto
twiceweekly,oneweeklythenonceafortnight
•Thecourseoftreatmentmaybespreadover8-12
weeks

26. PUVA
•ThisispsoralensplusUVAandisusedfroresistant
psoriasis
•Theoneusedforpsoriasisis8methoxypsoralyn
(8MOP)
•UVAisproducedfromfluorescenttubes,mounted
uprightinahexagonalshapedcabinetinsidewhich
patientstandthroughoutthetreatment
•ThespectrumofUVRemittedis330-390nmandpeak
at360nm

27. Method
•The patient takes 3-6 tablets of psoralen preferably
with milk 2 hours before exposure.
•Tablet dose is according to weight of the body
•UVA is calculate according to skin type in joules

28. Patient weight (kg) Dose (mg)
30 10
30-50 20
51-65 30
66-80 40
81-90 50
90-and over 60

29. Skin type start increase
I.Always burn, never tan½ ½
II.Always burn, then slight tan½ ½
III.Sometime burn, always tan1 1
IV.Never burn, always tan1 1
V.Lightly pigmented 1 ½ 1 ½
VI.Black 1 ½ 1 ½

30. Duration of treatment
•This may be 5 min at first for skin type I and II
•And progress by 1 minute up to 15 minutes
•It may be start at 6 minutes and progress by 2 minute
up to 20 minutes for skin type III and IV .
•It may start at & 7 minute and progress by 3 minutes
up to 25 minute for type V and VI

31. •Thepatientattendsthreetimesaweekuntilhealing
starts,thenfrequencyoftreatmentisreducedtotwice,
onceweekonceperfortnightormonthly“holding
session”

32. Precaution
Do not take psoralens on empty stomach
There is a real danger of cataract therefore used protective
goggles
Psoralen sunglasses must be worn from the time of taking
the psoraleneto at least 12 hours after.
Patient are advised to wear protective glasses out of the
doors for at least 24 hours after taking the psoraleneand
also whilst watching TV or in florescent lighting

33. Theskinmustbecoveredinbrightsunlightandahat
wornfor24hrsaftertreatment
StopusingallointmentduringPUVA
Iftheskinisdrysimpleoilorlubricatinglotionmay
beused
Donotbecomepregnantorfatherachild
ContraceptivemeasureareessentialduringPUVA
treatment
Acheckupisessentialeverymonthaftercompletion
oftreatment

34. Mechanism of action
•8-MOP bind to DNA and is activated by UVA
•The psoralen binds to DNA , producing cross-inking
which inhibits epithelial synthesis and cell division,.
•In essence therefore ,the accelerated reproduction of
epidermis in psoriasis is reduced

35. Long term management
Itmaytakeupto10weekstocleartheskinanda
further4-5weeksofmaintenancedosemaybe
givendependingonindividualresponse.

36. Thank
you…