PSORIASIS

Psoriasis is a chronic, noninfectious, inflammatory disease of the skin in which the

production of epidermal cells occurs faster than normal. The primary defect is unknown. The
basal skin cells divide too quickly, and the newly formed cells become evident as profuse
scales or plaques of epidermal tissue. As a result of the increased number of basal cells and
rapid cell passage, the normal events of cell maturation and growth cannot occur, which
prevents the normal protective layers of the skin to form. Current evidence supports an
immunologic basis for psoriasis. It may occur at any age but is most common between the
ages of 15 and 35 years. Main sites of the body affected are the scalp, areas over the elbows
and knees, lower part of the back, and genitalia, as well as the nails. Bilateral symmetry often
exists.

RISK FACTORS:
 Stress and anxiety
 Smoking
 Trauma
 Medication
o Lithium
o Antimalarial drugs
o Inderal
o Quinidine
o Indomethacin
 Infections
 Family history
 Immunocompromised
 Other things that may trigger psoriasis include:
o Allergies
o Diet
o Weather

TYPES OF PSORIASIS

Most people have only one type at a time. Sometimes, after the symptoms go away, a new
form of psoriasis will appear in response to a trigger.

1. Plaque Psoriasis. It is also known as Psoriasis Vulgaris. This is the most common type.
About 8 to 10 people with psoriasis have this kind.

Symptoms:
o Plaque psoriasis causes raised, inflamed, red skin covered with silvery,
white scales. These patches may itch and burn. It can appear anywhere on
the body, but it often pops up in these areas: scalp, elbows, lower back,
knees.
 Plaque Psoriasis. Image from https://www.webmd.com

2. Guttate Psoriasis. This type often starts in children or young adults. It happens 2% of
cases. This type of psoriasis may go away within a few weeks, even without treatment.
Some cases, though, are more stubborn and require treatment.
Symptoms:
o Guttate psoriasis small, pink-red spots on the skin. They often appear on the
scalp, upper arms, trunk, and thighs.

Guttate Psoriasis. Image from https://www.webmd.com

3. Inverse Psoriasis. The common triggers are friction, sweating, and fungal infection.
Symptoms:
o Patches of skin that are bright red, smooth, and shiny, but don't have scales
and getting worse with sweating and rubbing. This type usually found in
these locations: armpits, groin, under the breasts, and skin folds around the
genitals and buttocks.

Guttate Psoriasis. Image from https://www.webmd.com

4. Pustular Psoriasis. This kind of psoriasis is uncommon and mostly appears in adults. This
type may show up on one area of the body, such as the hands and feet. Sometimes it
covers most of the body, which is called "generalized" pustular psoriasis. Triggers include:
topical medicine or systemic medicine especially steroids, suddenly stopping systemic
drugs or strong topical steroids that you used over a large area of your body, getting too
much ultraviolet (UV) light without using sunscreen, pregnancy, infection, stress, and
exposure to certain chemical.
Symptoms:
o It causes pus-filled bumps (pustules) surrounded by red skin. These may
look infectious, but are not.
o Fever, chills, nausea, tachycardia, muscle weakness.

Pustular Psoriasis. Image from https://www.webmd.com

5. Erythrodermic or Exfoliative Psoriasis. This type is the least common, but it's very serious
and affects most of the body. Triggers include: suddenly stopping the systemic psoriasis
treatment, allergic drug reaction, severe sunburn, infection, medications such as lithium,
antimalarial drugs, cortisone, or strong coal tar products. This may also happen if the
psoriasis is hard to control.

Symptoms:
 Widespread, fiery skin that appears to be burned.
 Severe illness from protein and fluid loss, infection, pneumonia, or congestive
heart failure.
 Other symptoms include:
o Severe itching, burning, or peeling
o Tachycardia
o Changes in body temperature
 Erythrodermic Psoriasis. Image from https://www.webmd.com

6. Nail Psoriasis
 Up to half of those with psoriasis have nail changes. Nail psoriasis is even more
common in people who have psoriatic arthritis, which affects the joints.
 Symptoms:
o Pitting of your nails
o Tender, painful nails
o Separation of the nail from the bed
o Color changes (yellow-brown)
o Chalk-like material under your nails

Nail Psoriasis. Image from https://www.webmd.com

7. Psoriatic Arthritis. It is a condition where the affected person have both psoriasis
and arthritis. In 70% of cases, people have psoriasis for about 10 years before
getting psoriatic arthritis. About 90% of people with it also have nail changes.

Symptoms:
o Painful, stiff joints that are worse in the morning and after rest
o Sausage-like swelling of the fingers and toes
o Warm joints that may be discolored
 Psoriatic Arthritis. Image from https://www.webmd.com

CLINICAL MANIFESTATIONS
Symptoms range from a cosmetic annoyance to a physically disabling and disfiguring
affliction.
 Lesions appear as red, raised patches of skin covered with silvery scales.
 If scales are scraped away, the dark red base of lesion is exposed, with multiple
bleeding points.
 Patches are dry and may or may not itch.
 The condition may involve nail pitting, discoloration, crumbling beneath the free
edges, and separation of the nail plate.
 In erythrodermic psoriasis, the patient is acutely ill, with fever, chills, and an
electrolyte imbalance.

Psychological Considerations
 Psoriasis may cause despair and frustration; observers may stare, comment,
ask embarrassing questions, or even avoid the person.
 The condition can eventually exhaust resources, interfere with work, and
negatively affect many aspects of life.
 Teenagers are especially vulnerable to its psychological effects.

ASSESSMENT AND DIAGNOSTIC METHODS

 Presence of classic plaque-type lesions (change histologically progressing from early
to chronic plaques)
 Signs of nail and scalp involvement and positive family history

Medical Management
Goals of management: To slow the rapid turnover of epidermis, to promote resolution of the
psoriatic lesions, and to control the natural cycles of the disease. There is no known cure.
The therapeutic approach should be understandable, cosmetically acceptable, and not too
disruptive of lifestyle.

 First, any precipitating or aggravating factors are addressed.

 An assessment is made of lifestyle, because psoriasis is significantly affected by stress.
  The most important principle of psoriasis treatment is gentle removal of scales (bath
oils, coal tar preparations, and a soft brush used to scrub the psoriatic plaques).
 After bathing, the application of emollient creams containing alpha-hydroxy acids
(Lac-Hydrin, Penederm) or salicylic acid will continue to soften thick scales. Three
types of therapy are standard: topical, systemic, and phototherapy.

Topical Therapy
 Topical treatment is used to slow the overactive epidermis.
 Topical corticosteroid therapy acts to reduce inflammation.
 Medications include tar preparations (eg, coal tar topical [Balnetar]), alpha-hydroxy or
salicylic acid, and corticosteroids. Calcipotriene (Dovonex; not recommended for use
by elderly patients because of their more fragile skin, or in pregnant or lactating
women); and tazarotene (Tazorac) as well as vitamin D are additional nonsteroidal
agents.
 Occlusive (plastic) dressing may improve effectiveness. Medications may be in the
form of lotions, ointments, pastes, creams, and shampoos.

NURSING ALERT!
Assess the flammability of any plastic substances used;
caution patient not to smoke or go near open flame.

Systemic Therapy
 Biologic agents act by inhibiting activation and migration, eliminating the T cells
completely, slowing postsecretory cytokines or inducing immune deviation: infliximab
(Remicade), etanercept (Enbrel), efalizumab (Raptiva), alefacept (Amevive), and
adalimumab (Humira). Biological agents have significant side effects, making close
monitoring essential.
 Oral agents: methotrexate (patients should avoid drinking alcohol, should not be
administered to pregnant women), cyclosporine A, oral retinoids (ie, synthetic
derivatives of vitamin A and its metabolite, vitamin A acid), etretinate; laboratory
studies are monitored to ensure that hepatic, hematopoietic, and renal systems are
functioning adequately.

Photochemotherapy
 Psoralens and ultraviolet A (PUVA) therapy may be used for severely debilitating
psoriasis.
 Photochemotherapy is associated with long-term risks of skin cancer, cataracts, and
premature aging of the skin.
 Ultraviolet B (UVB) light therapy may be used to treat generalized plaque and may be
combined with the topical cream, calcipotriene (Dovonex). Excimer laser therapy may
be another treatment.
NURSING PROCESS

ASSESSMENT

*Assessment focuses on how the patient is coping with the skin condition, the appearance of
“normal” skin, and the appearance of skin lesions.
 Examine areas especially affected: elbows, knees, scalp, gluteal cleft, and all nails (for
small pits.
 Assess the impact of the disease on the patient and the coping strategies used for
conducting normal activities and interactions with family and friends.
 Instruct patient that the condition is not infectious, is not a reflection of poor personal
hygiene, and is not skin cancer.
 Create an environment in which the patient feels comfortable discussing important
quality-of life issues related to his or her psychosocial and physical response to this
chronic illness.

DIAGNOSIS
 Risk for infection
 Disturbed body Image
 Impaired skin integrity
 Social isolation
 Hopelessness
 Helplessness
 Deficient knowledge related to Psoriasis

PLANNING AND GOALS

 Goals for the patient may include:
o achievement and maintenance of skin integrity
o improved thought processes
o absence of infection
o increased comfort
o increased socialization
o increased knowledge regarding disease
o absence of complications

NURSING INTERVENTIONS

Promoting Understanding
 Explain with sensitivity that there is no cure and that lifetime management is
necessary; the disease process can usually be controlled.
 Review pathophysiology of psoriasis and factors that provoke it: any irritation or injury
to the skin (cut, abrasion, sunburn), any current illness, emotional stress, unfavorable
environment (cold), and drug (caution patient about nonprescription medication).
  Review and explain treatment regimen to ensure compliance; provide patient
education materials in addition to face-to-face discussions.

Increasing Skin Integrity

 Advise patient not to pick or scratch areas.
 Encourage patient to prevent the skin from drying out; dry skin causes psoriasis to
worsen.
 Inform patient that water should not be too hot and skin should be dried by patting
with a towel.
 Teach patient to use bath oil or emollient cleansing agent for sore and scaling skin.

Improving Self-Concept and Body Image

 Introduce coping strategies and suggestions for reducing or coping with stressful
situations to facilitate a more positive outlook and acceptance of the disease.

Monitoring and Managing Complications

 Psoriatic arthritis: Note joint discomfort and evaluate further.
 Educate patient about care and treatment and need for compliance.
 Consult a rheumatologist to assist in the diagnosis and treatment of the arthropathy.

Promoting Home- and Community-Based Care

Teaching Patients Self-Care
 Advise patient that topical corticosteroid preparations on face and around eyes
predispose to cataract development. Follow strict guidelines to avoid overuse.
 Teach patient to avoid exposure to sun when undergoing PUVA treatments; if
exposure is unavoidable, the skin must be protected with sunscreen and clothing, and
sunglasses should be worn.
 Remind patient to schedule ophthalmic examinations on a regular basis.
 Advise female patients of childbearing age that PUVA therapy is teratogenic (can cause
fetal defects). They may want to consider using contraceptives during therapy.
 If indicated, refer to a mental health professional who can help to ease emotional
strain and give support.
 Encourage patient to join a support group and to contact the National Psoriasis
Foundation for information

EVALUATION

Expected Patient Outcomes

 Maintains skin integrity
 Experiences no infections
 Maintains usual level of thought processes
 Experiences increased sense of comfort
 Experiences decreased sense of social isolation
 Reports increased understanding of Psoriasis and participates in self-care activities as
possible
 Remains free of complications
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References:

Huether, S.E. and Mc Kance, K. L.(2009). Understanding Pathophysiology, 4th ed. China:
Mosby Elsevier, Inc.

Smeltzer, S., et al.,(2010). Brunner and Suddarth’s Textbook of Medical-surgical Nursing, 12th
ed. Philadelphia: Lippincott Williams and Wilkins