Does this look familiar to you?

PSORIASIS
NCM 71

Condino, Kaye

Dablio, Nikka
Definition
A long-term autoimmune disease that causes skin cells to
multiply up to 10 times faster than normal
It is multifactorial
Onset may occur at any age, with a median onset at 28 years
Characterized by periods of remission and exacerbation
It is a noncommunicable disease
Worldwide, at least

125 million
individuals are affected

by psoriasis

Psoriasis affects around

1 million
people in the Philippines
Pathophysiology
Psoriasis
main cause is due to infiltration of T cells, dendritic cells,
macrophages into the skin
release of pro-inflammatory mediators
activation of keratinocytes
 Pathophysiology

Keratinocyte Psoriasis

Originate from basal layer

Keratinocytes migrate to

21 day life cycle stratum corneum in 3-5 days

to migrate to stratum corneum

Don't lose their nucleus

Lose their nucleus

IMMATURE KERATINOCYTES
 Medical Surgical Nursing

Plaque Psoriasis Nail Psoriasis

Guttate Psoriasis Pustural Psoriasis

Inverse Psoriasis Erythrodermic Psoriasis

What does it look like?

Plaque
PSORIASIS

Also called psoriasis vulgaris

Raised and inflammed red patches

of skin
Covered in silver scale
Commonly seen on: elbows, knees,

scalp, lower back, hands, and feet

What does it look like?

Guttate
PSORIASIS

"Gutta" - latin for droplet

Small Psoriatic papules
Common seen on the trunk of the

body and proximities

During or after streptococcal

infection
What does it look like?

Inverse
PSORIASIS

Not as much scaling

A lot of red glossy patches
Common seen on the folded areas

of the skin (armpit area, groin)

Usually seen in obese patients
What does it look like?

Nail
PSORIASIS

Tiny dents in your nails

(called “nail pits”)
White, yellow, or brown

discoloration
Crumbling nails
Nails separating from your finger

or toe
Buildup beneath your nai
What does it look like?

Pustular
PSORIASIS

Reddish, scaly, pus-filled bumps

Common seen on hands and feet
24-48 hrs: bumps join together and burst

open
As the pus dries: area turns red and glazed
On the red, glazed areaz: new pustules can

form
Requires immediate medical attention
What does it look like?

Erythrodermic
PSORIASIS

Red rash across the entire surface of

the body
Resembles a burn
Can cause chills, fever and

dehydration
Requires immediate medical

attention
 Complications

Asymmetric
Generalized

Rheumatoid Factor–
exfoliative

negative Arthritis dermatitis

Occurs in up to 42% of people

Also called erythroderma
with psoriasis Red rash affecting at least 90%

Most typical joints affected:

of the body surface area
those in the hands and feet psoriatic erythroderma is

A rheumatologist should be
responsible for ~25% of all cases

consulted of erythroderma
Assessment and Diagnonsis
Physical Exam
presence of the plaque-type lesions
signs of nail and scalp involvement
Family history
If one of your parents has psoriasis, you have about a 10 percent
chance of getting it.
If both of your parents have psoriasis, your risk is 50 percent.
About one third of people diagnosed with psoriasis have a relative
with psoriasis.
Skin Biopsy - a procedure to remove cells or skin samples from your
body for laboratory examination.
Classification of Psoriasis
Mild - if the plaques involve less thann 5% body surface area (BSA)
Moderate - if they involve between 5% and 10% of BSA
Severe - if more than 10% BSA is affected by plaque formation
Medical Management
There is no cure for psoriasis.
Goal: to slow the rapid turnover of epidermis, to promote resolution of the
psoriatic lesions, and to control the natural cycles of the disease.
Patient education on the disease and treatment.
Management of emotional factors
Lifestyle assessment
psoriasis is significantly affected by stress
Gentle removal of scales
Taking baths with added oils colloidal oatmeal preparations, or coal
tar preparations
A soft brush may be used to gently scrub the psoriatic plaques.
application of emollient creams containing alpha-hydroxy acids or
salicylic acid can soften thick scales after bathing
Encouraging patient to establish a regular skin care routine
 Pharmacologic
Therapy
Topical Agents Phototherapy Systemic Agents

used to slow effective as a effective

the overactive single-therapy because of its
epidermis. modality immunosuppre
ssive effects
 Topical Agents
Corticosteroids Diprolene Temovate Ultravate Vanos

Indication
Nursing Responsibilities
Reduce the redness,
swelling, scaling and plaque Educate the patient that high-potency topical corticosteroids
formation should not be used on the face and intertriginous areas, and their
use on other areas should be limited to a 4-week course of twice-
daily applications.
Educate the patient that a 4-week break should be taken before
repeating treatment with the high-potency corticosteroids.
Side effects Occlusive dressings may be applied to increase the effectiveness of
Skin atrophy, the corticosteroid. However, occlusive dressings should not remain
hypopigmentation, striae, in place longer than 8 hours.
and telangiectasias The skin should be inspected carefully for the side effects of
Burning or stinging sensation corticosteroids.
 Topical Agents
Non-steroidal Calcipotriene

Indication
suppress epidermopoiesis (i.e.,
development of epidermal cells)
and cause sloughing of the rapidly
Nursing Responsibilities
growing epidermal cells. Educate the patient that intertriginous areas and face should be
avoided when using this medication.
The patient should be monitored for symptoms of hypercalcemia.
Educate the patient that it is not recommended for use by older
Side effects adult patients because of their more fragile skin or by pregnant or
Local irritation lactating women
Itching
Redness
Burning
Stinging or tingling of skin
 Topical Agents
Non-steroidal Tazarotene

Indication
causes sloughing of the scales Nursing Responsibilities
covering psoriatic plaques
The patient should be cautioned to use an effective sunscreen and
avoid other photosensitizers (e.g., tetracycline, antihistamines)
Educate pregnant patients that tazarotene is teratogenic, and the
Side effects risk of use in pregnant women clearly outweighs any possible
Increased sensitivity to benefits.
sunlight A negative result on a pregnancy test should be obtained before
Burning initiating this medication in women of childbearing age, and an
Erythema effective contraceptive should be continued during treatment.
Irritation at the site of
application
 Phototherapy
Narrow-band ultraviolet-B (UVB) Ultraviolet-A (UVA) + psoralen: PUVA

Indication
For patients who do not respond
well to topical treatments
Slow rapidly growing skin cells
Nursing Responsibilities
Suppress an overly active immune Instruct the client to avoid sun exposure during
system photochemotherapy. PUVA therapy results in photosensitivity and
Reduce inflammation and allow the the client should avoid exposure to sunlight during this time.
skin to heal Explain to the patient the importance of going to weekly treatments
for phototherapy to be effective.
The skin should be inspected carefully for the side effects of
Side effects phototherapy
Sunburn-like reaction
Mild stinging or burning
Dark spots on the skin
Itching
 Systemic Agents
Cytotoxic agent Methotrexate

Indication
The first-line drug for treating
moderate to severe psoriasis Nursing Responsibilities
inhibit DNA synthesis in epidermal
Laboratory studies must be monitored to ensure that the hepatic,
cells, thereby reducing the turnover
hematopoietic, and renal systems are functioning adequately.
time of the psoriatic epidermis
The patient should be educated to avoid drinking alcohol while
taking methotrexate because alcohol ingestion increases the
Side effects possibility of liver damage.
Vomiting, nausea, loss of The medication is teratogenic and thus should not be given to
appetite, mouth sores, pregnant women.
redness and swelling inside
the mouth, and fatigue
 Systemic Agents
Biologic Agents Infliximab Ustekinumab Alefacept Adalimumab Secukinumab Ixekizumab

Indication
act by inhibiting activation and
migration, eliminating the T cells
completely, slowing postsecretory
cytokines or inducing immune
deviation.
Side effects
Shortness of breath, chills,
redness, itchiness, itchy eyes,
or itchy lips.
Nursing Responsibilities
Monitor vital signs every 15 minutes for 1st hour and every 30
minutes for the second hour during and after infusion
Report symptoms of hepatotoxicity; e.g., abdominal pain, vomiting,
anorexia, dark urine
Report symptoms of infection; e.g., fever, chills, tachycardia, sore
throat, cough, congestion, dysuria
Report skin changes that could indicate malignancy or medication
reaction
 Nursing Management
Impaired Skin Integrity Disturbed Body Image Deficient Knowledge
Impaired skin integrity related to lesions and

inflammatory response
Assess skin, noting color, moisture, texture, temperature; note erythema, edema,
tenderness.
Assess skin for lesions. Note presence of excoriations, erosions, fissures, or
thickening.
Identify aggravating factors and encourage patient to avoid them
Advised the patient not to pick at or scratch the affected areas
Advice the patient to bathe or shower using lukewarm water and mild soap or
nonsoap cleansers.
After bathing, allow the skin to air dry or gently pat the skin dry. Avoid rubbing or brisk
drying.
Apply topical lubricants immediately after bathing
Apply topical steroid creams or ointments as indicated
Prepare the patient for phototherapy as indicated
Disturbed body image related to

embarrassment over appearance and

self-perception of uncleanliness
Assess the patient’s perception of changed appearance
Assess the patient’s behavior related to appearance.
Allow patients to verbalize feelings regarding their skin condition
Assist the patient in articulating responses to questions from others
regarding lesions and contagion
Assist patients in identifying ways to enhance their appearance.
Deficient knowledge related to
insufficient information on the disease
Explaining the factors that provoke psoriasis
Explain treatment plan
Emphasize the importance of compliance
Caution patient about taking any nonprescription medications.
Advise the client receiving systemic cytotoxic therapy to; continue
taking the medication even if nausea and vomiting occur, increase
fluid intake, and to avoid alcoholic beverages.
Instruct the client to avoid sun exposure during photochemotherapy.
Give the client educational materials that include a description of the
therapy and specific guidelines