Skin Psoriasis

A Case Study

In partial accomplishment of the requirements in

Microbiology and Parasitology

Allija A. Ramos

Bachelor of Science in Nursing

March 2019
Patient Presentation

A nine-teen-year-old female presents with symptoms of psoriasis. She has several

thick scaly, well defined, erythematous plaques, which are silvery in color. The

patient reports that she has just returned from a twelve-day trip to Baguio City.

During the trip, she had significant frigid exposure, due to the cold weather of the

City and she also have some stress related problem. The expanded and

prominent plaques cover her elbows and thighs, and there is a patch on her scalp.

Her lesions cover about fifteen percent of her body. She occasionally applies

moisturizing lotion or witch hazel if it becomes too irritating. All other body systems

are normal.

Patient History

Past Medical History

“Some rashes,” German measles and Pneumonia otherwise non-contributory

Social History

Recent trip to Baguio City for a vacation.

Vaccination
Vaccine against Diphtheria-Tetanus-Whooping cough + Haemophilus influenzae

type B + Polio [DTaP-Hib-IPV] (Hebrew)

Vaccine against Measles-Mumps-Rubella (German measles) + Varicella (chicken

pox) [MMRV]

Vaccine against pneumococcus bacteria [PCV]

Vaccine against Hepatitis B

Vaccine against Hepatitis A

Medication: None

Allergies: None

Differential Diagnosis

 Psoriatic plaques have tree peculiar morphologic elements erythema,

infiltration, and desquamation. Differential diagnosis should be done with all

inflammatory, neoplastic and infection diseases. In the differential diagnosis

of psoriasis vulgaris generally, five dermatologic diseases should think.

 Nummular eczema (rounded, circular desquamative erythematous lesions

covered with vesicles, crusts, and scales, very itchy) Patients have whether

atopic or allergic diathesis. Epicutaneous allergy tests are frequently

positive.
  Mycosis fungoides a form of T-cell lymphoma shows erythematous patches

little infiltrated and finely desquamating. The worst response to treatment

should be suggested to carry out a biopsy in these cases which are crucial

for the diagnosis.

 Pityriasis rubra pilaris in typical cases follicular papules and infiltrating

scales are observed as well as typical hyperkeratosis.

 Duhring’s disease (dermatitis herpetiformis), its bilateral symmetric

localization on extensor surfaces of the limbs. With close-up observation

will show papules and vesicles on the erythematous skin. In eruptive phase

with crusts full of serum and blood and lichenification due to scratching. In

the chronic phase, this disease is constantly very itchy.

 Bowen’s disease squamous cell carcinoma inside of the skin erythematous

little infiltrated, finely desquamating mainly single patches. Showing no

improvement to photo and local therapy.

Examination

 Vital Signs

Temperature: 36°C

Heart rate: 60-99 beats for minute

Pulse: 60-99 beats per minute

Blood pressure: 120/80 mmgh

Respiratory rate: 12-16 breaths for minute

Oxygen saturation: 95-100%

PH: 7.3-7.5

 Anthropometry

Weight: 50 kg

Height : 5'1

BMI: 20.8 this is considered normal.

 General

Skin, abdomen, chest, cardiovascular, neurological, and masculoeskeletal are all

normal.

Subtle Dysmorphic Features: None

Investigation

The Doctor's examines the patient skin, scalp and nails. The patient have Plaques

in the skin. Plaques are patches of raised, reddened skin that are covered in a

layer of silvery scales. People with psoriasis have an immune system that is
overactive and with chronic levels of inflammation. This inflammation causes the

body to produce too many new skin cells, pushing older skin cells to the surface

where they build up as plaques.

Discussion

Psoriasis is an autoimmune disease that causes plaques, which are itchy or sore

patches of thick, red, dry skin. While any part of your body can be affected,

psoriasis plaques most often develop on the elbows, knees, scalp, back, face,

palms, and feet.Like other autoimmune diseases, psoriasis occurs when your

immune system — which normally attacks infectious germs — begins to attack

healthy cells instead.

According to the National Psoriasis Foundation, about 7.5 million people in the

United States have psoriasis, with the

disease affecting Caucasians

more than any other race.

The disease occurs about equally

among men and women. According

to the National Institutes of Health

(NIH), it is more common in

adults, and you are at a greater risk for the disease if someone in your family has

it. A study published in September 2016 in the journal PLoS One concluded that
“interactions between particular genes as well as genetic and environmental

factors play an important role” in the disease’s development.

People with psoriasis generally see their first symptoms between ages 15 and 30,

although developing the disease between 50 and 60 years of age is also common.

What Are the Symptoms and Complications of Psoriasis?

Psoriasis plaques can range from a few spots of dandruff-like scaling to major

eruptions that cover large areas. The disease’s symptoms and appearance vary

according to the type and severity of psoriasis.

For some, psoriasis can clear up for months or even years at a time. This is known

as remission.

Others experience psoriasis flares, or flare-ups, in cyclical patterns. For instance,

the disease may improve in the summer and worsen in the winter.

Psoriasis is associated with a number of health conditions, including high blood

pressure, high cholesterol, diabetes, and depression. It is estimated that up to 30

percent of people with psoriasis will also develop psoriatic arthritis, an

autoimmune disease that affects the joints. According to the National Psoriasis

Foundation (NPF), psoriasis occurs before joint disease in 85 percent of psoriatic

arthritis patients.
The risks for psoriasis-related complications are greater the younger a patient is

when diagnosed and the more severe the psoriasis. Anyone with psoriasis should

be aware that they are at risk for comorbid conditions and should monitor their

overall health accordingly.

The Species of STAPHYLOCOCCUS are usually the causative agents of

Psoriasis.

Treatment and Medication

 Psoriasis treatments reduce inflammation and clear the skin. Treatments

can be divided into three main types: topical treatments, light therapy and

systemic medications.

 Topical treatments used alone, creams and ointments that you apply to your

skin can effectively treat mild to moderate psoriasis. When the disease is

more severe, creams are likely to be combined with oral medications or

light therapy. Topical psoriasis treatments include:

- Topical corticosteroids. These drugs are the most frequently

prescribed medications for treating mild to moderate psoriasis.

They reduce inflammation and relieve itching and may be used

with other treatments.

 - Mild corticosteroid ointments are usually recommended for

sensitive areas, such as your face or skin folds, and for treating

widespread patches of damaged skin.

Your doctor may prescribe stronger corticosteroid ointment for smaller, less

sensitive or tougher-to-treat areas.

Long-term use or overuse of strong corticosteroids can cause thinning of the skin.

Topical corticosteroids may stop working over time. It's usually best to use topical

corticosteroids as a short-term treatment during flares.

Vitamin D analogues. These synthetic forms of vitamin D slow skin cell growth.

Calcipotriene (Dovonex) is a prescription cream or solution containing a vitamin D

analogue that treats mild to moderate psoriasis along with other treatments.

Calcipotriene might irritate your skin. Calcitriol (Vectical) is expensive but may be

equally effective and possibly less irritating than calcipotriene.

Anthralin. This medication helps slow skin cell growth. Anthralin (Dritho-Scalp) can

also remove scales and make skin smoother. But anthralin can irritate skin, and it

stains almost anything it touches. It's usually applied for a short time and then

washed off.

Topical retinoids. These are vitamin A derivatives that may

decrease inflammation. The most common side effect is skin

irritation. These medications may also increase sensitivity to

sunlight, so while using the medication apply sunscreen before

going outdoors.
 The risk of birth defects is far lower for topical retinoids than for oral

retinoids. But tazarotene (Tazorac, Avage) isn't recommended when you're

pregnant or breast-feeding or if you intend to become pregnant.

 Calcineurin inhibitors. Calcineurin inhibitors — tacrolimus (Prograf) and

pimecrolimus (Elidel) — reduce inflammation and plaque buildup.

 Calcineurin inhibitors are not recommended for long-term or continuous use

because of a potential increased risk of skin cancer and lymphoma. They

may be especially helpful in areas of thin skin, such as around the eyes,

where steroid creams or retinoids are too irritating or may cause harmful

effects.

 Salicylic acid. Available over-the-counter (nonprescription) and by

prescription, salicylic acid promotes sloughing of dead skin cells and

reduces scaling. Sometimes it's combined with other medications, such as

topical corticosteroids or coal tar, to increase its effectiveness. Salicylic acid

is available in medicated shampoos and scalp solutions to treat scalp

psoriasis.
  Coal tar. Derived from coal, coal tar reduces scaling, itching and

inflammation. Coal tar can irritate the skin. It's also messy, stains clothing

and bedding, and has a strong odor.

Coal tar is available in over-the-counter shampoos, creams and oils. It's also

available in higher concentrations by prescription. This treatment isn't

recommended for women who are pregnant or breast-feeding.

 Moisturizers. Moisturizing creams alone won't heal psoriasis, but they can

reduce itching, scaling and dryness. Moisturizers in an ointment base are

usually more effective than are lighter creams and lotions. Apply

immediately after a bath or shower to lock in moisture.

 Oral or injected medications

If you have severe psoriasis or it's resistant to other types of treatment, your

doctor may prescribe oral or injected drugs. This is known as systemic treatment.

Because of severe side effects, some of these medications are used for only brief

periods and may be alternated with other forms of treatment.

 Retinoids. Related to vitamin A, this group of drugs may help if you have

severe psoriasis that doesn't respond to other therapies. Side effects may
 include lip inflammation and hair loss. And because retinoids such as

acitretin (Soriatane) can cause severe birth defects, women must avoid

pregnancy for at least three years after taking the medication.

 Methotrexate. Taken orally, methotrexate (Rheumatrex) helps psoriasis by

decreasing the production of skin cells and suppressing inflammation. It

may also slow the progression of psoriatic arthritis in some people.

Methotrexate is generally well-tolerated in low doses but may cause upset

stomach, loss of appetite and fatigue. When used for long periods, it can

cause a number of serious side effects, including severe liver damage and

decreased production of red and white blood cells and platelets.

 Cyclosporine. Cyclosporine (Gengraf, Neoral) suppresses the immune

system and is similar to methotrexate in effectiveness, but can only be

taken short-term. Like other immunosuppressant drugs, cyclosporine

increases your risk of infection and other health problems, including cancer.

Cyclosporine also makes you more susceptible to kidney problems and

high blood pressure — the risk increases with higher dosages and long-

term therapy.

Management and Prevention

Although self-help measures won't cure psoriasis, they may help improve the

appearance and feel of damaged skin. These measures may benefit you:

Take daily baths. Bathing daily helps remove scales and calm inflamed skin. Add

bath oil, colloidal oatmeal, Epsom salts or Dead Sea salts to the water and soak.
Avoid hot water and harsh soaps, which can worsen symptoms; use lukewarm

water and mild soaps that have added oils and fats. Soak about 10 minutes then

gently pat dry skin.

Use moisturizer. After bathing, apply a heavy, ointment-based moisturizer while

your skin is still moist. For very dry skin, oils may be preferable — they have more

staying power than creams or lotions do and are more effective at preventing

water from evaporating from your skin. During cold, dry weather, you may need to

apply a moisturizer several times a day.

Expose your skin to small amounts of sunlight. A controlled amount of sunlight can

improve psoriasis, but too much sun can trigger or worsen outbreaks and increase

the risk of skin cancer. First ask your doctor about the best way to use natural

sunlight to treat your skin. Log your time in the sun, and protect skin that isn't

affected by psoriasis with sunscreen.

Avoid psoriasis triggers, if possible. Find out what triggers, if any, worsen your

psoriasis and take steps to prevent or avoid them. Infections, injuries to your skin,

stress, smoking and intense sun exposure can all worsen psoriasis.

Avoid drinking alcohol. Alcohol consumption may decrease the effectiveness of

some psoriasis treatments. If you have psoriasis, avoid alcohol. If you do drink,

keep it moderate.

Reference:
Brunton, L., Chabner, B., & Knollman, B. (2011). Goodman & Gilman’s: The

pharmacological basis of therapeutics (12 ed.). McGraw-Hill.

Katzung, B., Mastes, S., & Trevor, A. (2012). Basic & Clinical Pharmacology (12

ed.). McGraw-Hill.

National Institute of Health. (2012, January). Vectical ointment. Retrieved from

U.S. National Library of Medicine:

http://www.dailymed.nlm.nih.gov/dailymed/druginfo.cfm

PubMed Health. (2012, November). Psoriasis. Retrieved from PubMed Health:

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001470

1998-2019 Mayo Foundation for Medical Education and Research (MFMER).