PSORIASIS

• Psoriasis is a chronic T-cell mediated inflammatory disorder causing

secondary epidermal turnover, which occurs at a rate 6 to 9 times
faster than normal.
• Psoriasis is a non-infectious, chronic inflammatory disease of the skin,
characterised by well-defined erythematous plaques with silvery
scale, with a predilection for the extensor surfaces and scalp, and a
chronic fluctuating course.
• Psoriasis may start at any age but is unusual before 5 years.
• There are two epidemiological patterns of psoriasis, sometimes
referred to as type 1 and type 2.
• The first has an onset in the teenage and early adult years, often with
a fam ily history of psoriasis and an increased prevalence of the HLA
group Cw6.
• The onset of the second is in the fifties or sixties, when a family
history is less common and HLA Cw6 is not so prominent.
Aetiology
• Psoriasis is genetically complex and a large number of genes are
thought to be important in its pathogenesis.
• There is a large familial component.
• Formal estimates from twin studies suggest a hereditability of around
80%, and in monozygotes perhaps one-third will be concordant for
psoriasis.
• Formerly considered idiopathic, now thought to be genetically linked
and immune system modulated.
• May be caused by some antigenic stimuli that activate cytokines and T cells, thus
causing an extreme dermal response.
• Genes are being identified that may predispose a person to developing psoriasis.
• Condition tends to be lifelong, with flare-ups and remissions.
• May be exacerbated by infection; drugs, such as lithium, beta-adrenergic
blockers, angiotensin-converting enzyme inhibitors, antimalarial drugs,
and indomethacin; stress; and injury
• The keratinocytes hyperproliferate with
a grossly increased mitotic index and
an abnormal pattern of differentiation,
leading to the retention of nuclei in the
stratum corneum, not normally present
as the stratum corneum cells are dead.
• There is a large inflammatory cell
infiltrate.
Types of psoriasis include:
• Plaque most common type, occurs on knees, elbows, scalp, and other areas

• Guttate occurs on trunk, arms, legs; triggered by streptococcal infection.

• Inverse affects flexural areas, such as axilla and groin.
• Erythrodermic severe form that affects most of body.
• Pustular blisters contain puslike material on hand and feet or on widespread
area.
• Psoriatic arthritis ”arthritis and other abnormalities accompany skin
involvement.
Clinical Manifestations

• Erythematous plaques with silvery scales.

• Symmetric involvement.
• May be pruritic and painful.
• Characteristic pitting of nails in 50% of patients
• Arthritis in approximately 10% of patients.
General management of psoriasis
• Explanation, reassurance and instruction are vital.
• Patients may be very distressed by their appearance and doctors should
be aware of the impact that psoriasis can have.

• Parents may admit that they cannot take their young children swimming
because of the alarm their rash causes to other swimmers.
• Similarly, blood on bed sheets and the ubiquitous scale on bedclothes
and car pets may adversely affect personal relationship
Management
• Diagnosed by clinical features; rarely, a biopsy may be needed.
• Coal tar and anthralin preparations inhibit excessive skin turnover.
• Applied topically, with no systemic adverse effects.
• Application may be messy, odorous, and may stain clothing.
• Topical corticosteroids are the mainstay. Adverse effects may include
striae, thinning of the skin, adrenal suppression. Tachyphylaxis may
result if used for extended periods.
• Topical calcipotriene (Dovonex), a vitamin D derivative, used for mild
to moderate psoriasis; is generally without adverse effects
• Another topical preparation is tazarotene (Tazorac), a receptor selective
retinoid, which is potentially teratogenic (pregnancy category X).
• Phototherapy 20 to 30 short treatments. Narrow-band ultraviolet (UVB)
light is safer than full-spectrum UVB light, which carries the risk of
sunburn and skin cancer.
• Photochemotherapy ingestion of an oral photosensitizer (psoralen compound)
followed by ultraviolet A (PUVA) light therapy.
• Cataracts, nausea, and malaise are possible adverse effects of oral PUVA
• Oral methotrexate, the retinoid acitretin (Soriatane), and cyclosporine also
are used for severe cases.
• Hepatotoxicity may occur with methotrexate.
• Possibility of teratogenic with acitretin may occur if alcohol is consumed. Women
are still cautioned not to become pregnant with use or for 3 years after ceasing
therapies.
• Hypertension and renal failure may occur with cyclosporine.
• Newer oral biologic agents, such as etanercept (Enbrel) and infliximab
(Remicade) have demonstrated efficacy in the control of psoriatic arthritis.
Ultraviolet and PUVA therapy UV therapy
• Ultraviolet radiation (UVR) is the mainstay of outpatient
management of those with moderate to severe psoriasis.
• The main risks are burning in the short term, and increased
skin cancers in the long term.
• It has been known for almost a century that ultra violet B
(UVB) administered therapeutically improves psoriasis in
many patients, and many sufferers notice a spontaneous
improvement in summer.
• More recently, a particular type of UVB radiation produced
by the Philips TL01 lamp (narrowband UVB), delivered 2–5
times a week on an outpatient basis.
PUVA therapy
• Psoralens are natural photosensitisers found in a number of
plants.
• Psoralen molecules intercalate between the two strands of DNA
and, upon excitation with UVA, photons cross-link the DNA
strands.
• It is thus a pro-drug that is distributed throughout the body after
oral administration, but only activated by UVR in skin that is
exposed to UVA.
• Alternatively, psoralens can be applied in a bath before
irradiation with UVA (‘bath PUVA’).
• The therapy can be delivered between 2 and 5 times a week and
clearance may be expected in more than 75% of individuals within 8
weeks.
• Some patients may develop nausea in response to the psoralen.
Because the psoralen is present in the eye, patients must wear UVR-
resistant sunglasses for 24 hours after therapy.
• The long-term hazards of PUVA therapy are the result of its
mutagenicity; patients who have received a large amount of PUVA
therapy, particularly ‘maintenance therapy’ (continuous PUVA
lasting for 6 months to a year), are at increased risk of squamous
and basal cell carcinoma.
• The risk of melanoma may also be increased.
Biological therapies
• Recently, a range of new agents, including monoclonal antibodies, fusion
proteins and cytokines, have been shown to have striking activity against
psoriasis and appear as effective as classical agents.
• The long-term role of biological therapies in psoriasis is not yet defined;
they are currently extremely expensive and long-term toxicity has still to
be established.
• Of these agents, the anti-tumour necrosis factor (TNF) therapies are the
best studied.
• These include etanercept, which is a human recombinant TNF receptor
fusion protein, while infliximab is a human-murine anti-TNF-α
monoclonal anti body.
• Both bind TNF, preventing its action, and both seem highly effective in
clearing psoriasis.
• They have to be given either by infusion or by subcutaneous
injection, which may cause adverse reactions.
• Potential side effects include reactivation of latent tuberculosis and
the development of other opportunistic infections.
 Nursing Interventions and Patient Education
• Assist patient with daily tub bath to soften scales and plaques; may gently rub with bath
brush.
• Apply topical preparations after bath and scale removal.
• Warn patient that coal tar and anthralin preparations may stain clothing; let dry before
dressing.
• Advise patient to wear goggles for phototherapy, to prevent cataracts and to follow up with
periodic eye exams.
• Encourage patient to follow up closely with primary care provider or with dermatologist and
to report for blood work, to check renal function and liver function tests as indicated.
• Reinforce to women of childbearing age that retinoids and methotrexate are teratogenic;
woman must be using birth control.
• Encourage patients to try to identify triggers that may cause flare-ups and to practice
avoidance techniques, such as relaxation therapy, to avoid stress.
• Teach patients to avoid direct sun exposure by wearing protective clothing and sunscreen,
especially after photochemotherapy.
• Advise patients to use good lubricants to prevent drying and cracking of skin, which can lead