psoriasis is a chronic skin disease result in patches of thick red skin covered with silvery scaling.

1. PSORIASIS
By: Ms. DORJEE DOLKAR
M.Sc NURSING

2. INTRODUCTION
Psoriasis is a chronic skin disease result in
patches of thick red skin covered with the
silvery scales.
These patches are referred as plaque which
usually occur on the elbow, knees, legs,
scalp, lower back, face, palm and sole of
the feet, nails too.

3. HISTORY
The word psoriasis is derive from greek
word ‘psora’ means ‘itching’.
The greek physician Galen of perganon
(130-200 BC) use the term Psoriasis
vulgaris to refer all dermo and
epidermopathies accompanied by pruiritis.
Since 1950 local application and systemic
medications are used for the psoriasis.

4. DEFINITION
According to www.mayoclinic.com, “
psoriasis is defined as a persistent skin
disease causes cell to build rapidly on the
surface of the skin, forming thick silvery
scales, itchy,dry and red patches.”

5. ANATOMY AND PHYSIOLOGY

6. INCIDENCE
• 1-3% and in America and western
• Lower rates are found in Japanese
and psoriasis is rare in West Africans
• Psoriasis first appears during 2 peak age
ranges:The first peak occurs in persons aged
16-22 years, and the second occurs in persons
aged 57-60 years

7. ETIOLOGY
Idiopathic cause
Some of the factors that may trigger
psoriasis are:
Genetic
Autoimmune reaction
Infection
Injury to skin

8. Cont….
Medication:
lithium, antimalarial medications, inderal,
indomethacin
Stress
Obesity
smoking

9. PATHOPHYSIOLOGY
STRESS, GENECTIC, AUTOIMMUNE REACTION AND MEDICATION CAUSE
HYPERACTIVE OF T-CELLS
EPIDERMIS INFILTRATION AND KERATINOCYTE PROLIFERATION
DEREGULATED INFLAMMATORY PROCESS

10. LARGE PRODUCTION OF VARIOUS
CYTOKINES ( INTEFERRON, INTERLEUKIN-12)
SUPERFICIAL BLOOD VESSEL DILATED AND
VASCULAR ENGORGEMENT
EPIDERMAL HYPERPLASIA AND IMPROPER CELL
MATURATION
FAILS TO RELEASE ADEQUATE LIPIDS WHICH LEAD TO
FLAKING, SCALING PRESENTATION OF PSORIASIS LESION
SILVER SCALING OF SKIN

11. CLASSIFICATION
There are several types of psoriasis include:
-Plaque psoiasis
-Guttate psoriasis
-Inverse psoriasis
-Pustular psoriasis
-Erythrodermic psoriasis
-Nail psoriasis
-Psoriatic arthritis

12. PLAQUE PSORIASIS
-It is the most common type of
psoriasis.
-It is also known as psoriasis
vulgaris.
-It is appear as raised, inflammed,
red skin covered by silvery
patches or scales.
-Sites :Elbows, Knees, sacrum,
Scalp, loer back, Hands and
Feet.

13. GUTTATE PSORIASIS
(Latin Gutta=drop)
• Characterized by eruption
of small (0.5 to 1.5 cm in
diameter) papules over the
upper trunk and proximal
extremities
• Manifests at an early age
• Streptococcal throat
infection frequently
precedes or is concomitant
with the onset or flare

14. INVERSE PSORIASIS
• Localized in the major skin
folds, such as the axilla, the
inguinal and inflammatory
areas and sweating areas
• Scaling is usually minimal
or absent, and the lesions
appear glossy, smooth and
bright red.
• Its is commonly seen in
obese client.

15. PUSTULAR PSORIASIS
• It is usually uncommon but
mostly appear in adult.
• It appear as pus filled
lesion surrounded by red
skin.
• It appear mostly at hands
and feet.
• It is the serious condition
so immediate medical
attention is required.

16. ERYTHRODERMIC
PSORIASIS
• The disease affects all
body sites
• Erythema is the most
prominent feature with
superficial scaling /
peeling that may appear
like burning
• Causes: sun burn, allergic
reaction, strong coal
product use

17. NAIL PSORIASIS
-Commonly seen along with
psoriatic arthritis.
-It appear as a pitting –small
bit nail, yellow-brown nail,
tender and painful nail with
chalk like debris build up
under nails.
-Keep the mail short and
trimmed.
-Treated by steroid injected
into nail or light therapy

18. PSORIATIC ARTHRITIS
This is the condition
which involve both
psoriasis and joint
inflammation.
•The blue arrow = a normal joint space
• Red arrow = “cup and saucer” effect of the
fourth metatarsal bone being jammed into the
base of the fourth toe
•The yellow circle = “Pencil appearance”
destruction characteristic of the disease

19. PSORIATIC ARTHRITIS
The most distinctive features of psoriatic
arthritis are
• Distal interphalangeal joint arthritis
• Dactylitis

21. COMMON CLINICAL
MANIFESTATIONS:
It will vary according to types of at psoriasis.Intially
the first sign of psoriasis is often red spots on
the body.
The patches of skin:
Dry, swollen and inflammed
Covered with silver white flakes
Raised and thick skin
Other symptoms of psoriasis includes:
Pain, itching and burning

22. Restricted joint motion or pain
Cracked and bleeding skin
Dandruff on scalp
Pus filled blisters
Genital lesions in males.
Pitting, small depression on the
surface of the nail
Yellow, dicsolored nail
Koebner phenomenon
Arthritis

23. DIAGNOSTIC
INVESTIGATIONS
-Collect history
-Physical examinations
-Skin biopsy : under local
anesthesia
-Blood and radiography
test was done to rule out
psoriatic arthritis

24. MEDICAL MANAGEMENT
AIM:
-Interrupt the cycle that cause an
increased production of skin cells
thereby reducing inflammation
and plaque formation.
-Remove scales and smooth skin,
which is particularly remove by
topical treatment.

25. Cont….
Psoriasis treatment is divided
into three main type:
-Topical treatment
-Light therapy
-systemic medications

27. 1-Topical corticosteroids
• They are commonly first-line therapy in
mild to moderate psoriasis and in sites
such as the flexures and genitalia, where
other topical treatments can induce
irritation and skin folds.
• Improvement is usually achieved within 2
to 4 weeks.
• They slows the cells turnover by
suppressing the immune system which
reduce inflammation and relieves
associated itching

28. • Strong corticosteroids use for smaller area
of skin like hands and feet.
• Long term use may cause thinning of skin
and resistance too.
• Low potency steroids are usually
recommended for sensitive area and
treating wide spread patches damage skin.

29. TOPICAL STEROIDS
• To avoid systemic effects of class I
glucocorticoid, a maximum of 50 g
ointment may be used per week
• For small plaques (< 4cm), triamcinolone
acetonide aqueous suspension 10 mg/mL
diluted with normal saline is injected into
the lesion

30. 2- Vitamin D Analogues
Calcipotriene (calcipotriol)”Betdaivonex”
• Potent topical corticosteroids are superior
to calcipotriene. But calcipotriene was
more effective than coal tar or anthralin
• The efficacy of calcipotriene is not
reduced with long-term treatment
• Calcipotriene is applied twice daily
• Salicylic acid inactivates calcipotriene

31. • Hypercalcemia is the only major concern
• When the amount used does not exceed
the recommended 100 g/week,
calcipotriene can be used with a great
margin of safety
• It is often used in combination with or in
rotation with topical corticosteroids in an
effort to maximize therapeutic
effectiveness while minimizing steroid-
related skin atrophy.

32. • Other vitamin D analogues
are tacalcitol and
maxacalcitol
• In view of their efficacy,
cosmetic acceptability and
relative safety, they may
accepted as first-choice
therapies in the topical
treatment of mild to
moderate psoriasis.

33. 3-Coal Tar
• The use of tar to treat skin diseases dates
back nearly 2000 years
• Tar is the dry distillation product of organic
matter heated in the absence of oxygen
• In 1925, Goeckerman introduced “The
Goekerman technique” which uses crude
coal tar and UV light for the treatment of
psoriasis

34. Cont….
• Coal tar, in concentrations 5- 20% can
be compounded in creams, ointments,
shampoos and in pastes.
• It is often combined with salicylic acid
(2-5% ), which by its keratolytic
action leads to better absorption of the
coal tar
• Disadvantages include: allergic
reactions, folliculitis, it has foul smell
and appearance and can stain
clothing and other items. Coal tar is
carcinogenic

35. Tazarotene(zar, Zarotex)
• It is a third-generation retinoid
• It reduces mainly scaling and
plaque thickness, with limited
effectiveness on erythema by
normalize the DNA activity.
• It is available in 0.05 percent
and 0.1 % gels, and a cream
• When used as a monotherapy,
a significant proportion of
patients develop local
irritation(especially with the 1%
formulations). It will use along
with sun screen lotion.

36. 5-Topical Calcineurin Inhibitors
(Tacrolimus”Tarolimus” &
Pimecrolimus ”Elidel” )
• They inhibit activation of T-
cells which inturn reduces
inflammation and plaque
build up.
• They are not effective in
plaque psoriasis. However,
for treatment of inverse and
facial psoriasis, these agents
appear to provide effective
treatment

37. 6-Emollients
• Between treatment periods, skin care with
emollients should be performed to avoid
dryness
• Emollients reduce scaling, may limit painful
fissuring, and can help control pruritus
• They are best applied immediately after
bathing or showering
• The use emollients in combination with
topical treatments improves hydration while
minimizing treatment costs

38. PHOTOTHERAPY

39. Determination of the minimal
erythema dose (MED)
1-The patient wears a
thick cotton shirt which
has 10 small, vertical
holes on its back
2-The patient is
exposed to 50 mj of UV
on the back while all
the holes are opened

40. 3-The first hole is closed and another exposure is
given By that time the skin under the first hole was
exposed to 50 mj of UV while the skin under the
second hole was exposed to 100 mj
4-The second hole is closed and the procedure is
repeated in the same way (closing an hole and
giving a dose) for all the holes
5-After 24-72 hours the skin of the back is examined
and the first skin area showing well-defined
erythema is determined and the amount of UV
causing it is called "the minimal erythema dose"

41. SUN LIGHT:
-Ultraviolet light is a wavelength of light in
a range too short for human eye to see.
-When exposed to the UV light ,the
activated t –cells in the skin are destroy
which lead reduces scaling and
inflammation.
-Sun exposure should be for brief
duration of time to improve psoriasis.

42. ULTRAVIOLET BOARDBAND
PHOTOTHERAPY
-Control dose of UVB light from an artificial
light source may improve mild to moderate
psoriasis symptoms.
-UVB phototherapy is also called
“Broadband UVB” can be use to treat to
single patches and psoriasis resistant to
topical treatment.
-Side effect: reddness, dryness and itching
which can be minimize by using
moisturizer.

43. PHOTOCHEMOTHERAPHY /
PSORAIEN PLUS ULTRAVIOLET-A
-Photochemotherapy involves taking light
sensitizing medication (psoralen) before
exposure to UVA light.
-UVA light penetrate deeper in skin and
psoralen make more responsive to UVA
exposure
-Side effect: nausea, headache, burning
and itching, wrinkle skin or skin cancer.

44. EXIMER LASER
A controlled beam of UVB light of a
specific wavelength is directed to the
psoriasis plaque to control scaling and
inflammation.
It does not harm healthy skin
More powerful UVB light is used
Side effect : redness and blistering

45. PULSE DYE LASER
Pulse dye laser used different form of light to destroy the
tiny blood vessel that contribute to psoriasis plaque.
Side effect : bruising, scarring,
COMBINATION LIGHT THERAPY
Combine UV light with other treatment such as retinoids
frequently improve phototherapy effectiveness.

46. Devices used

47. SYSTEMIC THERAPY

48. Cyclosporin A
Neoral 100mg/ml Suspension & 100 mg capsules
Action
Binds cyclo-philin producing a complex that blocks calci-
neurin, reducing the effect of the NF-AT in T cells,
resulting in inhibition of interleukin 2
Dosage
High-dose method: 5 mg/kg daily, then tapered
Low-dose method: 2.5 mg/kg daily, increased every 2-4
wk up to 5 mg/kg daily, then tapered

49. Side effect
Nephrotoxicity
Hypertension
Immuno-suppression
Neurotoxicity
Increased risk of malignancy
Contraindication
Prior bone marrow depression
Pregnancy
Lactation
Renal abnormalities

50. METHOTREXATE
Methotrexate 2.5 mg tab & 50 mg/lm vial
Action
Blocks dihydrofolate reductase leading to inhibition of
purine and pyrimidine synthesis. Leading to
accumulation of anti-inflammatory adenosine
Dosage
Start with a test dose of 2.5 mg and then gradually
increase dose until a therapeutic level is achieved
(average range, 10-15 mg weekly; maximum, 25-
30 mg weekly

51. Side effect
Chronic use may lead to hepatic
fibrosis
Fetal abnormalities or death
Pulmonary fibrosis
Contraindication
Liver toxicity
Pregnancy

52. ACITRETIN
Acitretin 25 mg cap
Action
Binds to retinoic acid receptors. May
contribute to improvement by
normalizing keratinization and
proliferation of the epidermis
Dosage
Initiate at 25-50 mg daily.

53. Side effect
Hepatotoxicity
Lipid abnormalities
Fetal abnormalities or death
Alopecia,
Contraindication
Severe infections
Malignancy

54. NURSING DIAGNOSIS
Impaired skin integrity r/t lesion and inflammatory
response as evidence by itching all over body.
Risk for infection r/t hypoprotenimia as evidence
by lost of protein and fluid from psoraisis lesion.
Acute pain r/t inflammation as evidence by
verbalisation.
Ineffective tissue perfusion r/t decrease oxygen
and blood supply to peripherial as evidence by
peripheral cyanosis.

55. COMPLICATIONS
Infection
Fluid and electrolyte imbalance
Low self esteem
Depression
Stress
Metabolic syndrome
Hypertension
Joint damage

56. HEALTH EDUCATION
Take daily bath
Use moisturizer
Expose small amount of skin to sunlight
Cover the affected area over night
Apply medication cream or ointment
Avoid drinking alcohol and smoking
Eat healthy diet

57. SUMMARY