Psoriasis

1. PSORIASIS
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

2. 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

3. DEFINITION
“ 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. 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

6. ETIOLOGY
 Idiopathic cause
 Some of the factors that may trigger psoriasis are;-
 Genetic
 Autoimmune reaction
 Infection
 Injury to skin
 Medication:- lithium, antimalarial medications,
indomethacin
 Stress, obesity and smoking

7. PATHOPHYSIOLOGY

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

9. 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

10. CLASSIFICATION
There are several types of psoriasis include
 Plaque psoriasis-
 Guttate psoriasis-
 Inverse psoriasis-
 Pustular psoriasis-
 Erythrodermic psoriasis-
 Nail psoriasis-
 Psoriatic arthritis-

11. 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, lower back,
Hands and feet
GUTTATE PSORIASIS( (Latin Gutta=drop)

12. • 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

13. 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.
PUSTULAR PSORIASIS

14. • 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.
ERYTHRODERMIC
PSORIASIS

15. • 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

16. 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

17. 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

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

20. 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
 Restricted joint motion or pain
 Cracked and bleeding skin

21.  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

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

23. MEDICAL MANAGEMENT
:AIM
 Interrupt the cycle that cause an -
increased production of skin cells
thereby reducing inflammation .and
plaque formation

24.  Remove scales and smooth skin, -
which is particularly remove by
 .topical treatment
Psoriasis treatment is divided into
three main type
1. Topical treatment-
2. Light therapy
3. Systemic medications-

26. 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
• Strong corticosteroids use for smaller area of skin
like hands and feet.

27. • 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.
TOPICAL STEROIDS
• To avoid systemic effects of class I glucocorticoid, a
maximum of 50 g ointment may be used per week

28. • For small plaques (< 4cm), triamcinolone acetonide
aqueous suspension 10 mg/mL diluted with normal
saline is injected into the lesion
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

29. • Calcipotriene is applied twice daily
• Salicylic acid inactivates calcipotriene
• 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
steroidrelated skin atrophy.

30. • Other vitamin D analogues are tacalcitol and
maxacalcitol

31. • 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.
3-Coal Tar
• The use of tar to treat skin
diseases dates back nearly
2000 years

32. • 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
• Coal tar, in concentrations 5- 20% can be compounded in
creams, ointments, shampoos and in pastes.

33. • 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

34. 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

35. the 1% formulations). It will use along with sun screen
lotion.
5-Topical Calcineurin Inhibitors
(Tacrolimus”Tarolimus” &
Pimecrolimus ”Elidel” )

36. • They inhibit activation of Tcells 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
6-Emollients
• Between treatment periods, skin
care with emollients should be
performed to avoid dryness

37. • 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
1. Determination of the minimal )erythema
dose (MED
1-The patient wears a

39. 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
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

40. 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"
:SUN LIGHT
Ultraviolet light is a wavelength of light in - . a range
too short for human eye to see When exposed to

41. 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
ULTRAVIOLET BOARDBAND
PHOTOTHERAPY
Control dose of UVB light from an artificial - light
source may improve mild to moderate .psoriasis
symptoms

42. 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
PHOTOCHEMOTHERAPHY / PSORAIEN PLUS
ULTRAVIOLET-A
Photochemotherapy involves taking light - sensitizing
medication (psoralen) before .exposure to UVA light

43. 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
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

44. Side effect : redness and blistering 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
Devices used

45. SYSTEMIC THERAPY

46. Cyclosporin A
Neoral 100mg/ml Suspension & 100 mg capsules
Action
Binds cyclo-philin producing a complex that blocks calcineurin, 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

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

48. Renal abnormalities
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-

49. 30 mg weekly
Side effect
Chronic use may lead to hepatic
fibrosis
Fetal abnormalities or death Pulmonary fibrosis
Contraindication
Liver toxicity
Pregnancy

50. 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

51. Side Effects
 Hepatotoxicity
 Lipid abnormalities
 Fetal abnormalities or death ,
Alopecia
Contraindication
 Severe infections
 Malignancy

52. 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

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

54. 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

55.  SUMMARY

56. 