Psoriasis is a chronic skin disease characterized by recurring exacerbations and remissions of skin lesions. The lesions appear as erythematous papules and plaques covered with silvery scales. Genetic and environmental factors contribute to its development, and stress, infections, and injuries can trigger flare-ups. Treatment focuses on slowing skin cell production through topical creams, light therapy, oral medications, and managing symptoms, as there is no permanent cure. Patients require education on application of treatments, stress management, and prevention of exacerbations to help control the condition.

1. PSORIASIS
CLASS BY :ALBERT BLESSON, NURSING TUTOR , AIIMS PATNA

2. PSORIASIS
Psoriasis is a chronic skin disease marked by epidermal proliferation and characterized by recurring
remissions and exacerbations. Lesions appear as erythematous papules and plaques covered with silvery scales and
vary widely in severity and distribution.
The tendency to develop psoriasis is based strongly on genetic and environmental factors. Trauma can
trigger the isomorphic effect, or Koebner phenomenon, in which lesions develop at injury sites. Infections,
especially those resulting from beta-hemolytic streptococci, may cause a flare of guttate (drop-shaped) lesions.
Other contributing factors include pregnancy, endocrine changes, climatic conditions (cold weather tends to
exacerbate psoriasis), and emotional stress.
A skin cell normally takes 14 days to move from the basal layer to the stratum corneum, where, after an
additional 14 days of normal wear and tear, it is sloughed off. In contrast to this 28-day cycle, the life cycle of a
psoriatic cell is only 4 days, which does not allow time for the cell to mature. Consequently, the stratum corneum
becomes thick and flaky, producing the cardinal signs and symptoms of psoriasis

3. Signs and Symptoms
• Skin lesions that itch and burn and may be painful, erythematous, well-defined plaques covered with
characteristic silver scales; usually appear on the scalp, chest, elbows, knees, back, and buttocks
• In mild psoriasis, plaques scattered over a small skin area
• Scales that flake off easily (on palpation); scales that have thickened and have covered the lesion
• Fine bleeding points, or Auspitz sign, when attempting to remove scales
• Small guttate lesions, either alone or with plaques; typically thin and erythematous, with few scales

4. Looking at a Psoriatic

5. Identifying Types of Psoriasis
Psoriasis occurs in various forms, ranging from one or two localized plaques that seldom require long-term
medical attention to widespread lesions and crippling arthritis
ERYTHRODERMIC PSORIASIS Erythrodermic psoriasis is marked by extensive flushing, pain, and itching
all over the body, which may or may not result in scaling. The rash may begin rapidly, signaling new
psoriasis; it may develop gradually as chronic psoriasis; or it may occur as an adverse reaction to a drug.
GUTTATE PSORIASIS Guttate psoriasis typically affects children and young adults. Erupting in drop-sized
plaques over the trunk, arms, legs, and, sometimes, scalp, this rash of plaques generalizes in several days. It is
commonly associated with upper respiratory tract streptococcal infections

6. INVERSE PSORIASIS Smooth, dry, bright red plaques characterize inverse psoriasis. Located in skin folds—for
example, the armpits and groin—the plaques fissure easily.
PLAQUE PSORIASIS Plaque psoriasis is the most common type of psoriasis. It begins with red, dot-like lesions
that gradually enlarge and produce dry, silvery scales. The plaques usually appear symmetrically on the knees,
elbows, extremities, genitalia, scalp, and nails.
PUSTULAR PSORIASIS Pustular psoriasis features an eruption of local or extensive small, raised, pus-filled
plaques on the soles or palms or diffusely over the body. Precursors include emotional stress, sweat, infections,
and adverse drug reactions.
PSORIATIC ARTHRITIS Psoriatic arthritis affects the feet and hands of up to 30% of patients with skin
symptoms. Pain, stiffness, and joint damage may occur.

7. Treatment
• No permanent cure; treatment palliative
• Lukewarm baths and application of occlusive ointment bases, such as petroleum jelly, or preparations that contain urea or
salicylic acid that may soften and help remove psoriatic scales
• Steroid creams
• Methods to retard rapid cell production, such as exposure to UVB light or natural sunlight to the point of minimal
erythema
• Coal tar preparations to retard skin cell growth and relieve inflammation, itching, and scaling
• Topical corticosteroids for mild to moderate psoriasis of the trunk, arms, and legs; commonly used in combination with
emollients, coal tar preparations, and UV light therapy
• Topical vitamin D or calcipotriene topical ointment
• 0.025% triamcinolone acetonide (Kenalog) ointment for mild psoriasis involving the extremities
• 1% desonide cream or alclometasone dipropionate (Aclovate) for facial, groin, or axillary plaques
• 0.1% betamethasone valerate (Valisone) or 0.1% triamcinolone acetonide for moderate psoriasis

8. • Anthralin for large plaques that do not respond to coal tar or topical corticosteroid preparations
• Methotrexate (Rheumatrex), a drug that inhibits cell replication, for severe, unresponsive psoriasis
• Acitretin, a potent retinoic acid derivative, for psoriasis that is resistant to other drugs or treatments
• Goeckerman treatment, which combines topical coal tar treatment with UVA or UVB light therapy, for severe chronic
psoriasis
• Photochemotherapy program, called PUVA, that combines administration of psoralen, either orally or topically, with
exposure to UVA light
• Cyclosporine (Neoral), an immunosuppressant, for severe widespread psoriasis that results in dramatic clearing
• Ustekinumab (Stelara) to inhibit the production of proteins involved in inflammatory and immune responses
• Low-dose antihistamine therapy, oatmeal baths, emollients (perhaps with phenol and menthol), and open wet dressings to
help relieve pruritus; aspirin and local heat to help alleviate the pain of psoriatic arthritis; nonsteroidal anti-inflammatory
drugs for severe cases
• For psoriasis of the scalp, coal tar shampoo, followed by the application of a steroid lotion while the hair is still wet; no
effective treatment for psoriasis of the nails—usually improves as skin lesions improve
• Tumor necrosis factor inhibitors, such as infliximab (Remicade) or etanercept (Enbrel); may decrease the inflammatory
process in plaque psoriasis

9. Nursing Considerations
• Ensure proper patient teaching, and offer emotional support.
• Apply all topical medications, especially those that contain anthralin and coal tar, with a downward
motion to avoid rubbing them into the follicles. Wear gloves because anthralin stains and injures the skin.
After application, allow the patient to dust himself with powder to help prevent anthralin from rubbing
off on his clothes.
• Watch for adverse reactions to therapeutic agents, which may include allergic reactions to anthralin;
atrophy and acne from steroids; and burning, itching, nausea, and squamous cell epitheliomas from
PUVA.

10. • Initially, evaluate the patient on methotrexate weekly and then monthly for red blood cell, white blood cell,
and platelet counts because cytotoxins may cause hepatic or bone marrow toxicity. Liver biopsy may be
done to assess the effects of methotrexate.
• Monitor triglycerides, cholesterol, and liver function tests for acitretin. Patients on cyclosporine need renal
function and blood pressure monitoring.
• Encourage the patient to verbalize feelings about his appearance; feelings of embarrassment, frustration, or
powerlessness; or fear of rejection. Involve his family in the treatment regimen to reduce the patient’s
feelings of social isolation. Help the patient build a positive self-image by encouraging his participation in
activities that de-emphasize appearance.

11. Teaching About Psoriasis
• Explain the causes, predisposing factors, and course of psoriasis to the patient and his family. Stress that psoriasis is not
communicable. Advise them that exacerbations and remissions commonly occur but that they can usually control the
disorder by adhering to the treatment regimen.
• Make sure the patient understands his prescribed therapy; provide written instructions to avoid confusion. Teach correct
application of prescribed ointments, creams, and lotions.
• Instruct the patient to avoid scratching the plaques. Suggest that he wear gloves to help protect the skin from unconscious
scratching. Tell him that pressing ice cubes against the lesions or applying a mentholated shaving cream may provide
relief. Recommend using a humidifier in the winter to avoid dry skin, which may increase itching.
• Caution the patient to avoid scrubbing his skin vigorously. If a medication has been applied to the scales to soften them,
suggest that the patient use a soft brush to remove them.
• Warn the patient never to put an occlusive dressing over anthralin. Suggest the use of mineral oil and then soap and water
to remove anthralin.

12. • Caution the patient receiving PUVA therapy to stay out of the sun on the treatment day and to protect his eyes with
sunglasses that screen UVA for 24 hours after treatment. Tell him to wear goggles during exposure to this light.
• If the patient is using acitretin, inform him that the drug may remain in his body for up to 3 years after the
treatment ends. For this reason, discourage female patients who may want to become pregnant from using this
drug.
• Caution the patient using methotrexate not to drink alcoholic beverages; explain that alcohol ingestion increases
the risk of hepatotoxicity.
• Warn the patient and his family about possible adverse effects associated with the therapeutic agents; tell them to
notify the physician if any occur.
• Teach the patient stress-reduction techniques and injury prevention strategies to prevent exacerbations.
• Explain the relation between psoriasis and arthritis, but point out that psoriasis causes no other systemic
disturbances.
• Refer the patient to the National Psoriasis Foundation

13. THANK YOU
REFERENCE
LippincottVISUAL
NURSING
A Guide to Diseases,
Skills, and Treatments
Third Edition