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Psoriasis is a chronic, inflammatory autoimmune skin disease that affects as many as 7.5 million Americans, according to the National Institutes of Health. What's your role in caring for a patient with this condition? In this article, we'll take a look at nursing care and much more!!
Psoriasis develops when the immune system becomes overactive and produces too many white blood cells (called CD4 helper T cells), which causes an increase in blood flow to the skin, inflammation, and keratinocyte proliferation. Keratinocytes are epidermal cells that synthesize keratin and undergo chemical changes as they move upward from the basal layers of the epidermis. This means that new skin cells grow faster than the old skin can shed, known as cell turnover.
In about one-third of cases, there's a family history of psoriasis. Skin trauma is a common precipitating factor in individuals who have a family history of the disorder. Stress, illness, dry climate, and some medications (such as lithium and beta-blockers) have been known to worsen the symptoms of psoriasis.
Psoriasis lesions are generally red and circular, with a patchy appearance, and covered with heavy, dry, silvery scales. Often referred to as plaques, these patches are usually itchy and may be sore or painful. They most often occur on the elbows, knees, legs, scalp, lower back, face, palms, and soles of the feet; however, psoriasis lesions can occur anywhere on the body. Psoriasis lesions aren't contagious.
Plaque psoriasis is the most common form of the disorder, characterized by skin lesions that are red at the base and covered by silvery scales (see Picturing plaque psoriasis). Other forms of psoriasis include:
* guttate psoriasis-characterized by small, drop-shaped lesions that appear on the trunk, limbs, and scalp; most often triggered by upper respiratory infections
* pustular psoriasis-characterized by blisters of noninfectious pus; attacks may be triggered by medications, infections, stress, or exposure to certain chemicals
* inverse psoriasis-characterized by smooth, red patches that occur in the folds of the skin near the genitals, under the breasts, or in the armpits; symptoms may be worse with friction and sweating
* erythrodermic psoriasis-characterized by widespread reddening and scaling of the skin that may be a reaction to severe sunburn or taking corticosteroids or other medications; may also be caused by a prolonged period of increased activity of psoriasis that's poorly controlled.
Psoriasis lesions can look like other skin disorders, such as seborrheic dermatitis, squamous cell carcinoma, fungal infections, and some forms of cutaneous lupus. It's important to microscopically examine the lesion(s) to make a definitive diagnosis of psoriasis. Usually, the exam will show a large number of dry skin cells with mild inflammation and without infection.
Psoriasis may not always be limited to the skin. Psoriatic arthritis (PsA) can exist with or without skin lesions, or there may be nail involvement only. PsA affects ligaments, tendons, and joints anywhere in the body and usually occurs when skin involvement is more severe. Clinically apparent psoriasis, pain, and soft tissue swelling and/or limitation of motion in at least one joint for 6 weeks or longer are among the specific criteria for a diagnosis of PsA. You may assess that your patient has an elevated C-reactive protein level and erythrocyte sedimentation rate because of joint inflammation. Rheumatoid factor isn't usually found in PsA as in patients with rheumatoid arthritis.
The patient's symptoms, X-rays, and lab test results guide the healthcare team in developing a care plan. You should also perform a head-to-toe assessment and evaluate the characteristics and locations of your patient's lesions. The goal is to reduce symptoms and improve quality of life through pharmacologic and nonpharmacologic treatments. It's important for you to understand the various medications used to treat psoriasis and how you can best help your patient.
Keratolytic medications, corticosteroids, and emollients are used in mild cases of psoriasis. Lesions of the genitalia, scalp, and nails are treated with shampoos and various lotions. Moderate lesions may be treated with coal tar preparations that are sometimes effective in reducing inflammation and itching. Vitamin A derivatives, antihistamines, baths with colloidal oatmeal products, and moisturizers are often helpful. A combination of systemic corticosteroids and other immunosuppressants may be necessary in severe cases. Disease-modifying antirheumatic drugs (DMARDs) are gaining more recognition for the treatment of moderate-to-severe psoriasis and PsA because of their ability to target specific immune responses. See Medications used to treat psoriasis for topical and systemic agents used in the treatment of psoriasis and PsA.
Ultraviolet phototherapy is an effective nonpharmacologic treatment for psoriasis because it slows down excessive skin cell growth, which can clear symptoms for varying periods. Physical therapy and rehabilitation may be necessary for patients with PsA. Splints may be used to support a joint in a position to improve function and relieve pain and swelling. Joint replacement may be an option for patients with PsA when conservative treatment isn't effective.
Teach your patient to perform proper hand washing before and after the application of topical medications. Instruct him and his family members about the adverse reactions of medications. Fatigue, fever, or sore throat may indicate infection secondary to immunosuppressive therapy. Emphasize the importance of reporting drainage from lesions that may indicate infection. Encourage your patient to wear clothing that doesn't irritate his skin. He should limit exposure to light sources that could increase pain and discomfort in lesions. Medications, such as methotrexate, may also make him sensitive to light.
Some patients find that symptoms interfere with everyday life, including work, social events, and personal relationships. Mobility may be a major concern when arthritis is present along with skin symptoms. Don't forget to assess your patient's level of pain. Actively listen to his verbalization of pain and discomfort. Analgesics should be considered to manage pain. Sometimes people with psoriasis become self-conscious of lesions that impact their self-esteem. This may lead to anxiety, anger, embarrassment, and depression. Encouraging your patient and his family members to join a psoriasis support group may help alleviate self-image issues.
You can make a positive difference in the lives of your patients with psoriasis by joining them on their journey of coping with this chronic condition.
These online resources may be helpful to your patients and their families.
American Academy of Dermatology:
American College of Rheumatology:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/p
National Institute of Arthritis and Musculoskeletal and Skin Diseases:http://www.niams.nih.gov/Health_Info/Psoriasis/psoriasis_ff.asp
National Psoriasis Foundation:http://www.psoriasis.org
American College of Rheumatology. Psoriatic arthritis. http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/p.
Gottlieb AB, Kardos M, Yee M. Current biologic treatments for psoriasis. Dermatol Nurs. 2009;21(5):259-266,272.
Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008;58(5):851-864.
National Institute of Arthritis and Musculoskeletal and Skin Diseases. Psoriasis. http://www.niams.nih.gov/Health_Info/Psoriasis/default.asp.
National Psoriasis Foundation. About psoriasis. http://www.psoriasis.org/netcommunity/diagnosed_aboutps.
Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:1965-1970.
Tanghetti EA. The role of topical vitamin D modulators in psoriasis therapy. J Drugs Dermatol. 2009;8(8 suppl):s4-s8.
Weinberg JM. The management of psoriasis in the age of biologics: clinical update 2009. J Drugs Dermatol. 2009;8(9):5-13.
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