Types of Psoriasis

1. Guttate Psoriasis: Often triggered by a streptococcal infection (such as pharyngitis or perianal strep). It manifests as numerous small, scaly, red, tear-drop shaped lesions called papules. This type is predominantly seen in children and young adults.

2. Pustular Psoriasis: Characterized by the appearance of pustules, which are yellow, pus-filled lesions. It can present as Generalized pustular psoriasis (GPP), affecting large areas of the body, or Localized pustular psoriasis, confined to smaller areas, typically on the palms of the hands or the soles of the feet.

3. Plaque Psoriasis: The most common form of psoriasis, characterized by raised, inflamed, red patches covered with silvery-white scales. These plaques can be tender, itchy, and painful, commonly appearing on the back, elbows, knees, and scalp.

4. Erythrodermic Psoriasis (Psoriatic Erythroderma): A rare and severe form causing extensive redness and shedding of the skin in large sheets. It typically affects more than 70% of the body surface area. Erythrodermic psoriasis can be life-threatening, with symptoms including severe itching and pain, changes in heartbeat, fever, dehydration, and alterations in nail texture.

Diagnosis / Investigation

Diagnosing psoriasis involves a combination of methods:

• History: Gathering information about the patient’s history, including their age, family history of psoriasis, and past medical history, particularly any streptococcal, bacterial, or viral infections.

• Physical Examination: Identifying characteristic physical signs of psoriasis, such as erythematous, scaling papules and plaques.

• Enzyme-Linked Immunosorbent Assay (ELISA): In patients with severe psoriasis, ELISA testing may reveal increased levels of Long Pentraxin 3 protein (PTX3) in the plasma and in monocytic cultures.

• Skin Biopsy: A skin biopsy can be helpful in confirming the diagnosis. Common findings include perivascular and dermal inflammatory cell infiltration, vascular dilation, and an absent granular layer.

• Blood Test: Blood tests may be performed to rule out other health conditions that could be related to the development of psoriasis.

Management of Psoriasis

Management strategies aim to reduce symptoms and improve the patient’s quality of life.

Nursing Management:

• Body Hygiene: Daily bathing helps to remove scales and soothe inflamed skin.

• Apply Moisturizers: Regularly moisturizing the skin helps to smooth roughness and reduce itching and swelling.

• Avoid Psoriasis Triggers: Identifying and avoiding personal psoriasis triggers is crucial in managing the condition.

• Care for Pressure Areas: Providing meticulous care for pressure areas helps to prevent pressure sores.

• Avoid Alcohol Consumption: Alcohol can interfere with the effectiveness of some psoriasis treatments, so avoidance during treatment is advised.

• Give Psychological Care: Providing emotional support is important to alleviate anxiety associated with the condition.

• Follow a Healthy Lifestyle: Encourage a nutritious diet and abstaining from smoking. Advise on avoiding environmental pollution and dirt, which can exacerbate symptoms.

• Consult Dermatologist for Skin Products: Recommend consulting a dermatologist to choose appropriate shampoos and soaps that won’t irritate the skin.

• Advise Against Exposure to Sunlight: While controlled phototherapy is a treatment, excessive sun exposure can be harmful for some individuals.

• Physiotherapy: May be beneficial for patients with psoriatic arthritis to maintain joint mobility.

Pharmacological Management:

• First-Line Treatment:

  • Medicated Creams and Ointments: Applied directly to lesions to reduce inflammation, remove scales, slow skin turnover, and clear plaques.

  • Topical Corticosteroids: Such as betamethasone cream, to reduce inflammation.

  • Vitamin D Analogues: Like calcipotriol, to slow skin cell growth.

  • Combination Therapy: Topical betamethasone plus calcipotriene applied 12 hourly for 1 week is a common regimen.

• Second-Line Treatment:

  • Phototherapy: Controlled exposure to ultraviolet light can help clear or improve psoriasis.

  • Topical Steroids: Such as triamcinolone, to relieve itching, crusting, scaling, redness, inflammation, dryness, and discomfort. It can also be used as a dental paste for mouth sores.

  • Oral Retinoids: Like Acitretin, pills that slow down skin cell production, used for severe cases. Side effects include dry skin and muscle soreness, and they are contraindicated in pregnancy and breastfeeding.

  • Methotrexate: A powerful drug used for severe, disabling psoriasis unresponsive to topical treatments or phototherapy. It suppresses the overactive immune system.

  • Biologics: Newer, targeted drugs that specifically address the overactive part of the immune system causing psoriasis, minimizing damage to other organs.

Psoriatic Arthritis

A form of inflammatory arthritis that affects individuals with psoriasis.

Causes/Predisposing Factors:

• Autoimmune reactions.

• Physical trauma.

• Microbial infestation.

• Pre-existing psoriasis.

• Family history.

• Age (commonly affects people aged 30-50, but can occur at any age).

Signs and Symptoms:

• Joint involvement can be on one or both sides of the body.

• Symptoms resemble those of rheumatoid arthritis, including hotness, redness, tenderness, swelling, and joint stiffness.

• Commonly involves:

  • Lower back pain.

  • Foot pain.

  • Swollen fingers and toes (dactylitis).

Diagnosis:

• History taking.

• Physical examination.

• X-ray.

• MRI.

• Rheumatoid factor test (typically negative in psoriatic arthritis).

• Joint fluid test.

Management/Treatment:

• Nursing Management:

  • Apply moisturizers to the skin.

  • Use of warm compresses for joint pain relief.

  • Care for pressure areas.

  • Ensure general hygiene.

  • Provide psychological care.

  • Encourage a balanced diet.

  • Advise against excessive sun exposure.

  • Physiotherapy.

• Pharmacological Management:

  • Analgesics like paracetamol for pain relief.

  • NSAIDs like ibuprofen to reduce inflammation.

  • Immune suppressants like azathioprine or cyclosporine.

  • Biologic agents (DMARDs).

  • New oral medications like apremilast to decrease inflammatory enzyme activity.

• Surgical Treatment:

  • Joint replacement may be considered in severe cases.

Complications:

• Arthritis Mutilans: A severe, painful, and disabling form that can destroy small bones in the hands and feet.

• Conjunctivitis.

• Uveitis.

• High risk of cardiovascular diseases.