Psoriasis Nursing Management

Definition
  • Is a chronic, recurrent disease, marked by epidermal proliferation.
  • Its lesions, which appear as a erythematous papules and plaques covered with silver scales.
  • This disorder commonly affects young adults, it may strike at any age, including during infancy.
  • It is characterized by recurring partial remissions and exacerbations. Flare ups are commonly related to specific systemic and environmental factors but may be unpredictable; they can usually controlled by therapy.
Risk Factors
  • Incidence is highest among whites.
  • Hereditary
Etiology
  • The tendency to develop psoriasis is genetically determined. Researchers have discovered a significantly higher than normal incidence of certain human leukocyte antigens (HLA) in families with psoriasis, suggesting a possible immune disorder. Onset of the disease is also influenced by environmental factors.
  • Trauma can trigger the isomorphic effect or Koebner’s phenomenon, in which lesions develop at sites of injury. Infections, especially those resulting from beta-hemolytic streptococci,may cause a flare up of guttate (drop shaped) lesions. Other contributing factors include pregnancy, endocrine changes, climate (cold weather tends to exacerbate psoriasis), and emotional stress.
  • Generally, the skin cells takes 14 days to move from the basal layer to the stratum corneum, where after 14 days of normal wear and tear, it’s sloughed off. The life cycle of normal skin cell is 28 days, compared to only 4 days for a psoriatic skin cell. This markedly shortened cycle doesn’t allow time for the cell to mature. Consequently, the stratum corneum becomes thick and flaky, producing the cardinal manifestations of psoriasis.
image by : http://guttatepsoriasistreatment.org/

image by : http://guttatepsoriasistreatment.org/

Assessment/Clinical Manifestations/Signs and Symptoms
  • Lesions appear red, raised patches of skin covered with silvery scales
  • Patches are dry and may or may not itch
  • Nail pitting, discoloration, crumbling beneath the free edges and separation of the nail plate
  • Pruritus and pain
  • Possibly arthritic symptoms (e.g. joint stiffness)
Medical Management

Goal of management are to slow the rapid turnover of epidermis and to promote resolution of the psoriatic lesions. There is no known cure. The therapeutic approach should be understandable, cosmetically acceptable and not too disruptive of lifestyle.

Topical therapy
  • Topical treatment is used to slow the overactive epidermis without affecting other tissues
  • Medications include tar preparations and anthralin, salicylic acid, and corticosteroids. Medications may be in the form of lotions, ointments, pastes, creams and shampoos.
Intralesional therapy
  • Intralesional injections of traimcinolone acetonide (Aristocort, Kenalog-10, Trymex)
Systemic therapy
  • Systemic cytotoxic preparations (methotrexate) may be used in treating unresponsive psoriasis. Other systemic  medications in use include hydroxyurea (Hdydrea0 and cyclosporine A (CyA)
  • Laboratory studies are monitored to ensure that hepatic, hematopoietic, and renal systems are functioning adequately
  • Patient should avoid drinking alcohol while taking methotrexate (increases possibility of liver damage)
  • Oral retinoids (synthetic derivatives of vitamin A and vitamin A acid), etretinate ma be prescribed
Photochemotherapy
  • Psoralens and ultraviolet A (PUVA) therapy may be used for severely debilitating psoriasis
  • Photochemotherapy is associated with long-term risks of skin cancer, cataracts and premature aging of the skin
  • Ultraviolet B (UVB) light therapy may be used to treat generalized plaque and may be combined with topical coal tar.
Nursing Diagnosis
  • Deficient knowledge of disease and its treatment
  • Impaired skin integrity related to lesions and inflammatory response
  • Disturbed body image related to embarrassment over appearance and self-perception of uncleanliness
Nursing Management
  1. Administer prescribed medications, which may include coal tar therapy, and topical corticosteroids.
  2. Discuss and assist with the administration of additional medical treatments, which may include coal tar shampoos, intralesional therapy (i.e. injection of medication directly into lesion), systemic cytotoxic medication, photochemotherapoy, occlusive dressing.
  3. Enhance skin integrity
  4. Prevent infection.
  5. Provide client and family teaching.
    • Advise the client receiving systemic cytotoxic (e.g. methotrexate) therapy, which inhibits deoxyribonucleic acid synthesis in epidermal cells to speed the replacement of psoriatic cells, to continue taking the medication even if nausea and vomiting occur, to increase fluid intake to prevent nephrotoxicity, and to avoid alcoholic beverages.
    • Instruct the client to avoid sun exposure during photochemotherapy. This regimen of phototherapy with ultraviolet A (PUVA) light decreases cellular proliferation. PUVA therapy results in photosensitivity and the client should avoid exposure to sunlight during this time.
    • Be knowledgeable about treatment, and give the client written instructions.
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