c Mohd Fauzi Hamdan

2009453476
c Siti Rohaida bt Mohamed
2009248776
NRS 427- c Erlisha Wendy Likimas
FUNDAMENTAL 2009614498
SURGICAL NURSING
c Nurul Syakila bt Naziron
GROUP 6
2009607266
INFLAMMATORY SKIN c Nur Aida Jahari
DISORDER
2008403214
PSORIASIS
INTRODUCTION
c Psoriasis is a medical condition that occurs when skin
cells grow too quickly
c It is non-contagious common skin condition
c Rapid skin cell reproduction resulting in red, dry
patches of thickened skin
c Psoriasis is a medical condition that occurs when skin
cells grow too quickly
c It is non-contagious common skin condition
c Rapid skin cell reproduction resulting in red, dry
patches of thickened skin
TYPES OF PSORIASIS
&
CHARACTERISTIC
There are five types of psoriasis:
V Plaque
V Guttate
V Pustular
V Inverse
V Erythrodermic
v
v
 

 
 

c Plaque psoriasis is most typically characterized by

circular-to-oval red plaques distributed over extensor
body surfaces and the scalp

c The plaques usually exhibit scaling as a result of

epidermal hyperproliferation and dermal inflammation
v
v
 

 
 

c May also evolve into more severe disease, such as pustular

or erythrodermic psoriasis
c Also called psoriasis vulgaris
c Plaque psoriasis causes patches of thick, scaly skin that may
be white, silvery, or red
 Ä


 

c The word guttate is from the Latin word meaning "drop." This form
of psoriasis appears as small, red, individual spots on the skin

c Common in childhood or young adulthood

c Guttate lesions usually appear on the trunk and limbs. These spots
are not usually as thick as plaque lesions.
 Ä


 

c A variety of conditions can bring on an attack of guttate

psoriasis, including upper respiratory infections, streptococcal
throat infections (strep throat), tonsillitis, stress, injury to the
skin and the administration of certain drugs including
antimalarials and beta-blockers
 v

 

c Primarily seen in adults, pustular psoriasis is characterized by

white or yellowish blisters of noninfectious pus (consisting of
white blood cells) surrounded by red skin

c It begins with the reddening of the skin followed by formation

of pustules and scaling
 v

 

c May be triggered by internal medications, irritating topical

agents, overexposure to UV light, pregnancy, systemic
steroids, infections, stress and sudden withdrawal of systemic
medications or potent topical steroids
 4 
 

c Inverse psoriasis is found in the armpits, groin, under

the breasts, and in other skin folds around the genitals
and the buttocks
c This type of psoriasis appears as bright-red lesions
that are smooth and shiny
 4 
 

c Inverse psoriasis is subject to irritation from rubbing

and sweating because of its location in skin folds and
tender areas. It can be more troublesome in
overweight people and those with deep skin folds



 

c Psoriasis is a particularly inflammatory form of psoriasis that affects most

of the body surface

c It is characterized by periodic, widespread, fiery redness of the skin and the

shedding of scales in sheets, rather than smaller flakes

c The reddening and shedding of the skin are often accompanied by severe
itching and pain, heart rate increase, and fluctuating body temperature



 

c Erythrodermic psoriasis causes protein and fluid loss that can lead to severe
illness. The condition may also bring on infection, pneumonia and
congestive heart failure

c Known triggers of erythrodermic psoriasis include the abrupt withdrawal of

a systemic psoriasis treatment including cortisone; allergic reaction to a
drug resulting in the Koebner response severe sunburns; infection; and
medications such as lithium, anti-malarial drugs; and strong coal tar
products
RISK FACTOR
c Triggers can include:

V Genetic

c strong genetic component to psoriasis

V Emotional stress

c Stress can cause psoriasis to flare for the first time or aggravate existing
psoriasis

V Injury to the skin

V some types of infection

c upper respiratory infections, streptococcal throat infections (strep throat),

tonsillitis
V Reactions to certain drugs

c Certain medications, like antimalarial drugs, lithium and certain beta-blockers, are also known to
cause psoriasis flares

V Age

c The first peak occurs in persons aged 16-22 years, and the second occurs in persons aged 57-60
years

V Environmenet

c cold, dry climates are at much greater risk of developing psoriasis

c warm, humid weather helps to heal psoriasis symptoms.

V Diet

V Allergies
PATHOPHYSIOLOGY
c Psoriasis is fundamentally an inflammatory skin condition with reactive abnormal
epidermal differentiation and hyperproliferation

c Shorther skin cell cycle growth

V Keratinocytes migrate to stratum corneum in 4-7 days (normal: 14 days) ±

condition called hyperkeratosis

V Immature cells produce an abnormal keratin that form thick, flaky scale at skin
surface

V Rapid cell metabolism stimulates increase vascularity that contribute to

erythema of lession
c The inflammatory mechanisms are immune based and most
likely initiated and maintained primarily by T cells in the
dermis and interleukin (IL)

c Signals triggers an immune response, leading to T-cell

activation and the release of cytokines
c Cytokines will cause:

V Local effects of cytokines such as tumor necrosis factor lead to the

inflammation,

V Raises cell-mediated immune responses

V Undergoes epidermal hyperproliferation observed in persons with

psoriasis
c An interleukin (IL- IL-23)

V Recognized for its involvement in the establishment of chronic

inflammation and in the development of a T helper (Th)±cell subset
producing IL-17, designated Th17.

V Th17 cells are now recognized as a third T-effector cell subset, and the
IL-23/IL-17 pathway has been implicated in the induction and
progression of a number of inflammatory diseases, including psoriasis
MEDICAL TREATMENT
c Psoriasis treatments fall into 3 categories:
1) Topical (applied to the skin) ± Mild to moderate psoriasis
2) Phototherapy (light, usually ultraviolet, applied to the skin)
± Moderate to severe psoriasis
3) Systemic (taken orally or by injection or infusion) ±
Moderate, severe or disabling psoriasis
TOPICAL AGENT
c Topical (skin applied) medications :

V  
  


  

c very useful and often the first-line treatment for limited or small
areas of psoriasis

V  
 

 


 

c may be used in combination with topical steroids for better results

V    


c concentrations of salicylic acid, lactic acid, urea, and glycolic acid

may be helpful in psoriasis.

c These help moisten and lessen the appearance of thickened psoriasis

V 



c coal tar may help reduce the appearance and decrease the flakes in
psoriasis
LIGHT THERAPY
c PUVA (Psoralen and Ultraviolet A Radiation)
V special treatment using a photosensitizing drug and timed artificial-light
exposure
V the photosensitizing drug in PUVA is called psoralen
V administered in a physician's office two to three times per week
V psoralen, taken internally, acts as a skin sensitizer. The "sensitized" skin
affected by psoriasis can then be treated by ultraviolet A radiation
V UVB Treatment
c UVB phototherapy is an artificial light treatment using a special
wavelength of light
c It is frequently given daily or two to three times per week
c UVB is also a component of natural sunlight
c UVB dosage is based on time and exposure is gradually increased
by 15-60 seconds per treatment or per week
SYSTEMIC MEDICATION
c Oral medications include:

V ï 

c oral drug used for certain types of psoriasis.

c it may be used in males and females who are not pregnant and not
planning to become pregnant for at least three years

c major side effects include dryness of skin and eyes and temporarily
elevated levels of triglycerides and cholesterol (fatty substance) in the
blood
V K  

c potent immunosuppressive drug

c used for severe, difficult-to-treat cases of widespread psoriasis

c potential cumulative toxicity (not be used for more than one to two

years)

c major possible side effects include kidney and blood-pressure

problems.
V 


c Drug used for rheumatoid arthritis and, in high doses, for

cancer treatment
c Is usually given in small weekly doses (5 mg-15 mg)

c Blood tests are required before and during therapy

c The drug may cause liver damage in some patients

c Injection and infusion medication:

V Currently, the four main classes of biologic drugs for

psoriasis are:

1. TNF-alpha blockers (tumor necrosis factor)-Enbrel

(etanercept), Remicade (infliximab) and Humira (adalimumab)

2.drugs that block T-cell activation and the movement of

T-cells-Raptiva (efalizumab)
 3. drugs that decrease the number of activated T-cells-
Amevive (alefacept)

4. drugs that interfere with interleukin chemical

messengers of inflammation-Ustekinumab
NURSING CARE
 Impaired Skin Integrity

c Psoriatic skin lesion increase risk of infection, that delay

healing process
c Certain treatment (UVA and UVB) may cause erythematic
or peeling of skin and altered skin integrity
°

 
 °
    
    
  

Impaired skin Client will get Goal met. Client

integrity related smoother skin 1. Encourage client 1. To promote achieved
to take bath ʹ if
to immunology with control of client is
skin recovery smoother skin and
deficit lesions immobilize, 2. To reduce control of lesions
(psoriasis), nurse can risk for
lesions and perform bed infection and
bath ʹ do not
inflammatory chemical agent maintain
response 2. Use sterile hygiene
materials such as
sterile linen,
blanket, pillow
case and clothes
°

 
 °
    
    
  

Impaired skin Client will get 3. Administer 3.To remove Goal met. Client
integrity related smoother skin daily soaks scales. achieved
to immunology with control of and tepid, smoother skin and
deficit lesions wet control of lesions
(psoriasis), compresses
lesions and to the
inflammatory affected
response areas
°

 
 °
    
    
  

4.Encourage 4. To prevent
client to psoriasis
prevent the getting
skin from worsen Goal met. Client
Impaired skin Client will get drying out achieved
integrity related smoother skin smoother skin and
to immunology with control of 5.Inform patient 5. To avoid from control of lesions
deficit lesions that water burn of the
(psoriasis), should not skin
lesions and be too hot
inflammatory and skin
response should be
dried by
patting with
a towel
°

 
 °
    
    
  

6. Teach patient 6. To promote Goal met. Client

Impaired skin Client will get to use bath smooth skin achieved
integrity related smoother skin oil or and prevent smoother skin and
to immunology with control of emollient dryness control of lesions
deficit lesions cleansing
(psoriasis), agent for
lesions and sore and
inflammatory scaling skin.
response
 Disturbance of Body Image

c Chronic skin lesions of psoriasis cause permanent

skin rashes that can disturb client body image
°

 
 °
    
    
  

1. Give moral 1. To increase

support related Client self-
to self-esteem esteem
and how to
accept physical
appearance
þisturbances Client͛s will 2. Provide privacy Goal met. Client
of body accept his body to client accepted his body
image related image changing 3. Educate family 2. To avoid low image changing
to skin to give moral self-esteem
disorder support to of client
client 3. To increase
4. Advice client to Client self-
wear long esteem
sleeves. 4. To cover the
infected area
 Knowledge Deficit

c Client knowledge related to preventive measures,

treatment and medication available is less related to
psoriasis
°
 
 
 °
    
   
  

1. Assess client͛s 1. To plan the

knowledge further
level. interventions Goal met. Client͛s
Ènowledge Client͛s - facial knowledge level
deficit related to knowledge and expression increased.
complexity of understanding - Complaint
treatment. about the
treatment will be 2. Provide 2. To make
increased. physical client more
comfort and concentrate
quite on what is
atmosphere to being
client. discussed.
°
 
 
 °
    
   
  

3. To improve
3. Educate client client͛s
and relative knowledge
continuously 4. This is Goal met. Client͛s
Ènowledge Client͛s about the burn especially knowledge level
deficit related to knowledge and injury if they important increased.
complexity of understanding do not really when
treatment. about the understand. providing
treatment will be education to
increased. 4. Provide an patients with
atmosphere of different
respect, values and
openness, beliefs about
trust, and health and
collaboration. illness.
°
 
 
 °
    
   
  
5. Teach the 5.To make sure
client and the client can
relatives perform
about skin care wound care
when the
client returns
to her/his
home.
6. Encourage the 6. To prevent
client to infection and
maintain enhance
Ènowledge Client͛s hygienic level. wound healing Goal met. Client͛s
deficit related to knowledge and process. knowledge level
complexity of understanding increased.
treatment. about the 7. Provide 7. To give clear
treatment will be therapeutic and better
increased. communication understanding
with the client. about the
Eg:Using visual disease and
aid. treatment.
°
 
 
 °
    
   
  

Goal met. Client͛s

Ènowledge Client͛s 8. Introduce 8. To share the knowledge level
deficit related to knowledge and client to the experience, increased.
complexity of understanding other client with knowledge and
treatment. about the the same feeling.
treatment will be disease.
increased.
9. Reevaluate 9. To determine
client͛s level of the effectiveness
knowledge. of nursing
intervention that
have been done
 Risk for Infection

c The psoriasis may cause lesions or decrease skin

turgor

c So the open skin may expose to external environment

and high risk to get infection
°
 
 
 °
    
   
  
1. Asses the 1. To plan
appearance further
of the lesions intervention
such as its
location,
frequency,
level of
itching and
manifestation
s
2. Teach client 2. To prevent Goal met. Client
Risk for infection Client will not how to the infection not expose to
related to open expose to prevent from infection
lesions infection infection by spreading
proper hand
washing and
not
scratching
the lesions
3. Èeep the skin 3. to minimize
lubricated itching
°
 
 
 °
    
   
  

Risk for infection Client will not 4. Occlusive 4. To prevent Goal met. Client
related to open expose to dressing may and control not expose to
lesions infection be applied the lesions infection
following from getting
application of bigger
corticosteroid
to increase its
effectiveness
COMPLICATION
c Changes from mild psoriasis to severe psoriasis
c Side effect of treatment or medication
V Light therapy- Common side effects with PUVA and UVB include
burning, tanning of the skin, potential skin damage, increased brown
spots called lentigines, and possible increased risk of skin cancer,
including melanoma
V Cyclosporineð Effects include kidney and blood-pressure problems
V Acitretin- Elevated levels of triglycerides and cholesterol (fatty
substance) in the blood
c Thickened skin and bacterial skin infections caused by scratching in an
attempt to relieve severe itching
c Fluid and electrolyte imbalance in the case of severe pustular psoriasis
c Low self-esteem
c Depression
c Stress
c Anxiety
c Social isolation
c psoriatic arthritis can cause erosion in joints
c Impaired Temperature Regulation.

V Erythrodermic psoriasis (in which psoriasis covers the

entire skin) can cause abnormalities in the body's ability to
regulate temperature.
c wumbusch Psoriasis
V A combination of erythrodermic and pustular psoriasis
causes a serious condition called wumbusch psoriasis:
c The condition can develop abruptly.
c Symptoms may include fever, chills, weight loss, and
muscle weakness.
c Patients may develop excessive fluid build-up, protein
loss, and electrolyte imbalances
HEALTH TEACHING
c Self Care:

V Use anti-bacterial cleaner

c to inhibit microorganisms growth

V Keep the skin moist and lubricated

c to prevent skin dryness

V Try to avoid scratching and picking skin and skin injuries (cuts or scrapes)

c an injury to the skin can cause psoriasis patches to form anywhere on the
body, including the site of the injury. This includes injuries to your nails or
nearby skin while trimming your nails.
c

c Avoid infection such as strep throat

c may cause psoriasis to appear suddenly (called guttate

psoriasis), especially in children.

V Try to avoid medications such as beta-blockers and lithium

c to avoid worsen psoriasis symptoms

c Lifesytle:
V Try to avoid stress and anxiety.
c stress can cause psoriasis to appear suddenly (flare) or can make
symptoms worse
V Limit alcohol consume
c which can help control psoriasis, especially for men.
V Don't smoke smoking
c make you more likely to get psoriasis and may make it more
severe.
c Environmental control
V Try to avoid cold, dry climates
V Try to avoid pollutant area
V Try to avoid crowded area
V Avoid exposure to contagious illness such as
influenza
 h