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Psoriasis (inherited autoimmune disorder)
T cells reproduce uncontrollably and travel to surface of skin -> inflammation and build up of cells
Inflammation with psoriasis causes
Skin cells to form faster than they are shed (thickened layer of the skin cells)
Clinical manifestations of psoriasis depend on
The type of psoriasis
Most common type of psoriasis
Plaque psoriasis
Clinical manifestations of plaque psoriasis
Red raised plaques covered by silvery scales
Plaque psoriasis is common on
Traumatized areas like the elbows and knees
The silvery scales with plaque psoriasis are
The shedding of skin cells
Guttate psoriasis causes
Droplet like lesions on the trunk
Guttate Psoriasis may be triggered by
Strep infection
Nail psoriasis clinical manifestations
Pitting, deformed nails, separation, yellow-brown discoloration
Due to psoriasis being a systemic disease and not just a skin disease, what could occur?
Psoriatic arthritis
Psoriatic arthritis
Joint, stiffness, pain, edema
Palmoplantar psoriasis
Can cause a lot of pain due to scaly skin that can crack on hands and feet
Primary Psoriasis treatment
Avoid triggers of psoriasis
What can be done to treat psoriasis
Avoid damage to skin from scratching, infection, medications (beta blockers, NSAIDs), stress, alcohol, smoking, winter months when skin is not exposed to sun
Should a patient with psoriasis take a cold, warm, or hot shower?
Warm but not hot because heat can make it worse
A patient with psoriasis should do what right after taking a shower?
Moisturize using a fragrance-free moisturizer
What prevents moisture loss?
Occlusive agents (petrolatum, mineral oil, cocoa butter, shortening)
What pulls moisture up from lower layers of skin?
Humectants (Glycerin, urea, and gelatin)
What do some moisturizer products do?
Combine agents of both of these categories, which could cause something to absorb well, but still feel greasy
With psoriasis, you should
Expose the affected area to sunlight but AVOID sunburn
Some topical agents that are used to treat psoriasis might also cause
Photosensitivity (skin is more sensitive to light)
Potential issues with photosensitivity and people with darker skin
May not be used to having problems with the sun, but do have problems now
With increased exposure to the sun
Higher risk of premature aging and skin cancer
Topicals for psoriasis may be
Covered with plastic wrap to increase absorption of the topical agent
Should you cover every topical agent with plastic wrap?
Only if recommended for that drug
Topical keratolytics
Peeling agents help soften and remove psoriasis scales, helping other medications penetrate plaques
Examples of topical keratolytics
Salicylic acid or urea
Topical corticosteroids for psoriasis
Anti-inflammatory
What kind of psoriasis are topical corticosteroids used for?
Mild to moderate Psoriasis
Topical corticosteroids may cause
thinning of the skin
Can you use topical corticosteroids on large areas?
No, because they have systemic absorption
Corticosteroids can also be injected into the cuticle for
Nail Psoriasis
Injection into cuticle is extremely
Uncomfortable
Topical retinoids are derivative of
Vitamin A (also used for acne)
Common side effect of topical retinoids
Dry skin
Topical retinoids increase
Photosensitivity so use of sunscreen is very important
Topical retinoids must be used on no more than
20% of the skin surface at one time (1% is palm-sized)
People may do what for being sure topical retinoids are applied to all needed areas?
Locations where the medication is applied are rotated through (only a thin layer)
Topical retinoids cannot be taken during pregnancy because
Could have teratogenic effects as oral retinoids caused birth defects in the past
Topical vitamin D3 derivatives have what restricted
Total amount used
Topical vitamin D3 derivatives may cause
Skin irritation initially
Topical vitamin D3 derivatives is used for
Scalp psoriasis, which is applied at bedtime and covered with a cap
Old treatment for psoriasis
Topical coal tar derivatives
Topical coal tar derivatives reduce
Scaling, itching, and inflammation
Topical coal tar derivatives may still be used for
Scalp psoriasis (leave on during shower, then shampoo)
Topical coal tar derivatives have a low compliance d/t
Staining and odor as well as discoloring light hair
Topical immunomodulators (TIMs)
Pimecrolimus and Tacrolimus (anti-inflammatory)
Medications for moderate to severe psoriasis
With widespread psoriasis, topicals are not as effective as it is a large area to apply a topical agent to
Actiretin
Oral retinoid derived from Vitamin D
Actiretin reduces
Multiplication of skin cells
Actiretin can not be used during pregnancy due to
Severe birth defects
Side effects of Actiretin
Dryness, alopecia, nausea, Increased Triglycerides
Cyclosporine po
Immunosuppressant
Cyclosporine po was originally used for
kidney transplant patients to decrease the risk of the kidney being rejected
Side effects of Cyclosporine po
Increased risk for infection, increased risk of cancer, and renal impairment
What is important to monitor with cyclosporin po?
Renal function
Methotrexate po
Cancer chemo drug (blocks cell division)
Methotrexate po suppresses
Plaque formation and the immune system (infection risk)
Why is methotrexate po used for psoriasis?
slowing down cell division.
What type of cancer is increased down the road with methotrexate po?
Lymphomas
Sulfasalazine po
Anti-inflammatory drug for Crohn's disease (but works well with psoriasis)
Opremilast po
Oral phosphodiesterase 4 (PDE4) inhibitor
Opremilast po is used for
Plaque and psoriatic arthritis
Side effects of Opremilast PO (systemic) (Most serious side effects)
N&V, diarrhea, weight loss, depression, and suicidal thoughts interact with certain medications
Biologics used for psoriasis are very
Expensive (often advertised on TV)
Biologics decrease
Inflammation
Biologics are given via
SubQ self injection
Biologics for psoriasis
Adalimumab, etanercept inhibit tumor necrosis factor 4 (TNF4)
More biologics for psoriasis
Usetekinumab, ixekizumab, risankizumab-rzaa inhibit interleukins
Biologics increase the risk of
Infection
What should you screen for prior to biologic treament?
TB
What else could become reactivated with biologics?
Hepatitis B
Can you get live virus vaccines with biologics?
NO, could have a systemic effect
Biologics increase risk of
Certain types of cancers
Light treatments for psoriasis?
UVB light treatments
What are more effective and less likely to cause skin cancer for psoriasis treatment?
Narrow band UVB treatments
What areas are covered with UVB light treatments?
Unaffected and sun sensitive areas (eyes, lips, genitalia)
UVB light used over UVA
UVB may be more effective and less likely to cause cancer compared to UVA
Psoralen and ultraviolet A (PUVA) treatments
Psoralen orally or as a soak sensitizes skin to Ultraviolet A light
PUVA treatments are administered in a
Whole body cabinet or hand treatment unit
With PUVA
Unaffected/ sensitive areas are covered and the patient wears UVA protective goggles
Psoralen oral affects
All the skin on the body
Psoralen soak would be good for a patient with
Palmoplantar psoriasis
PUVA cabinet
Fluorescent bulbs to treat the whole body all at once
With incorrect timing of PUVA cabinet
Person can get a huge skin reaction
Side effects of PUVA
Sunburn, nausea, skin aging, increase risk of skin cancer
Oral psoralen can make skin and eyes
more sensitive for 24 hours (wear sunglasses and keep skin covered
Laser treatment for psoriasis
Smaller areas can be targeted precisely
What could laser treatment be great for
Elbow or knee psoriasis