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Understanding psoriasis and the treatment options

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VOL: 102, ISSUE: 26, PAGE NO: 47

Jane Freak, RGN, is clinical nurse specialist in skin cancer prevention, Wessex Cancer Trust MARC's Line, Dermatology, Salisbury District Hospital

Freak, J. (2006) Understanding psoriasis and the treatment options. Nursing Times; 102: 26, 47, 49

Psoriasis is a genetically determined, inflammatory and hyperproliferative skin disease. MacKie (2001) describes it...

Psoriasis is a genetically determined, inflammatory and hyperproliferative skin disease. MacKie (2001) describes it as a chronic relapsing and remitting scaling skin disease that may appear at any age and affect any part of the skin surface. Males and females are equally affected.

Psoriasis can present at any age but it is most common in adults. It often occurs between the ages of 15 and 25 years (Ashton and Leppard, 2005).

Precipitating factors

Both inherited and environmental factors influence the development of psoriasis. A child has a one in four chance of inheriting the condition if one parent is affected, and a three in five chance if both parents are affected (Riddoch, 2005). Although a very wide range of biochemical and pathological abnormalities have been reported, the exact cause of psoriasis and why it develops is not known (MacKie, 2001).

There are a number of risk factors for psoriasis, and these are shown in Box 1.

Signs and symptoms

A number of different clinical patterns of psoriasis have been identified. In some patients the scaly skin can itch, and painful splits may form in it. Some patients (5-10%) also have painful joints owing to an associated psoriatic arthropathy that commonly affects the fingers and toes.

Classic plaque psoriasis: This is the most common pattern of psoriasis. Characteristically, the lesions are symmetrical, affecting the elbows, knees, sacral area and lower legs, although any part of the skin can be involved, including the scalp and nails (Ashton and Leppard, 2005). The lesions are single or multiple red plaques (patches) of psoriasis, varying from a few millimetres to several centimetres in diameter, with a scaly surface. If the scale is scraped very gently, it reflects the light, giving a 'silvery' effect.

A small number of patients will have joint involvement as well (psoriatic arthropathy). The severity of the psoriasis arthropathy is often unrelated to the extent of the skin disease (Ashton and Leppard, 2005).

Guttate psoriasis: This is an acute form of psoriasis that appears suddenly 10-14 days after a streptococcal sore throat and is usually seen in children or young adults. The individual lesions look like those of psoriasis but they are all uniformly small (0.5-1.0cm in diameter). The rash may be widespread, but it spontaneously resolves after two to three months. Oral antibiotics may improve or even clear the psoriasis.

Scalp psoriasis: Psoriasis of the scalp is common (Ashton and Leppard, 2005) and is sometimes the only part of the body affected. It is characterised by thick, obvious scaling and redness, often most obvious at the hairline and behind the ears (MacKie, 2001). Lesions vary from one or two plaques to a sheet of thick scale covering the whole scalp surface. Rarely, the scale becomes very thick and attaches itself in large chunks to bundles of hair, and temporary hair loss may occur.

Nail psoriasis: Nail abnormalities are found in about half of people with psoriasis and are important diagnostic clues if skin lesions are few or atypical. Nail changes are usually present in arthropathic psoriasis.

Flexural psoriasis: Sometimes, psoriasis affects only the areas of the body known as the flexures: the groins, axillae (armpits) and, in women, the area below the breasts.

Generalised pustular psoriasis: This is a rare, acute, serious and unstable form of psoriasis and is often precipitated by withdrawal of systemic or very potent topical steroids. Pustular psoriasis: This is characterised by sterile yellow pustules, which are an obvious clinical feature on the palms of the hands and the soles of the feet (MacKie, 2001). These lesions do not respond well to treatment.

Erythrodermic psoriasis: In this form of psoriasis more than 90% of patients' body surface is red and scaly (Ashton and Leppard, 2005).

Grossly increased blood flow through the skin may lead to loss of thermo-regulation and to high output cardiac failure. The patient is unwell with pyrexia and tachycardia (Patient UK: www.patient.co.uk/showdoc).

Management

The goal of treatment is to reduce the epidermal proliferation and the underlying dermal inflammation. Other goals are to: l Improve the patient's quality of life;

- Achieve longer-term remissions and disease control;

- Reduce individual drug toxicity;

- Evaluate individual treatments and monitor cost-effectiveness.

Historically, topical preparations have been the first line of treatment for mild psoriasis. Topical therapy properly applied will control most psoriatic lesions.

Some patients will require more potent systemic therapy (MacKie, 2001). Phototherapy and photochemotherapy of ultraviolet radiation are also effective treatments (Riddoch, 2005) (Box 2).

Emollients and moisturisers are an essential part of treatment although they will not control psoriasis on their own. They help to moisturise dry and scaly skin, reduce itching and help with the absorption of topical agents.

Efalizumab and etanercept are two new treatments licensed for use in psoriasis. However, they are currently used only for patients with very severe psoriasis who are unable to take one of the standard treatments or who have failed to respond to them (www.nice.org.uk).

Topical preparations of tar and salicylic acid, coconut oil and tar ointment, vitamin D analogues and more potent topical steroids are often helpful for scalp psoriasis.

There are no effective topical treatments available for nail psoriasis. A local injection of a corticosteroid, such as triamcinolone acetonide (10mg/ml), may be given around the nail matrix and nail bed, although repeated treatments are necessary and obviously painful. These injections should be performed only by those experienced with the technique so as to reduce the risk of atrophy.

Conclusion

It is the responsibility of all healthcare professionals to improve their knowledge of the psychological effects of psoriasis and the inconvenience caused by treatments. By doing so they will be able to alleviate many of their patients' problems. They can also act as supporters, enabling patients to cope with a debilitating condition, so improving their quality of life (Cloote, 2000).

USEFUL WEBSITE

British Association of Dermatologists: www.bad.org.uk

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