Name the most common triggers for psoriasis and explain the different clinical types.
Psoriasis is a skin disease (chronic inflammatory dermatosis); that causes red, itchy scaly patches, most commonly on the knees, elbows, trunk and scalp. The most common triggers for the disorder include exposure to smoke, emotional stress, excess alcohol consumption, trauma, injury to the skin, extreme weather conditions such as cold or dry conditions, and infections of the throat of the skin. Certain medications can also influence as for example lithium, high blood pressure medications, antimalarial drugs, and rapid withdrawal of oral or systemic corticosteroids (Dogra, & Kamat, 2019).
According to Amatore et al., (2019), there are several types of psoriasis, including:
- Plaque psoriasis: The most common form, plaque psoriasis causes dry, raised, red skin patches (lesions) covered with silvery scales. The plaques might be itchy or tender, and may be few or many. They usually appear on elbows, knees, lower back and scalp.
- Nail psoriasis: Psoriasis can affect fingernails and toenails, causing pitting, abnormal nail growth and discoloration. Psoriatic nails might loosen and separate from the nail bed (onycholysis). Severe cases may cause the nail to crumble.
- Guttate psoriasis: This type primarily affects young adults and children. It’s usually triggered by a bacterial infection such as strep throat. It’s marked by small, drop-shaped, scaling lesions on the trunk, arms or legs.
- Inverse psoriasis: This mainly affects the skin folds of the groin, buttocks and breasts. Inverse psoriasis causes smooth patches of red skin that worsen with friction and sweating. Fungal infections may trigger this type of psoriasis.
- Pustular psoriasis: This rare form of psoriasis causes clearly defined pus-filled lesions that occur in widespread patches (generalized pustular psoriasis) or in smaller areas on the palms of the hands or the soles of the feet.
- Erythrodermic psoriasis: The least common type of psoriasis, erythrodermic psoriasis can cover your entire body with a red, peeling rash that can itch or burn intensely.
- Psoriatic arthritis: Psoriatic arthritis causes swollen, painful joints that are typical of arthritis. Sometimes the joint symptoms are the first or only symptom or sign of psoriasis. And at times only nail changes are seen. Symptoms range from mild to severe, and psoriatic arthritis can affect any joint. It can cause stiffness and progressive joint damage that in the most serious cases may lead to permanent joint damage.
There are several types of treatments for psoriasis, explain the different types and indicate which would be the most appropriate approach to treat this relapse episode for K.B. Also include non-pharmacological options and recommendations.
The primary aim of psoriasis treatments is to stop the abnormal growth of the skin cells and remove the scales. According to Amatore et al., (2019), the most common types of psoriasis treatment include:
- Topical medicines are treatments applied directly to your skin. Creams and ointments are examples of topical medicines. Topical treatments are usually one of the first medicines people try after they are diagnosed with plaque psoriasis.
- Phototherapy is also called light therapy. With phototherapy, areas of skin affected by plaque psoriasis are repeatedly exposed to ultraviolet (UV) light. Phototherapy is usually given in a dermatologist’s office or psoriasis clinic.
- Oral treatments: Oral medications are also called systemic treatments because they work throughout the body to fight plaque psoriasis.
- Some biologics called TNF-alpha inhibitors block the TNF-alpha molecule that triggers inflammation in your body. In plaque psoriasis, too much TNF-alpha is produced in the skin. This leads to the rapid growth of skin cells. Biologics that block TNF-alpha help stop the inflammation in psoriasis.
Treatment goals have been agreed to decide when and how to progress along treatment algorithms. Treatment goals are based on a selected list of outcome measures that consider not only the severity of skin symptoms but also the impact of disease on the quality of life. Generally, the choice of the right treatment option depends on the severity of the disorder and the patient’s response to previous medication (Amatore et al., 2019). Based on the case study, the most appropriate medication for K.B include calcineurin inhibitors which are useful in stopping inflammation responsible for the formation of lesions and salicylic acid to remove dead skin cells and scaly skin.
The association between psoriasis severity and metabolic comorbidities, anxiety, depression, smoking, and alcohol abuse has been confirmed in several studies. Despite these strong associations, limited data is available on the impact of non-pharmacological interventions on psoriasis. It has been recommended that blood pressure, body mass index, waist circumference, smoking, alcohol consumption serum lipids, and fasting glucose should be regularly assessed in patients with psoriasis, particularly in those with the more severe form.
The importance of knowing current medications for the patient
Preventing harm from medications, or adverse drug events (ADEs), remains a top patient safety priority not only in hospitals but also across the continuum of care for patients. Medication reconciliation is the process of creating the most accurate possible list of all medications a patient is taking; including drug name, dosage, frequency, and route.
Though healthcare professionals choose treatments based on the type of psoriasis, the part of the skin affected, and the severity of the disorder. Drugs carry specific, potential side effects, and patients must be thoroughly screened to assess whether they are appropriate candidates for a medications therapy. Before the treatment is started for the patient, it is essential to know previous medications and allergies to avoid remissions of the disorder, avoid side effects, toxicosis, and interactions with other drugs.
Example of, why medication reconciliation is important; is the fact that the long-term use of conventional systemic treatments in psoriasis is limited mostly by poor tolerability and cumulative toxicity including liver toxicity from methotrexate, renal toxicity from cyclosporine, and skin carcinogenesis from phototherapy, particularly psoralen plus ultraviolet A (PUVA) (Dogra, & Kamat, 2019).
Other manifestations for psoriasis
Other essential clinical manifestations for psoriasis include:
- burning sensation.
- cracked skin that may ooze.
- Red patches of skin covered with thick, silvery scales.
- Small scaling spots (commonly seen in children).
- Dry, cracked skin that may bleed or itch.
- Itching, burning or soreness.
- Thickened, pitted or ridged nails.
- Swollen and stiff joints.
Psoriasis patches can range from a few spots of dandruff-like scaling to major eruptions that cover large areas. The most commonly affected areas are the lower back, elbows, knees, legs, soles of the feet, scalp, face and palms. Most types of psoriasis go through cycles, flaring for a few weeks or months, then subsiding for a time or even going into remission (Dogra, & Kamat, 2019).
Eye diagnosis for C.J
Based on the case study, C.J presents various signs and symptoms associated with eye problems, including crusty and yellowish discharge from his eyes, blurred vision in the morning, throbbing pain on the left hear, and bilateral conjunctival erythema. Considering these clinical manifestations, C.J seems to be experiencing Conjunctivitis and Conjunctivitis-Otitis Syndrome. This diagnosis is because approximate 25% of patients with conjunctivitis have a concurrent otitis media, due to the proximity and communication trough nasal cavity. On typeable H. influenzae is the most common recovered bacterial in these cases. Identical pathogens are seen in the middle ear effusion and the purulent conjunctival discharge (Schellack et al., 2020).
The probable etiology of the eye affection presented
Conjunctivitis is the most prevalent etiology of eye redness and discharge. While there are many types of conjunctivitis, viral, allergic and bacterial are the three most common. Infectious conjunctivitis that can result from bacteria, viruses, fungi, and parasites. However, 80% of acute cases of conjunctivitis are viral, the most common pathogen being Adenovirus. Adenoviruses are responsible for 65 to 90% of cases of viral conjunctivitis; while Bacterial conjunctivitis is far more common in children than adults, and the pathogens responsible for bacterial conjunctivitis vary depending on the age group (Schellack et al., 2020). Staphylococcal species, specifically Staphylococcal aureus, followed by Streptococcus pneumoniae and Haemophilus influenzae are the most common cause in adults. We need to take into account that history and physical examination are essential in the diagnosis of conjunctivitis, and in determining the cause, likewise the treatment of the condition. The classic findings of the three most common types of conjunctivitis can be found below:
- Bacterial: symptoms of redness and foreign body sensation, morning matting of the eyes, white-yellow purulent or mucopurulent discharge, conjunctival papillae, infrequently preauricular lymphadenopathy.
- Viral: symptoms of itching and tearing, history of recent upper respiratory tract infection, watery discharge, inferior palpebral conjunctival follicles, tender preauricular lymphadenopathy.
- Allergic: symptoms of itching or burning, history of allergies/atopy, watery discharge, edematous eyelids, conjunctival papillae, no preauricular lymphadenopathy.
The patient age and the fact of no referring any STD or previous flu symptoms; together with the relationship between conjunctivitis and otitis media (Conjunctivitis-Otitis Syndrome); lead us to the most common etiology of the Haemophilus influenzae non-type B.
The best therapeutic approach to C.J problem
Antibiotics are used to treat people with serious H. influenzae non-type B infections. No treatment is needed for carriers, or people who have H. influenzae non-type B in their bodies but who don’t become sick. As general indication patients should do the following:
- Use hand sanitizer and/or wash their hands thoroughly after touching their eyes or nasal secretions
- Avoid touching the non-infected eye after touching the infected eye
- Avoid sharing towels or pillows
- Avoid swimming in pools
Since the patient is suffering from Conjunctivitis-Otitis Syndrome, the best treatment approach would be topical antibiotics such as tobramycin, chloramphenicol, trimethoprim, or fluoroquinolone at a frequency of four times in a day for a period of five to seven days and a systemic treatment should be added like, high dose (80 to 90 mg per kg per day), if the patient has no allergy to penicillin; because antibiotics used should cover beta-lactamase producing organisms (Schellack et al., 2020).
Amatore, F., Villani, A. P., Tauber, M., Viguier, M., Guillot, B., & Psoriasis Research Group of the French Society of Dermatology (Groupe de Recherche sur le Psoriasis de la Société Française de Dermatologie). (2019). French guidelines on the use of systemic treatments for moderate‐to‐severe psoriasis in adults. Journal of the European Academy of Dermatology and Venereology, 33(3), 464-483.
Dogra, S., & Kamat, D. (2019). Drug-induced psoriasis. Indian Journal of Rheumatology, 14(5), 37.
Schellack, N., Shirindza, N., & Mokoena, T. (2020). An overview of allergic and bacterial conjunctivitis. South African General Practitioner, 1(1), 14-22.