Audrey, age 28, is admitted to the hospital for surgery. The nurse who assesses her notes a large amount of psoriasis on her knees, elbows, arms, neck, and chest. When she asks about this, Audrey begins to cry. She says she has had psoriasis since elementary school, and treatments haven’t been effective. Her job in an automotive plant requires her to wear long sleeves, which help cover her source of embarrassment. Audrey believes people avoid her or turn away when she goes out in public. Lately, she has been avoiding public places. She states that sometimes she wishes she would die so she’d stop feeling the humiliation and shame of psoriasis.
The nurse listens quietly. After the examination, she gathers information from the websites of the National Psoriasis Foundation (www.psoriasis.org), Dermatology Nurses Association (www.dnanurse.org), and American Academy of Dermatology (www.aad.org). She contacts the hospital librarian for additional literature and visits the hospital’s dermatology office for pamphlets and brochures.
Later, after Audrey awakens from surgery, the nurse discusses alternative methods to control and reduce her psoriasis symptoms and the additional problems it can bring, such as psoriatic arthritis. With Audrey’s consent, she makes an appointment for her to see a dermatologist. Audrey smiles, explaining this is the first time anyone has really listened to her or taken the time to help her. She says she finally feels a sense of hope.
A chronic, T-cell mediated skin disease leading to cell proliferation, psoriasis affects nearly 2.2% of the world population. Approximately 250,000 new cases occur annually in the United States.
Psoriasis exists in five distinct types. Plaque psoriasis, the most common type, causes red, scaly, hardened, thick plaques with silver-white scales on the surface of the elbows, knees, scalp, sacral region, and groin. (See the box below.)
Five types of psoriasis
- Plaque psoriasis is the most prevalent type, affecting 8 of 10 psoriasis sufferers. It’s marked by raised, inflamed, red lesions covered with a silvery white scale.
- Guttate psoriasis tends to arise during childhood or young adulthood, appearing as small red spots on the trunk and limbs. Several triggers can cause it to come on suddenly.
- Inverse psoriasis appears as bright red, shiny lesions in the axilla, under the breasts, in skinfolds, and around the genitals and buttocks. Because of lesion locations, this form is more likely to be irritated by clothing and sweating.
- Pustular psoriasis is marked by noninfectious, pus-filled white blisters surrounded by red skin. Three types of pustular psoriasis exist, each affecting specific body areas. Palmoplantar pustulosis affects the palms and soles. Acropustulosis arises at the ends of the fingers and occasionally the toes. Von Zumbusch psoriasis may abruptly arise over the entire body, causing systemic effects such as fever, chills, dehydration, tachycardia, and muscle weakness.
- Erythrodermic psoriasis also affects much of the body and may be associated with von Zumbusch psoriasis. It’s characterized by fiery red skin and widespread shedding of scales. Patients experiencing erythrodermic or von Zumbusch pustular psoriasis should seek medical attention immediately.
Psoriasis causes pain, itching, tightness, and psychosocial distress; it’s not contagious. The exact cause—and cure—are unknown, but the disease may run in families. Researchers believe individuals may inherit certain genes that predispose them to psoriasis. Among that population, 2% to 3% have an immune response after exposure to a trigger that leads to development of the disorder. These triggers aren’t the same for everyone. Known triggers include stress, skin injury, and certain medications (such as lithium, antimalarials, propranolol, quinidine, and indomethacin). Many psoriasis patients believe allergies, diet, and the weather are triggers, although research hasn’t proven a link. Other possible contributing factors have been studied. (See the box below.)
A link between psoriasis and intestinal-wall permeability?
One study based on five cases found a possible link between psoriasis and structural abnormalities in intestinal-wall permeability. The authors suggest a permeable intestinal wall allows food particles and toxic substances normally too large to be absorbed to enter the circulation and initiate an immune response, resulting in psoriatic lesions. Additional research in this area is warranted.
Psoriasis exacts a high toll, both in economic costs and psychological and emotional distress. Like Audrey, many sufferers feel stress, embarrassment, rejection, depression, and shame. According to the National Psoriasis Foundation, almost 75% of patients say the disease has had a negative impact on their lives. Nearly 60% miss an average of 26 days a year from work and 20% have contemplated suicide.
What’s more, individuals with psoriasis are at increased risk of developing other chronic and serious health conditions, such as diabetes, cardiovascular disease, and obesity. The more severe the psoriasis, the higher the risk of one or more comorbidities. Effective psoriasis management may decrease the risk of comorbidities.
According to a survey by the National Psoriasis Foundation, about 30% of persons with psoriasis go untreated. For many sufferers, nurses are the first healthcare providers they see. Any discussion between the nurse and patient that encourages the patient to act is positive. As a nurse, you should seek to have such discussions with psoriasis sufferers to educate and support them and help improve treatment outcomes.
Psoriasis can affect the patient significantly in various ways, based on clinical severity and patient perceptions. Part of your role is to help patients find holistic ways to manage and cope with the disease. When performing the assessment, use a holistic approach and be sure to evaluate the patient’s quality of life.
Perform and document a detailed skin and overall health assessment, and obtain a family history. Ask about the patient’s diet, history of treatments (including failed treatments), use of dietary supplements, and perception of the disease. Assess for factors that increase the psoriasis risk, including the “trigger” medications discussed above, stress, infection, obesity, smoking, alcohol use, diabetes, folate and vitamin B12 deficiencies, and human immunodeficiency virus.
As appropriate, ask the patient to use the Koo-Menter Psoriasis Instrument for self-assessment. Results help identify the effect of psoriasis on quality of life and promote communication between patient and nurse.
Traditional psoriasis treatment involves topical, oral, and injectable medications, as well as phototherapy (ultraviolet B [UVB] therapy). Medications include acitretin, adalimumab, cyclosporine, etanercept, hydroxyurea, infliximab, and methotrexate. For patients taking these drugs, clinicians must monitor both patient response and treatment length, as long-term use can lead to serious infections and adverse effects (such as life-threatening lymphoma). With females of childbearing age, stress the importance of adhering to strict contraceptive methods when taking teratogenic drugs, such as acitretin; caution them to avoid conceiving within 3 years of discontinuing this drug.
The course of drug therapy may vary, and for many patients the cost can be exorbitant. What’s more, treatment costs continue to rise and have reached more than $3 billion annually. The need to curb rising costs and find effective treatments with reduced side effects has led to a search for alternative approaches. Many noninvasive and nonpharmacologic approaches exist, including helping patients develop effective coping strategies and urging them to make dietary and lifestyle changes that promote weight loss and decrease cardiovascular risk.
A proper diet is essential to promoting good health. In some psoriasis patients, certain foods can increase the risk of psoriasis or exacerbate existing psoriasis. Yet in other patients, these foods can improve symptoms.
Several studies show alcohol increases the risk of developing psoriasis and worsens its severity. Other studies have found eliminating dietary gluten may reduce psoriasis symptoms. Identifying helpful or harmful foods is difficult because psoriasis outbreaks may stem from many variables. One patient may improve after eliminating a certain food, while another may find the same food reduces symptoms. Some experts believe patients who test positive for antigliadin antibodies should increase their intake of fresh fruits, vegetables, fish oil, and vitamin D; limit fish, fowl, and lamb intake; and avoid red meats, processed foods, and refined carbohydrates.
Although experts debate whether nutritional deficiencies are linked directly to psoriatic lesion outbreaks, correcting deficiencies can improve both symptoms and the patient’s overall health. Advise patients to eat a healthy diet. Emphasize the importance of taking vitamin B6, vitamin B12, and folic acid supplements due to the link between psoriasis and cardiovascular disease.
Know that dietary changes won’t necessarily clear psoriasis but can improve general health and help patients maintain a healthy weight, which can reduce the risk of psoriatic arthritis. Although some evidence suggests dietary modification and fish oil consumption may control inflammation, more research is needed to clarify the value of lifestyle interventions in improving psoriasis symptoms.
What the evidence shows
Combination and rotational (alternating) treatments seem to be more efficacious than monotherapy and carry a lower risk of toxicity. In several studies, a combination of phototherapy and acitretin brought noticeable lesion improvements and satisfaction rates as high as 100%. This combination worked more rapidly than acitretin or phototherapy alone while reducing the patient’s UVB exposure.
Practitioners must weigh the pros and cons of each therapy when deciding which type to recommend. Research shows that dietary modifications aimed at reducing weight by avoiding saturated animal fats, trans fats, fried and processed foods, and refined carbohydrates reduce the formation of eicosanoids (hormones that control the immune system and promote tissue destruction). This, in turn, can decrease cardiovascular risk and increase therapeutic effectiveness. One study found that adding a psychological intervention as an adjunct to standard therapy reduced psoriasis severity and eased patients’ anxiety, depression, and stress levels.
Clinicians periodically should evaluate whether changes are needed in the patient’s current treatment, dietary modifications, and psychosocial adaptation to help reduce flare-ups and increase self-esteem. One approach to treatment modification involves counseling patients to increase their personal control, improve coping strategies, reform negative thoughts about the illness, and express emotions.
Empowering the patient to modify risk factors by adopting a healthier lifestyle can improve psoriasis symptoms and quality of life. Encourage the patient to manage risk factors through exercise, a healthy diet, smoking cessation, and moderate alcohol use (if any). When evaluating treatment options, use current evidence-based practice guidelines. Show empathy toward patients, giving them enough information to make informed decisions that ease symptoms and manage the disease. Encourage them to express their thoughts and feelings and to make appropriate lifestyle and diet modifications. Make sure they understand the impact of psoriasis, as well as the alternative treatment options available. (See the box below.)
Providing support and holistic care to psoriasis patients
Follow these guidelines when caring for psoriasis patients.
- Use appropriate assessment guidelines, such as the Koo-Menter Psoriasis Instrument.
- Evaluate the patient’s physical condition, staying alert for signs and symptoms of arthritis, cancer, and cardiovascular disease.
- Assess for factors that increase psoriasis risk, including certain medications, diabetes, infection, vitamin and mineral deficiencies, obesity, smoking, and alcohol use.
- Evaluate the patient’s perception of the disease. Note signs or symptoms of depression.
- Encourage patients to seek counseling and psychological support.
- Give patients a list of potentially offending foods that could exacerbate psoriasis symptoms.
- Urge patients to maintain a healthy weight. Provide guidance on weight loss, if appropriate.
- Instruct the patient in relaxation or meditation techniques.
- Give patients adequate time to discuss their illness, concerns, and feelings.
- Teach patients about the various treatment options available to ease symptoms.
- Help patients develop an appropriate exercise regimen.
- Direct patients to public places (such as gyms and swimming pools) where they won’t feel others are judging them.
- Refer patients to social services for aid in obtaining financial support for prescriptions and other expenses, if necessary.
- Give patients appropriate reading materials and direct them to credible websites, such as those of the National Psoriasis Foundation, Dermatology Nurses Association, and American Academy of Dermatology.
- Provide contact information for local support groups.
- Encourage patients to get involved in hobbies and to seek social groups where they’ll feel accepted.
- Discuss the patient’s treatment with the primary healthcare provider to ensure an appropriate plan of care is developed.
Multidisciplinary treatments are recommended for psoriasis patients. Typically, the first component of treatment is a combination of therapies based on initial assessment findings—for instance, a combination of phototherapy and a systemic drug. The amount of phototherapy therapy given is based on manufacturers’ recommendations and individual response after each treatment session.
The second component may be patient counseling to focus on personal control and expression of feelings, along with education on ways to cope with stressors. Another component should be a nutritional evaluation and ongoing education aimed at weight reduction to decrease the risk of comorbidities and improve response to treatment.
Hope for the future
Reducing the burden of psoriasis can bring immense gratification to patients and loved ones. Patients who receive education and effective treatment can experience significant symptom reduction and a better quality of life. Treatment success requires a team approach involving physicians, nurses, counselors, and nutritionists.
Shelly Chandler and Carol Murch are assistant professors of nursing at Henderson Community College in Henderson, Kentucky. Rita Driver is an Adult Clinical Nurse Specialist at Western Baptist Hospital in Paducah, Kentucky. Janie Arington is a staff nurse at Deaconess Hospital in Evansville, Indiana.
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