Goals of management are to slow the rapid turn over of epidermis and to promote solution of the psoriatic lesions. There is no known cure. The therapeutic approach should be understandable, cosmetically acceptable, and not too disruptive of lifestyle.
First, any precipitating or aggravating factors are addressed. An assessment is made of lifestyle, because psoriasis is significantly affected by stress. The most important principle of psoriasis treatment is gentle removal of scales (bath oils, coal tar preparation, and a soft brush used to scrub the psoriatic plaques). After bathing, the application of emollient crams containing alpha-hydroxy acids (LacHydrin, Penederm) or salicylic acid will continue to soften thick scales. Three types of therapy are standard: topical, intralesional, and systemic.
• Topical treatment is used to slow the overactive epidermis without affecting other tissues.
• Medications include tar preparations and anthralin (irritating), salicylic acid, and corticosteroids; calcipotriene (Dovonex; not recommended for use by elderly patients because their more fragile skin, or in pregnant or lactating women); and tazarotene (Tazorac) as well as vitamin D. Occlusive (plastic) dressing may improve effectiveness. Medications may be in the form of lotions, ointments, pastes, creams and shampoos.
NURSING ALERT: Assess the flammability of any plastic substances used; caution patient not to smoke or go near open flame.
Intralesional injections of trimcinolone acetonide (Aristocort, Kenalog-10, Trymex).
NURSING ALERT: Ensure that normal skin is not injected with the medication.
• Systemic cytotoxic preparations (methotrexate) may be used in treating unresponsive psoriasis. Other systemic medications in use include hydroxyurea (Hydrea) and cyclosporine A (CyA).
• Laboratory studies are monitored to ensure that hepatic, hematopoietic, and renal systems are functioning adequately.
• Patient should avoid drinking alcohol while taking methotrexate (increases possibility of liver damage).
• Oral retinoids (synthetic derivatives of vitamin A and vitamin A acid), etretinate may be prescribed.
• Psoralens and ultraviolet A (PUVA) therapy may be used for severely debilitating psoriasis.
• Photochemotherapy is associated with long-term risks of skin cancer, cataracts, and premature aging of the skin.
• Ultraviolet B (UVB) light therapy may be used to treat generalized plaque and may be combined with topical coal tar (Goeckerman’s therapy). Excimer laser therapy may be another treatment.
Assessment focuses on how the patient is coping with the skin condition, the appearance of “normal” skin, and the appearance of skin lesions.
• Note major skin manifestation (red, scaling papules that coalesce to form oval, well-defined plaques).
• Examine areas especially affected: elbows, knees, scalp, gluteal cleft, fingers, and toenails (for small pits).
• Deficient knowledge of disease and its treatment
• Impaired skin integrity related to lesions and inflammatory response
• Disturbed body image related to embarrassment over appearance and self-perception of uncleanliness
Collaborative Problems/ Potential Complications
• Psoriasis arthritis
PLANNING AND GOALS
Major goals include increased understanding of psoriasis and the treatment regimen, smoother skin with control of lesions, self-acceptance, and absence of complications.
• Explain with sensitivity that there is no cure and that lifetime management is necessary; the disease process can usually be controlled.
• Review pathophysiology of psoriasis and factors that provoke it: any irritation or injury to the skin (cut, abrasion, sunburn), any current illness, emotional stress, unfavorable environment (cold), and drug (caution patient about nonprescription medication).
Increasing Skin Integrity
• Advise patient not to pick or scratch areas
• Encourage patient to prevent the skin from drying out; dry skin causes psoriasis to worsen.
• Inform patient that water should not be too hot and skin should be dried by patting with a towel.
• Teach patient to use bath oil or emollient cleansing agent for sore and scaling skin.
Improving Self-Concept and Body Image
Introduce coping strategies and suggestions for reducing or coping with stressful situation to facilitate a more positive outlook and acceptance of the disease.
Monitoring and Managing Complications
• Psoriatic arthritis: note joint discomfort and evaluate further.
• Assist patient to rest joint, apply heat, and take salicylates.
• Educate patient about care and treatment and need for compliance.
Promoting Home and Community-Based Care
Teaching Patient Self-Care
• dvise patient that the topical agent anthralin leaves a brownishi-purple stain that subsides when treatment stops. Lesions should be covered to prevent staining clothing, furniture, and bed linens.
• Advise patient that topical corticosteroid preparations on face and around eyes predispose to cataract development. Follow strict guidelines to avoid overuse.
• Provide helpful tips on application of tar preparations.
• Teach patient to avoid exposure to sun when undergoing PUVA treatments.
• Remind patient to schedule ophthalmic examinations on a regular basis.
• Instruct patient to prevent nausea and bath oils to remove scales and dryness.
• Advise female patients of childbearing age that PUVA therapy is teratogenic (can cause fetal defects). They may want to consider using contraceptives during therapy.
• Encourage patient to join a support group and to contact the National Psoriasis Foundation for information.
Expected Patient Outcomes
• Demonstrates knowledge and understanding of disease and its treatment
• Demonstrate self-acceptance
• Achieves smoother skin and control of lesions
• Experiences relief of itching and discomfort
• Experiences no complications