42 | Nursing in Practice | Winter 2022
PICTURE QUIZ
Psoriasis
The following are examples of different forms of psoriasis , a systemic , immune-mediated , inflammatory skin disease that affects up to 3 % of the population . 1 Can you identify the different forms and how should they be managed ?
By Dr Toni Hazell , a GP in north London
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A 25-year-old male patient presents with these red , scaly bumps on his back . He has had a cough and sore throat over the past two weeks .
This 45-year-old male patient presents with a scaly , sore patch of skin on his knee , which he has had on and off for several years and which never really goes away .
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A 35-year-old man has come to see you because his joints are always very stiff in the mornings . As he sits down and puts his keys on your desk , you notice this appearance of his nails .
A 27-year-old woman presents with these lesions on her palms ; she has similar lesions on her soles . She says she ’ s had this before and thinks it comes on when she is run down .
Answers 1 Guttate psoriasis . Unlike most forms of psoriasis , this is self-limiting and usually resolves by itself within three to four months . It presents with small papules that may spread all over the body within a week of onset , and often occurs after an upper respiratory tract infection , particularly a streptococcal sore throat . It has been described following Covid-19 infection . Management is usually symptomatic with emollients and topical steroids , but if more than 10 % of the body is affected then a dermatologist should be consulted as phototherapy may be indicated . 2 Chronic plaque psoriasis . The aim of treatment is to control the symptoms , not to effect a cure . Patients may benefit from support groups such as the Psoriasis Association or the Psoriasis and Psoriatic Arthritis Alliance . Some patients will have their symptoms controlled with topical treatments such as emollients , topical steroids and topical vitamin D preparations . Others will need oral disease-modifying therapy with drugs such as methotrexate , which can only be initiated in secondary care . Psoriasis is associated with cardiovascular disease and the metabolic syndrome , so it is important to assess for cardiovascular risk . 3 Psoriasis of the nails . This commonly affects those with psoriatic arthritis . Features often include pitting ( seen here ), but also discolouration , detachment of the nail from the nail bed and proliferation of the nail bed causing the nail to lift . Treatment with a topical corticosteroid cream may be effective but more severe cases require referral for biologic drug injections , oral disease-modifying drugs like methotrexate or phototherapy . 4 Pustular psoriasis . If generalised over the whole body this may be an emergency requiring same-day dermatology review . If more localised it can be managed in primary care . Greater severity is indicated by rapid spread of erythema , white pustules that coalesce and an unwell patient with fever , malaise or tachycardia . Patients will often have a pre-existing history of chronic psoriasis . Unless an emergency case , routine dermatology referral should be made and advice sought about interim management – this may include topical treatments such as coal tar or salicylic acid . 2
References 1 NICE CKS . Psoriasis . 2022 . cks . nice . org . uk / topics / psoriasis 2 Psoriasis Association . Pustular psoriasis . 2017 . psoriasis-association . org . uk / pustular-psoriasis
ALAMY X4