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Community nurses will often encounter patients with psoriasis in their day-to-

day work, and may be involved in delivering care directly or monitoring the condition. However, psoriasis has various presentations and knowledge of these variations is beneficial for all clinicians working in the community, particularly when it comes to understanding the range of treatments available. This article, the first in a series on psoriasis, will discuss the types of psoriasis that can be encountered, while future articles will examine the different treatment options that are currently available, focusing on the National Institute for Health and Care Excellence’s (NICE, 2016) treatment pathway for managing patients with psoriasis (see Figure 1). The series will focus on each of the steps in the pathway and how they relate to nurses working in the community.

Identifying the different clinical presentations of psoriasis

Tonia Goman

Many treatments can be provided through primary care but once a patient has been referred to a dermatology outpatient setting more specialist management can be offered. The purpose of this series is to explain the processes by which patients with psoriasis receive treatment and how working as a team can empower patients to manage their skin condition. Understanding the different types of psoriasis will also help to alert community nurses when urgent medical care may be required.

PSORIASIS

When considering the symptoms of psoriasis, it is important to remember the impact the condition can have on patients’ daily activities as well as their mental wellbeing (De Arruda and De Moraes, 2001; Kimball et al, 2008). As much as psoriasis is a physical condition, the visual nature of the skin can also cause embarrassment, self-consciousness and, for some, bullying (Moon et al, 2013). Time-consuming and sometimes messy treatments can also cause problems within families, with flaking scales also causing tension. It is recognised that living with psoriasis can have an equal or greater effect than living with other long-term conditions such as chronic lung disease or congestive cardiac failure, however, is not afforded the same level of credibility (Rapp et al, 1999; Russo et al, 2004).

Psoriasis usually develops around the age of 15–25 years, with a second peak between 50–60 (Feingold and Grunfeld, 2012); it also occurs in 0.7% of children (World Health Organization [WHO], 2013). Psoriasis is an autoimmune disorder (see Table 1 for possible causes). Normal skin cell reproduction, where cells move from the dermis layer to the

Tonia Goman, dermatology specialist nurse, (inflammatory skin conditions) and lead phototherapy nurse, Bristol Dermatology Centre, Bristol Royal Infirmary; joint-chair of British Dermatology Nurse Group (BDNG) phototherapy sub-group; skin camouflage practitioner

burden on healthcare resources. Often seen by community nurses, psoriasis is a condition that requires careful management as well

how community nurses can recognise them. Future articles will look

managing patients with psoriasis.

KEYWORDS:Dermatology Psoriasis Diagnosis Autoimmune disorder

THE SCIENCE — WHAT IS PSORIASIS?

Approximately 2–3% of the UK population is affected by the chronic inflammatory skin condition, psoriasis (Dubois Declercq and Pouliot, 2013). There are various forms of psoriasis but it generally presents as red plaques that can become thick and scaled. It may start as small red lesions that eventually increase and coalesce (join together). Often starting at the

knees and elbows, for many it can be limited only to these areas, whereas for others it can affect other parts of the body such as the scalp. Men and women are equally affected, as are children (Van Onselen, 2011).

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58 JCN 2017, Vol 31, No 2

epidermis and then shed naturally, takes approximately 28 days, a process is known as proliferation. These cells are mainly made up of a protein called keratin. However, in psoriasis-affected skin, new cells (keratinocytes) turnover too quickly, often in a 3–4 day cycle, and are unable to mature properly (Van Onselen, 2011; Mitchell and Penzer, 2000).

Whereas a normal immune system will help to fight off infections, an overactive immune system effectively ‘turns on itself’ and in the case of psoriasis, this affects the cells responsible for normal skin function. A type of white blood cell (T-cells) that should regulate the immune system stops functioning, resulting in the overactive cell growth and inflammation.

PSORIASIS ASSESSMENT

Psoriasis area severity indexSome community nurses will have come across the Psoriasis Area Severity Index (PASI) scoring system. This is an assessment tool that provides an indication of the extent of the body covered by psoriasis and was devised in 1978 by Fredriksson and Pettersson to measure the response to a systemic retinoid (Fredriksson and Pettersson, 1978). The system divides the body into four sections:

Head and neckUpper limbs (arms)TrunkLower limbs (legs and buttocks).

conscious they have felt about their skin, whether it has influenced the clothes they have worn, and whether it has caused problems with work/study, friends/family, hobbies/sports, etc. Answers are graded as ‘very much’ (scores three points), ‘a lot’ (scores two points), ‘a little’ (scores one point), or ‘not at all’ (scores zero points). There is a maximum score of 30. The higher the score, the more the symptoms of psoriasis are considered to be affecting the patient.

It is often thought that the higher the PASI result, the more likely the DLQI score is to be elevated, but this is not always the case. In the author’s experience, some people may find it very difficult to cope with minimally active psoriasis, whereas others with more severe psoriasis may be more resilient about their symptoms and have a lower DLQI score.

These results of these scoring systems can provide the community

Each area is then checked for the level of redness (erythema), thickness of psoriasis (induration) and grade of scaling (desquamation). These are scored and the amount of coverage over each section calculated, before a final overall severity score is arrived at (Oakley, 2016). The higher the score the more affected the patient is, for example a score of 2.3 suggests that there is some active psoriasis, whereas a score of 10.9 would suggest that the patient requires more intensive treatment. PASI is not necessarily precise due to subjectivity, but is a very helpful tool and is often used to evaluate the effectiveness of treatments (Ronda, 2009).

Daily living quality indexWith the Daily Living Quality Index (DLQI), patients are asked to complete a questionnaire about how they feel about their skin and how it affects them on a daily basis. This helps to assess how much the skin condition affects them. Again, the higher the score the more problematic the skin condition is perceived to be.

The DLQI was introduced by Finlay and Khan in the early 1990s to evaluate the psychological impact that psoriasis had on patients’ daily lives (Finlay and Khan, 1994). This questionnaire comprises 10 questions, directing the patient to consider how they have felt about their skin over the past week. Questions relate to how itchy, sore or painful the patient’s skin has been, how self-

Table 1: Established causes of psoriasis

The ‘on button’ Already dormant in the body, a combination of genes or a specific trigger factor sets off the overactive immune system

Streptococcal infections such as tonsillitis, bronchitis or other upper respiratory infections such as flu or pneumonia can set off guttate psoriasis

MedicationCartain medications can cause psoriasis, including lithium, propanolol and other beta blockers, quinine, tetracyclines and antimalarials

Stress It is recognised that the immune system may react to mental or emotional factors

Alcohol and smoking

There is a reported connection between developing and aggravating psoriatic changes by triggering inflammation, drying and irritating the skin. Antioxidants in red wine are thought to be the reason that moderate intake appears to protect against heart disease risk, which is raised in people with psoriasis (Serafini et al, 1998; Lopez-Velez et al, 2003)

Weight Obesity is thought to increase the risk of developing psoriasis

Figure 1.The psoriasis treatment pathway (adapted from NICE [2016]).

Person with psoriasis

Principles of care

Assessment

Topical therapy

Specialist referral

Systemic biologic therapy

Phototherapy Systemictherapy

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Pustular psoriasisPustular psoriasis consists of well-defined, raised white or yellow pustules on the skin, often affecting the hands and/or feet only, which is known as palmoplantar pustular psoriasis (PPPP). The pustules are filled with non-infectious pus and the surrounding skin is reddish in colour. Although relatively rare, generalised pustular psoriasis that spreads to large areas of the body requires urgent medical care due to loss of heat and fluid (Van Onselen, 2011). In these cases, the skin will be very hot, although the patient will feel very feverish and very unwell. This kind of emergency can be triggered when large supplies of strong steroids have been used to treat widespread plaques. Pustular psoriasis can be very debilitating, making daily activities very difficult to manage.

Erythrodermic psoriasisAlthough rare, erythrodermic psoriasis is also a medical emergency. It is extremely inflammatory and can affect most of the body’s surface causing the skin to become bright red and inflamed. It appears as a red, peeling rash that feels itchy or with a burning sensation. There are no pustules, but again as with pustular psoriasis, there is a loss of fluid and heat. It often develops slowly as a result of the incorrect use or sudden withdrawal of steroid treatments.

Scalp psoriasisPsoriasis commonly develops on the scalp. This is often noticeable on the hairline, with redness and fine dry scale, although the scalp can also be affected by fine-to-heavily crusted plaques, which may flake in clumps. Scalp psoriasis may resemble seborrheic dermatitis (a form of eczema that predominantly affects young adults and the elderly [Oakley, 2014]), although in seborrheic dermatitis the scales are greasy and not dry. Hair growth is not normally affected, but where any hair loss does occur, it will usually grow back when the psoriasis has resolved. Scalp psoriasis can be very difficult to manage.

Scalp psoriasis can be very difficult to maintain, particularly when the scale becomes thicker and many of the treatments available are renowned for being ‘messy’ and

nurse with a valuable insight into how a patient is coping with their skin condition and how problematic the treatments may be. Baseline PASI scores can also be used to monitor the effectiveness of treatments and can be referred to as management progresses.

IDENTIFYING DIFFERENT TYPES OF PSORIASIS

Psoriasis vulgaris or plaque psoriasisPsoriasis vulgaris (‘vulgaris’ means common) or plaque psoriasis affects approximately 90% of people with psoriasis (Van Onselen, 2011; Doqra and Mahajan, 2016). It is defined by classic, raised, red plaques with a silvery-scale, which is made up of dead skin cells. The scale loosens and sheds frequently and the plaques can range in size from a few millimetres to those that cover large areas of the body. They are often symmetrical and common on ‘extensor’ surfaces such as the elbows and knees.

The exact cause of plaque psoriasis is still uncertain, though it is accepted that overactive T-cells attack the immune system, affecting healthy skin. Oakley (2014) reported that immune factors and inflammatory cytokines (messenger proteins) are known to be responsible for the condition. It is common for plaque psoriasis to develop at trauma sites such as surgical wounds, scars, tattoos and vaccination punctures. This is known as the Koebner phenomenon. Similarly, some people may find psoriasis develops to the upper thighs due to friction from keys and coins in their pockets (National Psoriasis Foundation, 2016a).

Physical symptoms include soreness, itching and cracking skin (fissures), which can be very painful. When the feet are affected, mobilising can be very difficult and plaque psoriasis on the hands creates daily problems as washing can aggravate the condition. The genitalia can also be itchy and cause great embarrassment.

Equally, other people’s reactions to sore, flaky skin can reduce the patient’s desire to socialise (Moon et al, 2013). During the summer months, long sleeves or trousers may be worn

to cover up the ‘unsightly’ appearance of the skin, and Alexandroff and Johnstone (2010) noted that psoriasis, being a visual condition, creates a psychological burden similar to that experienced by people with cancer, diabetes, and heart disease.

Guttate psoriasisGuttate is Latin for ‘rain drop’ and with this presentation it can often appear as though the psoriasis has ‘rained’ over the body, appearing as small, salmon-pink coloured drops on the skin. There is usually a fine silver-white scale on the plaque. Guttate psoriasis affects about 10% of people with psoriasis (National Psoriasis Foundation, 2016b) and is often triggered by a streptococcal (bacterial) throat infection, appearing between three days to three weeks later. Outbreaks of guttate psoriasis can resolve spontaneously, however, and never recur (Mitchell and Penzer, 2000). This form of psoriasis can develop quickly and children and young adults are particularly affected. Most people with guttate psoriasis complain of the appearance more than any other symptom, although some report problems with itching.

Inverse or flexural psoriasisInverse psoriasis appears as very red lesions in skin folds, most commonly under the breasts, armpits, near the genitals, under the buttocks or in abdominal folds. It appears as red and shiny patches of skin but with less scale than is often present in other types of psoriasis. Sweat and skin friction can irritate these inflamed areas and yeast overgrowth, which is common in these areas, can trigger this kind of psoriasis (Mitchell and Penzer, 2000).

Flexural psoriasis can be tender due to the nature of the sites on which it develops, which can also be prone to chafing due to sweat. The areas affected by flexural psoriasis can result in acute embarrassment, cause relationship difficulties and general discomfort. Fungal infections such as Candida albicans (thrush) may develop and increased itch, particularly around the anus, can result in a type of eczema, lichenification due to excess rubbing and scratching (Stanway, 2004).

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to confirm as it too can have the appearance of psoriasis and exhibit similar symptoms. Finally, mycosis fungoides (a kind of cutaneous T-cell lymphoma) may be mistaken for psoriasis, but will not respond to routine psoriatic treatments (Pugsley, 2009). Histology can confirm this but mycosis fungoides is notoriously difficult to identify in its early stages.

CONCLUSION

Psoriasis is a common skin problem that can cause significant distress and can impact patients’ lives on many levels. There are many forms of psoriasis and various options for treatment, although the condition does require careful management. Community nurses can play a valuable role in reassuring patients that there are treatments available that can and will resolve the symptoms as well as reducing the outward presentation of a condition that can have a devastating effect on self-esteem. Following this piece, the next article in the series will begin to look at the management of psoriasis, starting with topical treatments. JCN

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De Arruda LHF, De Moraes APF (2001) The impact of psoriasis on quality of life. Br J Dermatol 144(58): 33–6

Doqra S, Mahajan R (2016) Psoriasis: epidemiology, clinical features, comorbidities and clinical scoring. Indian Drmatol Online J 7(6): 471–80

Dubois Declercq S, Pouliot R (2013) Promising new treatments for psoriasis. The Scientific World Journal Available online: www.hindawi.com (accessed 6 January, 2017)

Feingold K, Grunfeld C (2012) Psoriasis: it’s more than just the skin. Journal of Lipid Research 53: 1618–24

Finlay AY, Khan GK (1994) Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use. Clin Exp Dermatol 19: 210–16

Fredriksson T, Pettersson U (1978) Severe psoriasis — oral therapy with a new retinoid. Dermatologica 157: 238–44

Kimball AB, Gladman D, Gelfand JM, et al (2008) National Psoriasis Foundation

clinical consensus on psoriasis comorbidities and recommendations for screening J Am Acad Dermatol 58: 1031–42

Lopez-Velez M, Martinez-Martinez F, Del Valle-Ribes C (2003) The Study of phenolic compounds as natural antioxidants in wine. Crit Rev Food Sci Nutr 43: 233–44

Mitchell T, Penzer R (2000) Psoriasis at Your Fingertips. Class Publishing, London

Moon H-S, Mizara A, McBride SR (2013) Psoriasis and psycho-dermatology. Dermatol Ther 3(2): 117–30

National Psoriasis Foundation (2016a) Causes and triggers. Available online: www.psoriasis.org (accessed 5 January, 2017)

National Psoriasis Foundation (2016b) Guttate Psoriasis. Available online: www.psoriasis.org (accessed 5 January, 2017)

National Psoriasis Foundation (2016c) About psoriatic-arthritis. Available online: www.psoriasis.org (accessed 5 January, 2017)

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causing odour, as well as being time-consuming. These treatments can be difficult to wash out and those which need to be left on the scalp overnight can cause problems with washing the hair in the morning before work, school etc. Treatments can be greasy and difficult to remove or leave the hair limp and they can be slow, taking up to four weeks to take effect. Many topical treatments are also alcohol-based, which can further irritate the scalp, (Psoriasis and Psoriatic Arthritis Alliance [PAPAA], 2013).

Psoriatic arthritisPsoriatic arthritis is a type of arthritis (inflammation of the joints) accompanied by inflammation of the skin (psoriasis). It can affect up to 10% of those with psoriasis. Psoriatic arthritis is an autoimmune disorder, where the body’s defences attack the joints causing inflammation and pain. It often develops about 5–12 years after psoriasis begins and about 30% of people with psoriasis will develop this condition (National Psoriasis Foundation, 2016c).

Nail psoriasisNail psoriasis is potentially disabling condition that can involve the fingernails or toenails and commonly accompanies symptoms of psoriatic arthritis. Presentation ranges from small pits or large yellow toned separations on the nail plate called ‘oil-spots’, to complete destruction of the nails, which may then lift away. The nails may also appear very thick. Nail psoriasis can be hard to treat but may respond to other psoriasis or psoriatic arthritis treatments, including the application of topical steroids to the cuticles, steroid injections at the cuticle, or oral medications.

Differential diagnosisThere are some conditions that present with similar symptoms to psoriasis such as pityriasis lichenoides chronica, which can present similarly to guttate psoriasis. Lichen planus can also resemble psoriasis, presenting on the legs, palms or penis. Both candidiasis and tinea corporis (ringworm) can also have psoriatic characteristics and should be swabbed or scraped accordingly and sent for histology. Eczema can be difficult

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