Case Study of the Week: Psoriasis

For those of you who are not aware, August is Psoriasis Awareness month.  Psoriasis affects not only an individual's appearance but also their overall health and emotional well-being.  1-2% of the U.S. population, or 5.5 million people suffer from psoriasis.  Of those, up to 30% also suffer from psoriatic arthritis.  Due to the complexity of this disease and it's significant affect on an individual's life, it is important that psoriasis be properly managed.  In order to increase awareness and understanding of this life-changing disease, I have decided to highlight it in the case study of the week. 

Presentation

A 58 year old male presents to your clinic with a complaint of itchy patches of red skin on his arms bilaterally.  The patches are covered with loose, silvery, dry skin.  The patient denies any know contact with allergens.  He denies fever and any symptoms of illness.  He states he has had this problem twice before, however the lesions went away in the course of a few weeks and he did not seek medical treatment.  The patient's vital signs are stable and he is afebrile.  He has not medical history and admits to smoking one pack of cigarettes per day.  On exam, you note large, plaque-like lesions over his elbows and forearms.  You also observe one similar lesion to his scalp.  This patient's fingernails also appear discolored and pitting is noted.  The lesions are covered with loose, flaky dry skin. They are non-tender and are not warm to the touch.  Based on the appearance of these lesions, you quickly diagnose this patient with psoriasis.  You elect not to confirm your diagnosis with a skin biopsy as based on the typical presentation of this case, you are certain of your diagnosis.

Management and Outcome

This patient's lesions are localized to the arms, so you elect to prescribe the topical steroid Kenalog.  You instruct the patient to keep the lesions well moisturized and avoid picking at or trying to peel off the lesions as this will cause his lesions to crack, bleed and become painful.  You also educate this patient that sun exposure may encourage resolution of the lesions.  You schedule a follow up appointment in one week.  When the patient returns his lesions are still present but have decreased in size.  You instruct him to continue use of topical steroids and encourage daily sun exposure to the affected area.  Within the month, this patient's lesions have almost completely resolved. 

Discussion

Psoriasis affects all races and also affects men and women equally.  Onset of the disease typically occurs between ages 16-22 or 57-60.  Psoriasis is caused by a disorder of the immune system where T-cells trigger inflammation and rapid division of skin cells.  Skin cells then pile up on the skin's surface resulting in plaque formation.  Injury to the skin, stress, HIV, smoking and hormonal changes have all been identified as triggers of psoriasis.  Medications such as lithium, beta-blockers, NSAIDS and antimalarials may also trigger outbreaks.

There is currently no cure for psoriasis, however flare-ups of the disease can be managed with home care and medications.  Patient management of psoriasis at home includes applying heavy moisturizer to keep lesions moist.  Exposure to sunlight may also help alleviate the lesions.  Medically, topical corticosteroids and retinoids may be prescribed to encourage resolution of psoriatic lesions.  The area of skin affected by the disease must be considered as in patients with extensive lesions, topical therapies may not be practical.  Phototherapy has been shown to reduce inflammation and slow the production of skin cells in psoriasis patents.  A UVB light unit may be prescribed by the provider for home use.  Systemic agents for treatment of psoriasis are indicated after topical therapies and phototherapy have failed.  Medications such as Enbrel, Methotrexate and Humira are used to treat psoriasis.  Use caution with these medications as they may affect liver and kidney function as well as result in immunocompromise.  Because most patients are affected emotionally by psoriasis, support groups and counseling should be considered.  Information about support groups is available through the National Psoriasis Foundation.

The outcome of psoriasis therapy varies significantly.  Itching and peeling of the skin can lead to pain and self-esteem issues affecting quality of life.  Smoking and alcohol use can increase frequency and severity of psoriasis flare-ups.  Plaques usually resolve in weeks to months and frequency of psoriasis flares varies on an individual basis.

Psoriasis treatment and management must be taken seriously as the disease affects not only a patient's health but also quality of life.  If you are unable to manage psoriasis on your own or have a patient with a complex or difficult to treat case, referral to a dermatologist is warranted.

References

Lui, Harvey. Psoriasis, http://www.emedicinehealth.com/psoriasis/page3_em.htm

National Psoriasis Foundation psoriasis.org

Psoriasis, The Mayo Clinic, http://www.mayoclinic.com/health/psoriasis/DS00193