psoriasis and physiotherapy

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PSORIASIS : 

PSORIASIS Dr. Dibyendunarayan Bid Senior Lecturer The Sarvajanik College of Physiotherapy, Rampura, Surat, India

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Definition Psoriasis is a noncontagious, chronic inflammatory disease of the skin characterized by clearly defined dry, rounded red patches with silvery white scales on the surface.

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Aetiology Age: Common age of first occurrence is 15-30 years. It can occur as young as 2 years. Also it can start as late as 80 years. Sex: Both sexes are equally affected. Climate: The condition is worse in damp, cold climates. It has been known to clear if a patient who suffers quite badly in the UK goes to a sunny climate.

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Predisposing / precipitating factors A number of factors appear to predispose or precipitate an exacerbation of the psoriasis. These are: Heredity: There is an inherited defect in the skin which results in psoriasis developing in certain circumstances; 30 percent of patients have blood relative with the condition. Infection: Psoriasis has been known to develop after, for example, an upper respiratory tract infection. Trauma: Lesions tend to develop at sites of potential or actual trauma, e.g. mechanical friction, cuts, stings etc. Anxiety: Psoriasis often appears in relation to mental stress, e.g. bereavement, examinations etc. Drugs: Some drugs, e.g. chloroquine, may precipitate the condition. Diabetes: Some patients with diabetes develop the condition. Arthropathy: Sero-negative arthritis develops in some patients.

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Causes Lesions of psoriasis are caused by an increase in the turnover rate of dermal cells from the normal 23 days to 3-5 days in affected areas. Silver scale on the surface of lesions is a layer of dead skin cells and may be scraped away from most lesions even if the scale is not apparent on visual inspection. Patients with psoriasis have a genetic predisposition for the disease. Perceived stress can cause exacerbation of psoriasis. Autoimmune function - significant evidence is accumulating that psoriasis is an autoimmune disease. Lesions of psoriasis are associated with increased activity of T cells in underlying skin. Guttate psoriasis has been recognized to appear following certain immunologically active events, such as streptococcal pharyngitis, cessation of steroid therapy, and use of antimalarial drugs.

Pathological changes : 

Pathological changes Epidermis: There is increased reproduction in the stratum germinativum. The stratum spinosum is thicker due to an increased number of cells plus edema. The stratum granulosum is absent. The strata lucidum and corneum are replaced by several layers of nucleated, incompletely keratinized, soft cells (para-keratotic cells). There is no time for the normal changes to take place through the skin layers. The cells at the surface are sticky and do not fall off like normal keratin. Accumulation of these cells forms scales, which over 2-3 weeks dry out and fall off in big flakes.

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Dermis The capillaries are dilated with increased blood flow. The papillae are elongated and there are changes of inflammation.

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Healing The center of the patch heals first causing circular lesions. Normal skin recovery takes place without scarring.

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Clinical features: Sharply defined red and pink areas are termed as plaques. Scales look silvery due to light reflecting from the swollen stratum spinosum.

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Distribution: Elbows, knees, scalp and sacrum are covered in thickly scaled patches. Plaques of varying sizes appear any where on the body. Nail become pitted, ridged or separated from the nail bed. This can be the only evidence of the disorder in some people. Skin contact areas can be badly affected- between fingers, axillae, groin, between toes, under breast and behind ears. The face is rarely affected.

FIGURE X.1. Common areas of distribution of psoriasis. The lesions are usually symmetrically distributed and are characteristically located on the ears, elbows, knees, umbilicus, gluteal cleft and genitalia. The joints (psoriatic arthritis), nails and scalp may also be affected. : 

FIGURE X.1. Common areas of distribution of psoriasis. The lesions are usually symmetrically distributed and are characteristically located on the ears, elbows, knees, umbilicus, gluteal cleft and genitalia. The joints (psoriatic arthritis), nails and scalp may also be affected.

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- The size of plaques and distribution varies so that different types are described. They are: Plaque psoriasis is characterized by raised inflamed lesions covered with a silvery white scale. The scale may be scraped away to reveal inflamed skin beneath. This is most common on the extensor surfaces of the knees, elbows, scalp, and trunk.

FIGURE X.2. A primary lesion of plaque-type psoriasis.The typical lesion is a well-demarcated, thick, erythematous plaque with a silvery scale. : 

FIGURE X.2. A primary lesion of plaque-type psoriasis.The typical lesion is a well-demarcated, thick, erythematous plaque with a silvery scale.

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Guttate psoriasis presents as small red dots of psoriasis that usually appear on the trunk, arms, and legs; the lesions may have some scale. It frequently appears suddenly after an upper respiratory infection (URI). This type responds well to UVR. Inverse psoriasis occurs on the flexural surfaces, armpit, groin, under the breast, and in the skin folds and is characterized by smooth, inflamed lesions without scaling. Pustular psoriasis presents as sterile pustules appearing on the hands and feet or, at times, diffusely, and may cycle through erythema, pustules, and scaling. UVR has limited success in this type.

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Erythrodermic psoriasis presents as generalized erythema, pain, itching, and fine scaling. This type does not usually respond to UVR. Scalp psoriasis affects approximately 50% of patients, presenting as erythematous raised plaques with silvery white scales on the scalp. Nail psoriasis may cause pits on the nails, which may develop yellowish color and become thickened. Nails may separate from the nail bed.

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Prognosis Psoriasis clears completely with no marks but unfortunately can recur. There can be no sign in the evening and next morning it has started. It tends to be better in summer, worse in winter and recurs if the patient is worried. It has lifelong involvement, with waxing and waning, with progression to arthritis in about 10% of cases. It is usually benign. It may be may be refractory to treatment.

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Treatment This may be considered in four headings: General Management Topical Applications Systemic Applications Physiotherapy Management

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General management A sympathetic, considerate approach is required together with reassurance. Any anxiety or worry should be identified and the patient encouraged to relax or seek appropriate help. Reassurance that it is not infectious or disfiguring must be given to both patient and family. Also an ‘open door’ system should operate so that the patient can get to a dermatologist or physiotherapist immediately there is an eruption. Dieting may be tried if there appears to be any allergy factor.

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Topical Applications Many patients do well on topical treatment. Treatment may be: Simple bland aqueous cream. Coal tar applications with salicylic acid and zinc oxide in soft paraffin may be used alone or with UVR. The patient is usually admitted to hospital. The ointment is applied every day to the whole body except face and scalp. Every 24 hours it is washed off in a bath containing coal tar solution. If UVR is given, it must be after a bath because suberythema general treatment is given daily using the Theraktin. This is the Goeckerman regimen. Diathranol in Lassar’s paste is used for resistant psoriasis. It is highly effective but can burn the normal skin. The patient may be admitted to hospital or treated as an outpatient. If the patient is applying the physiotherapist should look out for blisters or reddish purple stains on the skin and warn the patient of the danger. UVR with the Theraktin may be given in conjunction with diathranol as a daily suberythema dose. The paste is removed in coal tar bath before the UVR and is then reapplied afterwards.

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Corticosteroids cream produces good results at first but when treatment stops the diseases can return worse than before. It is useful in an acute eruption and on the face and hands because there is greater absorption in moist areas. The dangers of side effects make long-term use inadvisable.

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Systemic Applications Retinoids- a variant of vitamin A- taken in tablets form produces marked improvement. Retinoic acid or etritinate is marketed as Tigason. Unfortunately, this produces unpleasant side effects such as dryness and cracking of the mouth, alopecia and pruritus. It is teratogenic (produces malfunction in a fetus), therefore must be avoided in pregnancy. Cytotoxic drugs such as methotrexate are sometimes used in severe cases. These have dangers such as damage to bone marrow, intestinal and liver tissues. Cyclosporine also may be useful in severe cases.

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Physiotherapy Management Psoriasis can be treated very successfully with UVR. Two sources are used: the Theraktin and PUVA. The Theraktin This is usually in the form of a tunnel with four fluorescent tubes. The patient lies flat for the treatment, therefore in order to treat the whole body the patient is generally naked and lies supine for half the treatment session and prone for other half. The spectrum of UVR emitted is 390-280nm and peak emission is around 313nm,therefore this constitutes UVB treatment. It may be used alone or in conjunction with coal tar or diathranol.

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Treatment A suberythema dose is given daily or three times a week. The prominent parts of the body have a mild erythema, which fades before the next treatment is due. The time is maintained to maintain the reaction (e.g. 12.5% every 1-2 treatments.). When the lesions start to flatten and heal the same time is repeated and frequency of treatment reduced to twice weekly, once weekly and then once a fortnight. The course of treatment may be spread over 8-12 weeks. These patients tend to deteriorate during the autumn and need treatment in the winter or spring. About 75% of patients with guttate psoriasis respond to UVB.

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PUVA This is psoralen plus UVA and is used for resistant psoriasis. Psoralen is photosensitizing substance, which occurs in plants such as parsley, parsnips and celery. The one used for psoriasis is 8-methoxy psoralen (8-MOP). UVA is produced from fluorescent tubes, mounted upright in a hexagonal shaped cabinet inside which the patient stands throughout the treatment. The spectrum of UVR emitted is 330-390 nm and peaks at 360 nm. Infrared rays are also emitted and it is essential to have a cooling fan so that the patient can tolerate up to ½ hour in the cabinet.

Slide 27: 

Method The patient takes 3-6 tablets of psoralen preferably with milk 2 hours before exposure. Tablet dosage is according to body weight (Table: X.1). UVA is

Table: X.1: dosage of 8-MOP : 

Table: X.1: dosage of 8-MOP

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Calculated according to skin type in joules (Table X.2). There is little erythema with UVA; therefore the skin type chart has to be used. (To produce an erythema with UVA requires a dosage 1000 times greater than UVB.).

Table: X.2 UVA dosage in PUVA treatment : 

Table: X.2 UVA dosage in PUVA treatment

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The dosage is recorded in Joules/cm2. An exposure meter is used to test the output and measures milliwatts/cm2; 1 mW/ cm2 = 1/1000 Joules/second.

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PUVA Treatment Unit

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Duration of treatment This may be 5 minutes at first for skin types I and II and progressed by 1 minute up to 15 minutes. It may start at 6 minutes and progress by 2 minutes up to 20 minutes for skin type III and IV. It may start at 7 minutes and progress by 3 minutes up to 25 minutes for skin type V and VI. A record is kept of the total Joules count. This is essential because there is an undeniable risk of malignant melanoma in patients who have been exposed to between 1500 J and 2000 J. The patient attends three times a week until healing starts, and then frequency of treatment is reduced to twice weekly, once weekly, once per fortnight or monthly ‘holding sessions’.

Slide 34: 

Precautions/ dangers/ advice to patients on PUVA. Do not take psoralen on an empty stomach. There is a real danger of cataract; therefore protective goggles are essential during exposure. Polaroid sunglasses must be worn from the time of taking the psoralen to at least 12 hours after. The psoralen is excreted in 8 hours but the effect of photosensitizing continues. The physiotherapist should test the glasses with a Black ray meter; the glasses must screen 90% of UVA. Patients are advised to wear protective glasses out of doors for at least 24 hours after taking the psoralen and also whilst watching television, a VDU screen or in fluorescent lighting. The skin must be covered in bright sunlight and a hat worn for 24 hours after treatment. Stop using all ointments during PUVA. If the skin is dry simple oil or lubricating lotions may be used. Do not become pregnant or father a child- contraceptive measures are essential during PUVA treatment. A check up is essential every month after completing of treatment. During treatment if patient feels fainting; the physiotherapist must be called immediately.

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Mechanism of action 8-MOP binds to DNA and is activated by UVA. The psoralen binds to DNA thiamine bases, producing cross-linking, which inhibits epithelial synthesis and cell division. In essence, therefore, the accelerated reproduction of epidermis in psoriasis is reduced, hence the beneficial results. Long-term management It may take up to 10 weeks to clear the skin and a further 4-6 weeks of maintenance doses may be given depending on individual response. Thereafter 2-6 monthly review is necessary. Once discharged, the patient should have access to treatment as soon as there is a recurrence.   Pustular psoriasis This may be successfully treated by PUVA when the condition is on the soles and hands. They can be treated with a special piece of equipment in which the fluorescent tubes are horizontal and the hands or feet are placed on a grid over them.

Figure X.3: Psoriasis of back, buttocks and upper limbs : 

Figure X.3: Psoriasis of back, buttocks and upper limbs

Figure X.4: Plaque psoriasis on the elbow. : 

Figure X.4: Plaque psoriasis on the elbow.

Figure X.5: Plaque psoriasis on the back. : 

Figure X.5: Plaque psoriasis on the back.

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