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PSOARIASIS DISEASE

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FAKULTAS KEDOKTERAN
UNIVERSITAS LAMPUNG
2016
 CHAPTER I
INTRODUCTION

Psoriasis is a common chronic inflammatory, immune-mediated disease that

predominantly affects the skin and joints. Given the estimated population prevalence of
psoriasis of 1.5 to 3%, over 100,000 people are affected in Scotland. Approximately 20% of
people with psoriasis may also have psoriatic arthritis (PsA), ie 20,000 people in Scotland.
Onset may occur at any age but peaks in the second and third decades of life. The course of
the disease is characterised by relapses and remissions but the condition tends to persist
throughout life. Over the past 20 years there have been many developments in the
understanding of the genetic, molecular and cellular mechanisms that underlie these
inflammatory processes and many new and effective treatments have been developed.
The negative impact of these diseases on health-related quality of life (QoL) is
comparable to that of ischaemic heart disease, diabetes, depression and cancer.In many
instances this disability can be reduced by effective treatment. In addition, severe psoriasis
and PsA are associated with an increase in the standardised mortality ratio (SMR). In a study
comparing patients with and
without psoriasis in the United Kingdom General Practice Research Database, men with
severe psoriasis died on average 3.5 years younger (95% CI 1.2 to 5.8 years, p<0.001) than
controls and women with severe psoriasis 4.4 years younger (95% CI 2.2 to 6.6 years,
p<0.001) than controls.
The visible nature of psoriasis can create a sense of stigmatisation amongst those
affected. Swollen joints, joint deformity, and physical disability in patients with PsA can lead
to experiences of stigmatisation.Psoriasis and PsA vary widely in their severity. In mild
psoriasis, topical treatment in primary
care can be effective if used appropriately. Severe forms need prompt and intensive
treatment, usually in secondary care, with phototherapy, systemic treatment, biologic
treatment or inpatient treatment. The varied manifestations of PsA may be difficult to
recognise, particularly in the absence of an acute phase response. General practitioners (GPs)
may be uncertain when to refer patients to secondary care and may be unaware of the
treatments available to their
patients locally.
In both primary and secondary care, the biological severity of the disease and the
resulting disability are not always fully explored and documented.
The management of patients with the combination of severe psoriasis and PsA may be
particularly challenging and require close collaboration between several specialties. Despite
the availability of a variety of treatments, effective and safe control of disease activity is not
always easy to achieve and there is no standard therapeutic approach. For these and other
reasons there is considerable
dissatisfaction amongst patients concerning psoriasis and its treatment.
 CHAPTER II
CONTENTS

2.1 UPPER LIMB

The humerus is a bone in the upper arm. It runs from the shoulder to the elbow. Proximally it
articulates with the scapula forming the shoulder joint, or glenohumeral joint. Distally the
humerus articulates with the radius and ulna to form the elbow joint.
The proximal portion of the humerus can be divided in three. The rounded humeral head
projects medially and articulates with the glenoid cavity of the scapula. Immediately adjacent
to the head is the narrowed anatomical neck which allows for a wider range of movements of
the head within the shoulder joint. Finally, the greater and lesser tubercles are found at the
most superior end of the main shaft of the humerus. The four rotator cuff muscles attach to
these tubercles, strengthening and maintain the shoulder joint. Between the two tubercles lies
a deep grove termed the intertubercular sulcus through which the tendon of the long head of
the biceps brachii runs.

Humerus
The humerus attaches proximally to the scapula (shoulderblade) at the humeral head and
distally with the radius and ulna (lower-arm bones) at the trochlea and capitulum,
respectively.

Below this proximal region lies the shaft which is separated from the proximal region by the
surgical neck, so termed as this in an area of frequent fracture. A major feature of the shaft is
the deltoid tuberosity located laterally to which the deltoid muscle attaches. As well as the
deltoid the corocobrachialis, brachialis and brachioradialis attach to the anterior surface with
the triceps brachii attaching to the posterior.
Distally the humerus flattens to articulate with the ulna and radius at the elbow joint. The
medially located trochlea articulates with the ulna. Located laterally to this is
the capitulum which articulates with the radius. Several muscles of the forearm responsible
for extension at the wrist attach to the humerus immediately above the capitulum and
trochlea.
The forearm contains two bones the radius and the ulna which extend in parallel from the
elbow where they articulate with the humerus to the wrist where they articulate with the
carpals. The space between the two bones is spanned by the interosseous membrane.
Lower arm

The radius and ulna are the bones of the lower arm.

The Ulna
Anatomically the ulna is located medially to the radius, placing it nearer the little finger. The
ulna is slightly larger than the radius. Proximally there are five key regions of the ulna. The
olecranon is a projection of bone which extends proximally from the ulna, the triceps brachii
muscle attaches to it superioly. The cornoid process is a similar project which together with
the olecranon forms the trochlear notch in which articulates with the trochlea of the humerus.
Laterally to the trochlear notch lies the radial notch which articulates with the head of the
radius forming the proximal radioulnar joint. Finally, immediately distal to the coronoid
process is the tuberosity of ulna to which the brachialis muscle attaches.
The shaft of the ulna is triangular and numerus muscles involved in pronation and flexion of
the forearm attach to its surface.
Distally the ulna is much small and terminates with a rounded head which articulates with the
ulnar notch of the radius to form the distal radioulnar joint. The styloid process of the ulna
extends distally and is the site of attachment for ligaments found in the wrist.

The Radius
Anatomically the radius is located laterally to the ulna placing it nearer the thumb. The radius
is slightly smaller than the ulna and pivots around the ulna to produce movement at the
proximal and distal radioulnar joints. Proximally the radius terminates with a disk shaped
head which articulates with the capitulum of the humerus and the radial notch of the ulna.
Immediately below the head lies the radial tuberosity to which the biceps brachii attaches. As
with the ulna the shaft of the radius is triangular in shape and numerous muscles including the
protonator teres attach to it.
Distally the radius expands, medially the ulnar notch articulates with the head of the ulnar.
Immediately adjacent to the ulnar notch the radius articulates with the scaphoid and lunate
carpal bones forming part of the wrist.

The hand contains 27 bones. Each one belongs to one of three regions: the carpals, wrist, or
the metacarpals, which forming the palm and the phalanges, which form the digits.

Carpals
The eight irregularly shaped carpals are the most proximal bones of the hand. The carpals are
often split into two rows, the proximal row containing the scaphoid, lunate, triquetrum and
pisiform moving lateral to medial. The scaphoid and lunate articulate with the radius, and the
lunate and triquetrum articulate with the articular disk of the wrist. The pisiform carpal is a
sesamoid bone, located within a tendon and is not involved in movement at the wrist.
In the distal row contains the trapezium, trapezoid, capitate and hamate moving lateral to
medial. The trapezium articulates with the scaphoid proximally and the first, thumb, and
second metacarpal distally. The trapezoid articulates with the scaphoid proximally and the
second metacarpal distally. The capitate articulates with the scaphoid and lunate proximally
and the third and fourth metacarpal. Finally the hamate articulates with the lunate and
triquetral proximally and the fourth and fifth, little finger, metacarpals distally.
Carpals of the left hand

CarpalsThere are eight carpal bones in each wrist: scaphoid, lunate, triquetral, pisiform,
trapezium, trapezoid, capitate, and hamate.

Metacarpals
The hand contains five metacarpal bones which articulate proximally with the carpals and
distally with the proximal phalanges. They are numbered moving lateral to medial starting
with the thumb which is metacarpal I, and ending with metacarpal V, the little finger. Each
metacarpal consists of a base, shaft and head, with the concave lateral and medial borders of
the shaft allowing attachment of the interossei muscles.
Metacarpal bones of the left hand

The metacarpals connect the carpal bones of the wrist with the phalanges (fingers).

Phalanges
The digits are named in a similar fashion to the metacarpals moving lateral to medial starting
at the thumb. With the exception of the thumb each digit contains a proximal, intermediate
and distal phalange; the thumb lacks an intermediate phalange. The length of the phalanges
decreases distally.
2.2 EPIDEMIOLOGY

Although psoriasis occurs worldwide, its prevalence variesconsiderably.

In the USA, approximately 2% of the population is affected. High rates of psoriasis have
been reported inpeople of the Faroe islands, where one study found 2.8% of the population to
be affected. 1 The prevalence of psoriasis islow in certain ethnic groups such as the Japanese,
and maybe absent in aboriginal Australians 2 and Indians from South America. Psoriasis can
present at any age and has been reported at birth and in older people of advanced age.
Accurate determination of the age of onset of psoriasis is problematic,as studies which do so
typically rely on a patient’s recall of the onset of lesions or determine the onset from the
physician’s diagnosis as recorded on the initial visit. Data based on patient recall can be
inaccurate; determining onset based on first visit to a physician could underestimate the time
of disease occurrence, as minimal disease may be present for years before a consultation is
sought.
A bimodal age of onset has been recognised in several large studies.
The mean age of onset for the first presentation of psoriasis can range from 15 to 20 years of
age, with a second peak occurring at 55–60 years. 4–7 Henseler and Christophers examined a
series of 2147 patients and reported two clinical presentations of psoriasis, type I and II,
distinguished by a bimodal age at onset. Type 1 begins on or before age 40 years; Type II
begins after the age of 40 years. Type I disease accounts for more than 75% of cases. 7
Patients with early onset, or type I psoriasis, tended to have more relatives affected and more
severe disease than patients who have a later onset of disease or type II psoriasis. In addition,
strong associations have been reported with human leucocyte antigen (HLA)-Cw6 in patients
with early onset, compared with later onset of psoriasis. The course and progress of psoriasis
is unpredictable. In one study, 39% of patients reported complete remission of disease for
between one and 54 years.8 Higher figures have been reported in Japan.
2.3 CLASSIFICATION OF PSORIASIS
The phenotyping of psoriasis has traditionally been based on historical morphologic
descriptions.Although this phenotyping is very useful for classification purposes, clinical
findings in individual patients frequently overlap in more than one category.

Plaque
Plaque psoriasis is the most common form, affecting approximately 80% to 90% of patients.
The vast majority of all high-quality and regulatory clinical trials in psoriasis have been
conducted on patients with this formof psoriasis. Plaque psoriasis manifests as well-defined,
sharply demarcated, erythematous plaques varying in size from 1 cm to several centimeters
(Figs 1 and 2). These clinical findings are
mirrored histologically by psoriasiform epidermal hyperplasia, parakeratosis with intracorneal
neutrophils, hypogranulosis, spongiform pustules, an infiltrate of neutrophils and lymphocytes
in the epidermis and dermis, along with an expanded dermal papillary vasculature. Patients
may have involvement ranging from only a few plaques to numerous lesions covering almost
the entire body surface. The plaques are irregular, round to oval in shape, and most often
located on the scalp, trunk,buttocks, and limbs, with a predilection for extensor surfaces such
as the elbows and knees. Smaller plaques or papules may coalesce into larger lesions, especially
on the legs and trunk.
Painful fissuring within plaques can occur when lesions are present over joint lines or on the
palms and soles. Psoriatic plaques typically have a dry, thin, silvery-white or micaceous scale,
often modified by regional anatomic differences, and tend to be symmetrically distributed over
the body (Fig 1). Approximately
80% of those affected with psoriasis have mild to moderate disease, with 20% having moderate
to severe psoriasis affecting more than 5% of the body surface area (BSA) or affecting crucial
body areas such as the hands, feet, face, or genitals.

Inverse
Inverse psoriasis is characterized by lesions in the skin folds. Because of the moist nature of
these areas, the lesions tend to be erythematous plaques with minimal scale. Common locations
include the axillary, genital, perineal, intergluteal, and inframammary areas. Flexural surfaces
such as the antecubital fossae can exhibit similar lesions (Fig 1, B).
Erythrodermic
Erythrodermic psoriasis can develop gradually from chronic plaque disease or acutely with
little preceding psoriasis. Generalized erythema covering nearly the entire BSA with varying
degrees of scaling is seen (Fig 1, E ). Altered thermoregulatory properties of erythrodermic
skin may lead to chills and hypothermia, and fluid loss may lead to dehydration.Fever and
malaise are common.

Pustular
All forms of psoriasis may contain neutrophils in the stratum corneum. When the collections
of neutrophils are large enough to be apparent clinically, it is termed ‘‘pustular psoriasis.’’
Pustular psoriasis may be generalized or localized. The acute generalized variety (termed the
‘‘von Zumbusch variant’’) is an uncommon, severe form of psoriasis accompanied by fever
and toxicity and consists of widespread pustules on an erythematous background (Fig 1, D, and
Fig 2, C ). Cutaneous lesions characteristic of psoriasis vulgaris may be present before, during,
or after an acute pustular episode. There is also a localized pustular variant of psoriasis
involving the palms and soles, with or without evidence of classic plaque-type disease.

Guttate
Guttate psoriasis is characterized by dew-droplike, 1- to 10-mm, salmon-pink papules, usually
with a fine scale. This variant of psoriasis, common in individuals younger than 30 years, is
found primarily on the trunk and the proximal extremities and occurs in less than 2% of patients
with psoriasis. A history of upper respiratory infection with group A beta-hemolytic
streptococci often precedes guttate psoriasis, especially in younger patients, by 2 to 3 weeks.
This sudden appearance of papular lesions may be either the first manifestation of psoriasis in
a previously unaffected individual or an acute exacerbation of long-standing plaque psoriasis
(Fig 2, D).

Nail disease (psoriatic onychodystrophy)

Nail psoriasis can occur in all psoriasis subtypes. Fingernails are involved in approximately
50% of all patients who are psoriatic and toenails in 35% of patients. These changes include
pitting, onycholysis, subungual hyperkeratosis, and the oil-drop sign (Fig 3). Up to 90% of
patients with psoriatic arthritis may have nail changes. Psoriasis of the nails is a significant
therapeutic challenge.
Psoriatic arthritis
Psoriatic arthritis is an inflammatory arthropathy associated with psoriasis that will be
discussed at length in Section 2 of the guidelines

2.4 TREATMENTS

Psoriasis treatments aim to:

 Stop the skin cells from growing so quickly, which reduces inflammation and plaque
formation
 Remove scales and smooth the skin, which is particularly true of topical treatments
that you apply to your skin
Psoriasis treatments can be divided into three main types: topical treatments, light therapy
and systemic medications.

Topical treatments

Used alone, creams and ointments that you apply to your skin can effectively treat mild to
moderate psoriasis. When the disease is more severe, creams are likely to be combined with
oral medications or light therapy. Topical psoriasis treatments include:

 Topical corticosteroids. These powerful anti-inflammatory drugs are the most

frequently prescribed medications for treating mild to moderate psoriasis. They slow
cell turnover by suppressing the immune system, which reduces inflammation and
relieves associated itching. Topical corticosteroids range in strength, from mild to
very strong.

Low-potency corticosteroid ointments are usually recommended for sensitive areas, such
as your face or skin folds, and for treating widespread patches of damaged skin. Your
doctor may prescribe stronger corticosteroid ointment for small areas of your skin, for
persistent plaques on your hands or feet, or when other treatments have failed. Medicated
foams and scalp solutions are available to treat psoriasis patches on the scalp.

Long-term use or overuse of strong corticosteroids can cause thinning of the skin and
resistance to the treatment's benefits. To minimize side effects and to increase
effectiveness, topical corticosteroids are generally used on active outbreaks until they're
under control.

 Vitamin D analogues. These synthetic forms of vitamin D slow down the growth of
skin cells. Calcipotriene (Dovonex) is a prescription cream or solution containing a
vitamin D analogue that may be used alone to treat mild to moderate psoriasis or in
combination with other topical medications or phototherapy. This treatment can
 irritate the skin. Calcitriol (Rocaltrol) is expensive but may be equally effective and
possibly less irritating than calcipotriene.
 Anthralin. This medication is believed to normalize DNA activity in skin cells.
Anthralin (Dritho-Scalp) also can remove scale, making the skin smoother. However,
anthralin can irritate skin, and it stains virtually anything it touches, including skin,
clothing, countertops and bedding. For that reason, doctors often recommend short-
contact treatment — allowing the cream to stay on your skin for a brief time before
washing it off.
 Topical retinoids. These are commonly used to treat acne and sun-damaged skin, but
tazarotene (Tazorac, Avage) was developed specifically for the treatment of psoriasis.
Like other vitamin A derivatives, it normalizes DNA activity in skin cells and may
decrease inflammation. The most common side effect is skin irritation. It may also
increase sensitivity to sunlight, so sunscreen should be applied while using the
medication. Although the risk of birth defects is far lower for topical retinoids than for
oral retinoids, tazarotene isn't recommended when you're pregnant or breast-feeding
or if you intend to become pregnant.
 Calcineurin inhibitors. Currently, calcineurin inhibitors — tacrolimus (Prograf) and
pimecrolimus (Elidel) — are approved only for the treatment of atopic dermatitis, but
studies have shown them to be effective at times in the treatment of psoriasis.
Calcineurin inhibitors are thought to disrupt the activation of T cells, which, in turn,
reduces inflammation and plaque buildup.

Calcineurin inhibitors are not recommended for long-term or continuous use because of a
potential increased risk of skin cancer and lymphoma. They may be especially helpful in
areas of thin skin, such as around the eyes, where steroid creams or retinoids are too
irritating or may cause harmful effects.

 Salicylic acid. Available over-the-counter (nonprescription) and by prescription,

salicylic acid promotes sloughing of dead skin cells and reduces scaling. Sometimes
it's combined with other medications, such as topical corticosteroids or coal tar, to
increase its effectiveness. Salicylic acid is available in medicated shampoos and scalp
solutions to treat scalp psoriasis.
 Coal tar. A thick, black byproduct of the manufacture of petroleum products and
coal, coal tar is probably the oldest treatment for psoriasis. It reduces scaling, itching
and inflammation. Exactly how it works isn't known. Coal tar has few known side
effects, but it's messy, stains clothing and bedding, and has a strong odor.

Coal tar is available in over-the-counter shampoos, creams and oils. It's also available in
higher concentrations by prescription. This treatment isn't recommended for women who
are pregnant or breast-feeding.

 Moisturizers. By themselves, moisturizing creams won't heal psoriasis, but they can
reduce itching and scaling and can help combat the dryness that results from other
 therapies. Moisturizers in an ointment base are usually more effective than are lighter
creams and lotions.
Light therapy (phototherapy)

As the name suggests, this psoriasis treatment uses natural or artificial ultraviolet light. The
simplest and easiest form of phototherapy involves exposing your skin to controlled amounts
of natural sunlight. Other forms of light therapy include the use of artificial ultraviolet A
(UVA) or ultraviolet B (UVB) light either alone or in combination with medications.

 Sunlight. Ultraviolet (UV) light is a wavelength of light in a range too short for the
human eye to see. When exposed to UV rays in sunlight or artificial light, the
activated T cells in the skin die. This slows skin cell turnover and reduces scaling and
inflammation. Brief, daily exposures to small amounts of sunlight may improve
psoriasis, but intense sun exposure can worsen symptoms and cause skin damage.
Before beginning a sunlight regimen, ask your doctor about the safest way to use
natural sunlight for psoriasis treatment.
 UVB phototherapy. Controlled doses of UVB light from an artificial light source
may improve mild to moderate psoriasis symptoms. UVB phototherapy, also called
broadband UVB, can be used to treat single patches, widespread psoriasis and
psoriasis that resists topical treatments. Short-term side effects may include redness,
itching and dry skin. Using a moisturizer may help decrease these side effects.
 Narrow band UVB therapy. A newer type of psoriasis treatment, narrow band UVB
therapy may be more effective than broadband UVB treatment. It's usually
administered two or three times a week until the skin improves, then maintenance
may require only weekly sessions. Narrow band UVB therapy may cause more severe
and longer lasting burns, however.
 Goeckerman therapy. Some doctors combine UVB treatment and coal tar treatment,
which is known as Goeckerman treatment. The two therapies together are more
effective than either alone because coal tar makes skin more receptive to UVB light.
Once requiring a three-week hospital stay, a modification of the original treatment can
be performed in a doctor's office.
 Photochemotherapy or psoralen plus ultraviolet A (PUVA). Photochemotherapy
involves taking a light-sensitizing medication (psoralen) before exposure to UVA
light. UVA light penetrates deeper into the skin than does UVB light, and psoralen
makes the skin more responsive to UVA exposure. This more aggressive treatment
consistently improves skin and is often used for more-severe cases of psoriasis.
PUVA involves two or three treatments a week for a prescribed number of weeks.
Short-term side effects include nausea, headache, burning and itching. Long-term side
effects include dry and wrinkled skin, freckles, and increased risk of skin cancer,
including melanoma, the most serious form of skin cancer. Because this treatment
makes you more sensitive to sunlight, it's important to avoid sun exposure when
 possible and to wear a broad-spectrum sunscreen with an SPF of at least 30. To
protect your eyes, wear UVA-protective sunglasses.
 Excimer laser. This form of light therapy, used for mild to moderate psoriasis, treats
only the involved skin. A controlled beam of UVB light of a specific wavelength is
directed to the psoriasis plaques to control scaling and inflammation. Healthy skin
surrounding the patches isn't harmed. Excimer laser therapy requires fewer sessions
than does traditional phototherapy because more powerful UVB light is used. Side
effects can include redness and blistering.
Oral or injected medications

If you have severe psoriasis or it's resistant to other types of treatment, your doctor may
prescribe oral or injected drugs. Because of severe side effects, some of these medications are
used for only brief periods and may be alternated with other forms of treatment.

 Retinoids. Related to vitamin A, this group of drugs may reduce the production of
skin cells if you have severe psoriasis that doesn't respond to other therapies. Signs
and symptoms usually return once therapy is discontinued, however. Side effects may
include lip inflammation and hair loss. And because retinoids such as acitretin
(Soriatane) can cause severe birth defects, women must avoid pregnancy for at least
three years after taking the medication.
 Methotrexate. Taken orally, methotrexate helps psoriasis by decreasing the
production of skin cells and suppressing inflammation. It may also slow the
progression of psoriatic arthritis in some people. Methotrexate is generally well-
tolerated in low doses but may cause upset stomach, loss of appetite and fatigue.
When used for long periods, it can cause a number of serious side effects, including
severe liver damage and decreased production of red and white blood cells and
platelets.
 Cyclosporine. Cyclosporine suppresses the immune system and is similar to
methotrexate in effectiveness. Like other immunosuppressant drugs, cyclosporine
increases your risk of infection and other health problems, including cancer.
Cyclosporine also makes you more susceptible to kidney problems and high blood
pressure — the risk increases with higher dosages and long-term therapy.
 Drugs that alter the immune system (biologics). Several immunomodulator drugs
are approved for the treatment of moderate to severe psoriasis. They include
etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira) and ustekinumab
(Stelara). These drugs are given by intravenous infusion, intramuscular injection or
subcutaneous injection and are usually used for people who have failed to respond to
traditional therapy or who have associated psoriatic arthritis. Biologics work by
blocking interactions between certain immune system cells and particular
inflammatory pathways. Although they're derived from natural sources rather than
chemical ones, they must be used with caution because they have strong effects on the
 immune system and may permit life-threatening infections. In particular, people
taking these treatments must be screened for tuberculosis.
 Other medications. Thioguanine and hydroxyurea (Droxia, Hydrea) are medications
that can be used when other drugs can't be given.
 Experimental medications. There are a number of new medications currently being
researched that have the potential to improve psoriasis treatment. Some of the
treatments being looked at include A3 adenosine receptor agonists; anti-interleukin-
17, anti-interleukin-12/23 and anti-interleukin-17 receptor agents; Janus kinase (JAK)
inhibitors; and phosphodiesterase 4 inhibitors.
Treatment considerations

Although doctors choose treatments based on the type and severity of psoriasis and the areas
of skin affected, the traditional approach is to start with the mildest treatments — topical
creams and ultraviolet light therapy (phototherapy) — and then progress to stronger ones
only if necessary. The goal is to find the most effective way to slow cell turnover with the
fewest possible side effects.

In spite of a range of options, effective treatment of psoriasis can be challenging. The disease
is unpredictable, going through cycles of improvement and worsening, seemingly at random.
Effects of psoriasis treatments also can be unpredictable; what works well for one person
might be ineffective for someone else. Your skin also can become resistant to various
treatments over time, and the most potent psoriasis treatments can have serious side effects.

Talk to your doctor about your options, especially if you're not improving after using a
particular treatment or if you're having uncomfortable side effects. He or she can adjust your
treatment plan or modify your approach to ensure the best possible control of your symptoms.

2.5 SIDE EFFECTS

 Goeckerman therapy
Goeckerman therapy is considered safe although use of tar may have the side-effects of
contact dermatitis and mild local burning due to tar hypersensitivity. A retrospective
study by Stern et al., of 1,373 patients concluded that there was an increase in skin
cancers in those receiving repeated Goeckerman treatments compared to the control
group. This has been refuted by other authors, including Pittelkow et al., who state there
has not been an increase in skin cancers among those treated compared to the general
population and Menter and Cran, who felt that the Stern study was too crude to have
validity and felt a 10-year prospective study would be needed to confirm safety concerns.
 photochemotherapy / psoralen plus ultraviolet A (PUVA)
Treatments are given no sooner than 48 hours apart because the burn (if there is one)
induced by PUVA is often delayed for as long as two days (unlike ordinary sunburns).
Unless there is a problem, the amount of energy administered to the patient is increased
appropriately at each visit depending on the patient's coloration. After about 30
 treatments, a decision is made as to whether to continue treatments. PUVA is not always
effective. If there is no improvement after these treatments, it is probably unlikely that
continuing this form of treatment is worthwhile. On the other hand, if significant clearing
has occurred, it is probably prudent to decrease the frequency of treatments in order to
maintain the improvement. Since there is a relationship between the amount of light
energy administered and the degree of photo-aging and the induction of skin cancers, it is
wise to limit the light exposures as appropriate.
 excimer laser

Excimer laser therapy causes blisters if the dose is too high, however these are confined
to the areas being treated. The aim of treatment is to deliver a dose that induces visible
redness in the psoriatic lesion (supraerythematous dose) but which doses not induce a
blister or second-degree burn.

Other side effects included erythema (redness), hyperpigmentation and erosions (sores).
In most cases these were tolerated well and didn’t require stopping of treatments.

Long term exposure to ultraviolet radiation ultimately causes skin ageing and skin
cancer. Although the risk from excimer laser therapy is unknown, research to date
suggests it is less risky than narrowband UVB as it doesn’t expose the whole body to UV
radiation.

 Retinoid

o Side Effect: Irritation, redness, and dry skin

Irritation from retinoids comes in many forms. When people say their skin is
irritated by a retinoid, they usually mean the retinoid makes their skin red and more
sensitive. Retinoids turn my skin a pinkish shade, especially immediately upon
application, and they make my skin feel prickly for one to two days afterwards. My
skin does seem to be a little more sensitive than the average person, but when I was
using Differin, it made my normal moisturizer and cleanser (sometimes even water)
sting. I had redness, almost to the point of itchiness, under my eyes and around my
cheekbones. My skin would also randomly flush red and hot and then disappear.

You can tell if something is irritation versus an allergic reaction if the symptoms
subside once you stop using the retinoid. I had to give my skin breaks every few
days to recuperate and after a day or two of not using retinoids, my skin went back
to normal.

Aside from redness and sensitivity, another common side effect of retinoids is dry
skin. Your skin may peel, flake, and be all kinds of ugly (regardless of how much
moisturizer you slather on) until it gets used to the retinoid. From personal
experience, my skin looked horrible under foundation when I was first using
Differin. There was nothing I could do to smooth out the skin-colored flakes, but
after I got used to Differin, the dryness gradually subsided.

o Side Effect: Irritation around the eyes

Retinoids should not be applied to your eyelids, but they can be used under your
eyes. When using retinoids around this delicate area, you have to be careful because
 the skin there is already thinner and more sensitive than other areas of your face. I
received an email from a reader saying that her eyelids got swollen after every time
she applied a retinoid, even though she wasn't putting the product anywhere near her
eyes. One reason could be because the natural oils on her face caused the product to
migrate. If your eyes are extremely sensitive, I would suggest putting a layer of
Vaseline around your eyes to protect them from any treatment products, retinoids or
otherwise.

o Side Effect: Initial breakouts and purging

Initial breakouts are another common side effect of retinoids. To tell if you are
purging or simply breaking out from the product (ingredients-wise), take a good
look at where your breakouts are occurring.

Purging is usually the worsening of already-present acne symptoms. So, for

example, if you have clogged pores, they may turn into bigger pimples. If you have
small whiteheads, they may turn into inflamed whiteheads. If you are experiencing
breakouts in areas of your face where you normally don’t break out or are
experiencing breakouts that occur in tiny, red clusters, you may be suffering from an
allergic reaction instead. Whatever you do, consult your dermatologist to see if you
should stick through with the acne flares or if you should switch to a new product.

o Side Effect: Sun sensitivity

Retinoids increase your skin's sensitivity to sunlight, making it more vulnerable to
harmful UV rays. Some researchers have also shown that natural retinoids can break
down and turn toxic (though more has to be studied) in daylight. While retinoids can
help repair sun damage, not protecting your skin from the sun while using retinoids
can potentially cause you to get more sun damage.

o Retinoid use with other products

It's also a good idea to avoid using any exfoliants while you are on retinoids.
Chemical or manual exfoliation could cause your skin to be even more sensitive and
irritated. Retinoids offer a hefty amount of exfoliation on their own. However, if you
feel like your retinoid is not strong enough, you can use AHAs or BHAs for extra
exfoliation.

Some people believe that AHAs and BHAs can help increase a retinoid's
penetration. However, it will depend on the formulation of the product. For example,
if you use a BHA lotion, the emollients in the lotion may decrease penetration more
than the acid would increase penetration. But if you use a BHA liquid or something
alcohol-based, it may enhance penetration.

o Retinoids during pregnancy

Lastly, do not use retinoids while pregnant, breastfeeding, or trying to conceive.
Retinoids, like all other skin care products, are absorbed into the body through your
skin. Since there haven't been enough studies done on how retinoids affect
developing fetuses, it's best to go the safe route and not use them at all.

 Methotrexate
 Nausea, vomiting, stomach pain, drowsiness, or dizziness may occur. If any of these
effects persist or worsen, tell your doctor or pharmacist promptly.

Temporary hair loss may occur. Normal hair growth should return after treatment has
ended.

Remember that your doctor has prescribed this medication because he or she has
judged that the benefit to you is greater than the risk of side effects. Many people
using this medication do not have serious side effects.

Tell your doctor right away if you have any serious side effects, including: mouth
sores, diarrhea, signs of anemia (such as unusual tiredness, pale skin), signs of liver
problems (such as dark urine, persistent nausea/vomiting, stomach/abdominal pain,
yellowing eyes/skin), easy bruising/bleeding, black stools, enlarged glands/lymph
nodes, bone pain, unusual pain and discoloration of the skin, signs of kidney problems
(such as change in the amount of urine), dry cough, muscle weakness.

Get medical help right away if you have any very serious side effects, including:
weakness on one side of the body, neck stiffness, severe headache, vision changes,
irregular heartbeat, mental/mood changes, seizures.

This medication may lower your ability to fight infections. This may make you more
likely to get a serious (rarely fatal) infection or make any infection you have worse.
Tell your doctor right away if you have any signs of infection (such as fever, chills,
persistent sore throat, cough).

This medication can affect sperm production, an effect that may lower male fertility.
Consult your doctor for more details.

A very serious allergic reaction to this drug is rare. However, get medical help right
away if you notice any symptoms of a serious allergic reaction, including: rash,
itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble
breathing.

 Cyclosparine

Shaking, headache, dizziness, unusual growth of body hair, nausea/vomiting,

diarrhea, stomach upset, or flushing may occur. If any of these effects last or get
worse, tell your doctor or pharmacist promptly.

Unusual growth and swelling of the gums may occur. Brush your teeth and floss daily
to reduce this problem. See your dentist regularly.

Remember that your doctor has prescribed this medication because he or she has
judged that the benefit to you is greater than the risk of side effects. Many people
using this medication do not have serious side effects.

This medication may raise your blood pressure. Check your blood pressure regularly
and tell your doctor if the results are high. Your doctor may control your blood
pressure with medication.
 Any serious side effects, including: signs of kidney disease (such as a change in the
amount of urine), signs of liver disease (such as nausea/vomiting that doesn't stop,
dark urine, yellowing eyes/skin, stomach/abdominal pain), easy bruising/bleeding,
unusual tiredness, muscle weakness/spasms, slow/irregular heartbeat, numb/tingling
skin, severe leg pain.

Get medical help right away if any very serious side effects, including: mental/mood
changes (such as confusion, difficulty concentrating), vision changes, problems with
speech, clumsiness, loss of coordination, weakness on one side of the body, chest
pain, seizures.

A very serious allergic reaction to this drug is rare. However, get medical help right
away if you notice any symptoms of a serious allergic reaction, including: rash,
itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble
breathing.

 Sunlight

Causes skin cancer – UV is an environmental human carcinogen. It’s the most

prominent and universal cancer-causing agent in our environment. There is very
strong evidence that each of the three main types of skin cancer (basal cell carcinoma,
squamous cell carcinoma and melanoma) is caused by sun exposure. Research shows
that as many as 90% of skin cancers are due to UV radiation.
Causes sunburn - UV burns the skin. Sunburn is a burn that occurs when skin cells are
damaged. This damage to the skin is caused by the absorption of energy from UV
rays. Extra blood flows to the damaged skin in an attempt to repair it, which is why
your skin turns red when you are sunburnt.
Damages immune system – Over-exposure to UV radiation has a harmful suppressing
effect on the immune system. Scientists believe that sunburn can change the
distribution and function of disease-fighting white blood cells in humans for up to 24
hours after exposure to the sun. Repeated over-exposure to UV radiation can cause
even more damage to the body's immune system. The immune system defends the
body against bacteria, microbes, viruses, toxins and parasites (disease and infection).
You can see how effective the immune system is by looking at how quickly
something decays when it dies and the immune system stops working.
Damages eyes – Prolonged exposure to UV or high intensities of UV (for example, in
sunbeds) damages the tissues of eyes and can cause a ‘burning’ of the eye surface,
called ‘snow blindness’ or photokeratitis. The effects usually disappear within a
couple of days, but may lead to further complications later in life. In 1998, the Journal
of the American Medical Association reported that even low amounts of sunlight can
increase the risk of developing eye damage such as cataracts (which, left untreated,
will cause blindness), pterygium and pinguecula. UV damage to the eyes is
cumulative, so it is never too late to start protecting the eyes.
Ages skin – UV speeds up the aging of skin, since the UV destroys collagen and
connective tissue beneath the top layer of the skin. This causes wrinkles, brown ‘liver’
spots and loss of skin elasticity. The difference between skin tone, wrinkles, or
pigmentation on the underside of a person's arm and the top side of the same arm
illustrate the effects of sun exposure on skin. Usually, the top side of the arm has had
more exposure to the sun and shows greater sun damage. Because photo-aging of the
 skin is cumulative, it is never too late for a person to start a sun protection
programme. Otherwise, though a tan may look good now, you could be paying for it
with wrinkly leathery skin or skin cancer later.
Weakens plastics – Many polymers used in consumer items (including plastics, nylon
and polystyrene) are broken down or lose strength due to exposure to UV light.
Fades colours – Many pigments (used for colouring food, cosmetics, fabric, plastic,
paint, ink and other materials) and dyes absorb UV and change colour. Fabrics,
furnishings and paintings need protection from UV (fluorescent lamps as well as
sunlight) to prevent colour change or

 Narrow Band UVB

Narrow-band UVB can result in burning, just like sunlight and broadband UVB.
Frequent emollients should be applied to burned skin, and if recommended by the
therapist, topical steroids. It sometimes provokes polymorphous light eruption.
Long term exposure to ultraviolet radiation ultimately causes skin ageing and skin
cancers. In theory, less UV exposure occurs because the patient is only exposed to
therapeutic wavelengths. Although the risk from narrow-band UVB is unknown,
research to date suggests it is no more risky than broadband UVB and probably less
risky than photochemotherapy (PUVA).

The epidermis is a complicated organ. For years we've been told to moisturize our
skin to keep it hydrated, but now some are calling to question whether this is actually
harmful to the skin's natural process. To moisturize or not, that is the question.

It's probably key to understand how the skin functions. Normal skin has oil producing
sebaceous glands that naturally lubricate the skin and keep it properly hydrated by
preventing excessive water loss or absorption. Natural moisturizing factors (NMF) are
free amino acids and other chemicals present in the stratum corneum that are
responsible for keeping the skin moist and pliable by attracting and holding water, a
property called hygroscopic.

The major factor responsible for dry, scaly skin can therefore be related to the loss of
water from the stratum corneum, which fluctuates with environmental humidity
levels, damage to the barrier by denaturing keratin protein, removing NMF and
interrupting lipid bilayers. Dry skin arises from distress or damage to the skin's lipid
barrier - structural deterioriation exposes skin cells to external threats and contributes
to trans-epidermal water loss (TEWL) as cells become dehydrated. This could also
occur from using solvents, detergents, excessive use of water and soap and other
irritating chemicals.

Moisturizers work to prevent water loss by coating the skin with a substance to trap
moisture - replicating what the healthy sebum balance does normally. Studies show
that for dry skin syndromes like xerosis, moisturizers are effective. But some believe
that topical hydrators should support the natural hydration process rather than simply
supplementing moisture. The moisturizer may offer temporary relief, but the cell
disruption must be isolated and corrected for dry skin to actually be alleviated.

Regardless, how, then, would moisturizers themselves be harmful to the natural

hydration process? Dermatologist Dr. Zein Obagi says that when cells recognize that
 an outside source has already hydrated the skin, there's no need for natural hydration
to take place. This means that the cells become inactive and stop the moisture
production process, which leads to dry skin. The doctor likens it to a moisturizer
addiction.

Dr. Hauschka has a similar theory. He advises against using a night cream because
regular application interferes with the tasks your skin undergoes at night like
regenerating, balancing oil production and expelling impurities. Based on this theory,
regular application over time means that the skin becomes less able to care for itself.

Studies do show that over time, moisturizer use has an impact on the skin. A study
from the University of Copenhagen confirmed that skin barrier function could be
adversely affected by use of moisturizers. In the study, transepidermal water loss was
significantly higher on the arm treated with moisturizer than on the control arm,
which suggests that long-term treatment with moisturizers on normal skin may
increase susceptibility to irritants. But, it isn't quite clear if the natural hydration
process is quelled because of the moisturizers' regular hydration or if the other
ingredients in them are simply damaging the cells and causing irritation.

A study in the American Journal of Clinical Dermatology suggests that certain types
of emulsifiers may weaken the skin barrier. Other studies pose questions as to whether
moisturizers' inherent capacitance is a source of false positive results.

Too much moisturizing comes with other problems as well. Oil based moisturizers
can run the risk of clogged pores and water-friendly ingredients like glycerin, which is
supposed to attract and retain moisture, can only do so at a level of humidity above
70%.

The key may be to not overuse moisturizer if it isn't needed. For those of us with
normal skin, developing a dependence on moisturizer is just not necessary, especially
when our complicated epidermis has the functions in place to keep us hydrated and
well. And for those prone to dry skin, it may be necessary to find a deeper solution
than just slopping on a standard moisturizer.

 Coal Tar

Applies to coal tar topical: topical bar, topical cream, topical emulsion, topical foam,
topical gel/jelly, topical kit, topical liquid, topical lotion, topical ointment, topical
shampoo, topical soap, topical solutionIn animal studies, coal tar has been shown to
increase the chance of skin cancer.
In addition to its needed effects, some unwanted effects may be caused by coal tar
topical. In the event that any of these side effects do occur, they may require medical
attention.
Severity: Moderate
If any of the following side effects occur while taking coal tar topical, check with
your doctor or nurse as soon as possible:
Rare
o Skin irritation not present before use of this medicine
o skin rash
 Minor Side Effects
Some of the side effects that can occur with coal tar topical may not need medical
attention. As your body adjusts to the medicine during treatment these side effects
may go away. Your health care professional may also be able to tell you about ways
to reduce or prevent some of these side effects. If any of the following side effects
continue, are bothersome or if you have any questions about them, check with your
health care professional:
More common:
Stinging (mild)—especially for gel and solution dosage forms
Not all side effects for coal tar topical may be reported. You should always consult a
doctor or healthcare professional for medical advice. Side effects can be reported to
the FDA here.
Get emergency medical help if you have any of these signs of an allergic reaction:
hives; difficult breathing; swelling of your face, lips, tongue, or throat.
Stop using this medicine and call your doctor at once if you have:
severe stinging, burning, swelling, or other irritation of the treated skin.
Common side effects may include mild skin irritation or skin rash.

 Salicylic Acid

Applies to salicylic acid topical: topical cream, topical dressing, topical foam, topical
gel/jelly, topical liquid, topical lotion, topical ointment, topical pad, topical paste,
topical shampoo, topical soap, topical solution, topical stick
As well as its needed effects, salicylic acid topical may cause unwanted side effects
that require medical attention.
Major Side Effects
If any of the following side effects occur while taking salicylic acid topical, check
with your doctor immediately:
Less common or rare:
Skin irritation not present before use of this medicine (moderate or severe)
Incidence not known:
o Difficult breathing
o dryness and peeling of skin
o fainting
o hives or itching
o redness of the skin
o swelling of the eyes, face, lips, or tongue
o tightness in the throat
o unusually warm skin
If any of the following symptoms of overdose occur while taking salicylic acid
topical, get emergency help immediately:
Symptoms of overdose:
o Confusion
o diarrhea
o dizziness
o fast or deep breathing
o headache (severe or continuing)
o hearing loss
o lightheadedness
o nausea
 o rapid breathing
o ringing or buzzing in the ears (continuing)
o severe drowsiness
o stomach pain
o vomiting

Minor Side Effects

Some salicylic acid topical side effects may not need any medical attention. As your
body gets used to the medicine these side effects may disappear. Your health care
professional may be able to help you prevent or reduce these side effects, but do
check with them if any of the following side effects continue

 Topical Corticosteroids

Side effects: in contrast to the able and very strong, moderate and weak corticosteroid
group rarely cause side effects. The stronger the preparations, the more it needs to be
careful, because the absorption of the skin can cause Cushing's syndrome and adrenal
suppression (see 8.3.2) depending on the area of the body treated and duration of
treatment. Keep in mind that the highest absorption occurs on the skin is thin, the
rough surface and the folds of skin and absorption is enhanced by occlusion.

Local side effects include:

Spreading and worsening of untreated infection;
Thinning of the skin that is not necessarily recovered after treatment was discontinued
due to the original structure probably will not be back
Striae atrofis settled;
Contact dermatitis;
Perioral dermatitis;
Acne, exacerbation of acne or rosacea;
Depigmentation light; which may be temporary, but may persist as white patches;
Hypertrichosis.
To minimize side effects of topical corticosteroids, the use of these preparations
should be applied to thin it in the area to be treated and corticosteroid use very little
strength but effective.
The frequency of application: The preparation of corticosteroids should be
administered once or twice daily alone. No need to rub this drug more often. Topical
corticosteroids leveled thinly on the skin. Length / amount of ointment / cream is
removed from the tube can be used to determine the amount of drug applied to the
skin. Here is a great packaging corticosteroid dosage appropriate prescribing for
specific body areas.
o Face and neck 15 to 30 g
o Hands of 15 to 30 g
o Scalp 15 to 30 g
o Sleeve 30 to 60 g
o Legs 100 g
o Body 100 g
o Groin and genitalia of 15 to 30 g

This amount is usually appropriate for an adult to use twice a day for a week. Mixing
topical skin preparations se-can possibly be avoided, preferably at least 30 minutes
 between the intermittent use of different dosage. The use of emollients shortly before
the use of corticosteroids is inappropriate.

 Vitamin D

Vit D is a drug-free, but also necessary in consuming the appropriate dose that does
not happen things - things that are not desirable. Vita D dose given to a patient to be
considered based on several factors, including the age of the patient, the patient's
health, and also the severity of the disease suffered by the patient.
In general, the dose given by the physician to overcome the shortage of medicine
Vitamin D is 1,000 International Units, or 25 micrograms per day.

 Anthralin

Doctors sometimes use a 15 - to 30-minute application of anthralin ointment, cream,

or paste to treat chronic psoriasis lesions. However, this treatment often fails to
sufficiently clear lesions, may irritate the skin, and skin blemishes and clothing brown
or purple. In addition, anthralin unsuitable for acute or actively inflamed eruptions.

 Topical Retinoids

The retinoid tazarotene (Tazorac) is a fast-drying, clear gel applied to the skin surface.
Although this preparation does not act as quickly as topical corticosteroids, has fewer
side effects. Because the normal skin irritant, should be used with caution in skin
folds. Women of childbearing age must use contraception while using tazarotene.

 Calcineurine Inhibitor

Blood drug concentration measurements should be used to minimize the adverse

effects of these agents and ensure adequate immunosuppression. The most widely
used measure of calcineurin inhibitor exposure is the predose trough concentration;
however, some authors debate its ability to accurately predict outcomes in kidney
transplant recipients.[10] Proposed alternatives include the area under the
concentration-time curve (AUC) at 4 hours (AUC0–4 ) and 12 hours (AUC0–12 hr)
and blood drug concentrations at 2, 3, or 4 hours after administration. Therapeutic
cyclosporine concentrations differ with the measurement technique, institution,
surgical procedure, and protocol. In general, the therapeutic trough whole blood and
serum concentrat and 100-300 and 75-150 ng/mL, respectively, when measured with
high-performance liquid chromatography.[3,4] Therapeutic trough whole blood
concentrations of tacrolimus are 15-20 (initial concentration), 10-15 (at one month),
and 5-12 ng/mL (at three months posttransplantation) (equivalent to free plasma
concentrations of 0.5-2 ng/mL).[5] Published serum concentrations for the calcineurin
inhibitors are only a guide, and individual therapy should be tailored specifically to
each patient based on risk factors and the clinical situation

 Salicylic Acid

Salicylic acid is used to remove scales, and are most effective when combined with
topical steroids, anthralin, or coal tar.
However, as with other drugs, salicylic acid also has side effects, ranging from mild
to severe. Some minor side effects that often occur is dry skin.
If this happens, lightweight oil-free moisturizer can usually help overcome dry skin.
Skin irritation is a common side effect caused by salicylic acid.Other side effects are
serious, usually called salicylic acid poisoning, including the severe headaches, rapid
breathing, or ringing in the ears.
 CHAPTER III

CONCLUTION

Psoriasis is a chronic autoimmune disease. The exact cause of psoriasis is unknown, but it
generally occurs due to a combination of genetic factors and environmental triggers cause
disease. Psoriasis treatment options depend on the severity of the disease, as well as the
impact on quality of life, and may include topical treatment, systemic medications,
phototherapy, and complementary alternative medicine.