Inflammatory Reactions of the Skin: Psoriasis

Inflammatory Reactions of the Skin

• Psoriasis: A chronic, non-contagious, inflammatory autoimmune disease characterized by hyper-proliferation.
  • Etiology: Autoimmune, likely with a genetic component, exacerbated by smoking, obesity, alcohol use, and infections.
  • Epidemiology: More common in Caucasians and certain age groups.
  • Signs & Symptoms: Erythematous papules and plaques covered in silvery scales, severe itching (pruritus), Auspitz's sign (punctate bleeding upon scraping), Koebner phenomenon (new psoriasis develops at sites of skin trauma). Common affected areas include scalp, extensor surfaces, back, chest, groin, armpits.
  • Common Comorbidities: Psoriatic arthritis (5-30% of psoriasis patients), characterized by joint pain, stiffness, swelling, and tenderness. Nail bed involvement (1/3 of psoriasis patients).
  • Diagnosis: Clinical examination, skin biopsy for complex cases.
  • Treatment: Topical corticosteroids, over-the-counter moisturizers, controlled UV light, antihistamines for pruritus. Massage is a local contraindication if broken skin is present, light massage may be performed with patient consent.
• Rosacea: A chronic, progressive, erythematic skin condition causing facial redness.
  • Etiology: Idiopathic, with possible genetic and/or immune system involvement.
  • Epidemiology: Most common age range 30-50, more common in females and those with fair complexions.
  • Signs & Symptoms: Persistent facial erythema, dryness, warmth, swelling, tiny pustules, telangiectasia (spider veins), thickened skin, possible rhinophyma (bulbous nose). Symptoms tend to have flare-up/remission phases. Triggered by various factors.
  • Rosacea Phases: Pre-rosacea (redness), vascular (spider veins), inflammatory (acne), late-stage (rhinophyma).
  • Treatment: Avoiding known triggers (sunlight, exercise, extreme temperatures, spicy foods, alcohol). Topical antibiotics for inflammatory phase. No cure exists.
  • Prognosis: Increased risk of migraines; association with IBD, celiac disease, IBS/SIBO. Massage is affected by the severity of the disease; avoiding areas with pustules.
• Hidradenitis Suppurativa: A chronic, scarring, acne-like inflammatory process, most common in axillae, groin, and around nipples and anus.
  • Etiology: Idiopathic, hair follicle blockage potentially related to hormonal imbalances, genetics, smoking, or obesity.
  • Symptoms: Small, painful nodules under the skin, followed by pus drainage, painful fibrotic bands in chronic cases, foul odor. No pruritus.
  • Treatment & Prognosis: Drug therapy not always effective, but potentially topical antibiotics and steroids, warm compresses to drain, laser hair removal, surgical excision. Can cause scarring.
  • Massage: Local contraindication due to pustules. Inquire about patient sensitivity.

Drug Eruptions and Reactions

• Erythema Multiforme: An inflammatory reaction characterized by target-shaped skin lesions, oral mucosa involvement, considered a type IV hypersensitivity reaction.
  • Etiology: Primarily triggered by herpes simplex virus (HSV).
  • Symptoms: Mildly itchy, symmetrically distributed red, raised skin with target lesions, blistering, and mucous membrane involvement. Potential for oozing blood. Systemic symptoms like fatigue, joint pain, and fever.
  • Treatment: Self-limiting (2-4 weeks), antiviral treatment if HSV is the cause. Massage is a local contraindication until lesions have fully healed.
• Stevens-Johnson Syndrome (SJS): Life-threatening type IV hypersensitivity reaction with dermis separation from epidermis, involves mucous membranes.
  • Etiology: Primarily due to medications (especially sulfa drugs). Infections can also be a cause.
  • Symptoms: Severe blistering, pain when moving mouth/eating (drooling), dysphagia, painful eye swelling with pus, dysuria with genital involvement. Systemic symptoms (fever, fatigue, sore throat).
  • Treatment: Supportive care (analgesics, IV fluids, NG tube/parenteral nutrition). Massage is a contraindication until full recovery.
• Urticaria (Hives): Inflammatory skin disorder usually associated with allergic reactions (Type I hypersensitivity).
  • Etiology: Allergen triggers immune response (medications, insect bites, foods, idiopathic).
  • Symptoms: Itching followed by wheals (small, elevated lesions) and flares (surrounding redness), often last few hours, immediate appearance. Angioedema (edema of deeper tissues) is a serious complication.
  • Treatment: Oral antihistamines, topical corticosteroids, monitor for lesions around mouth, hives in throat can be life-threatening. EpiPen for anaphylaxis. Massage is contraindicated in acute/allergic urticaria, and is a local contraindication in chronic cases.

Pressure/Decubitus Ulcers

• Definition: Breakdown of skin integrity due to prolonged pressure, reduced blood flow, and tissue necrosis.
  • Etiology: Prolonged pressure (bedridden, wheelchair-bound, casts), paralysis, coma, diabetes.
  • Stages:
    • Stage I: Non-blanchable erythema of intact skin.
    • Stage II: Partial thickness skin loss with exposed dermis.
    • Stage III: Full thickness skin loss to subcutaneous fat.
    • Stage IV: Full thickness skin loss to muscle/bone.
  • Treatment: Repositioning of the client, medical treatment (wound care specialist), antibiotics for infection.
  • Massage: Local contraindication, avoid working over infected or discharging ulcers.

Dermatitis

• Definition: Superficial inflammation of the skin, common presentations including pruritus, redness, edema, oozing, crusting, and scaling.
• Types:
  • Atopic Dermatitis (Eczema): Most common inflammatory skin disorder, immune-mediated inflammation, often linked with asthma and allergies. Triggers include food, environmental allergies, stress, humidity, and irritation.
  • Primary Irritant Contact Dermatitis: Inflammation due to contact with irritant non-immunological response, symptoms resolve within days of removal of the irritant.
  • Allergic Contact Dermatitis (ACD): Type IV delayed hypersensitivity reaction, rash at the site of contact, caused by exposure to allergens like cosmetics, metals, plants, or chemicals.
  • Phototoxic Dermatitis: Skin reaction within minutes/hours after sun exposure to light-absorbing substances, no allergy reaction.
  • Photoallergic Dermatitis: Type IV cell-mediated immune response 1-3 days after sun exposure to photosensitizing agents, prior exposure required.
  • Stasis Dermatitis: Inflammation of the lower legs due to chronic venous insufficiency (blood/fluid pooling). Risk factors include history of DVT, varicose veins, obesity, pregnancy, lack of physical activity, and smoking.

Neurodermatitis (Localized Scratch Dermatitis or Lichen Simplex Chronicus):

• Chronic, itchy inflammation that leads to thickened epidermis. Linked to psychogenic factors.
• Etiology: Unknown; potentially psychological factors, anxiety, stress.
• Symptoms: Itchy, dry, scaling rash with dark, thickened patches resulting from the itch-scratch cycle. Common areas include arms, legs, neck, anus, vagina.
• Treatment: Address the cause of the itching (psyc psychological factors). Patient education regarding scratching, topical corticosteroids, antihistamines.

Seborrheic Dermatitis:

• Chronic inflammatory disease of skin rich with sebaceous glands (like "cradle cap").
• Etiology: Associated with the yeast Malassezia Furfur, weakened immune system, stress, cold/dry climate, diet, and/or genetics.
• Symptoms: Pruritus, dandruff, yellow, greasy flakes due to excess sebum. Common on face, hairline, scalp.
• Treatment: Anti-inflammatory shampoos, antifungal topicals.
• Massage: Assess patient history, sensitivity, and use thin, water-based lubrication.

Perioral Dermatitis:

• Dermatitis surrounding the mouth, often mistaken for acne or rosacea.
• Etiology: Idiopathic, often associated with topical steroid use.
• Symptoms: Acne-like papules/pustules, scaling, erythema, but NO pruritus. Often limited to immediately around the mouth.
• Treatment: Remove potential triggers, appropriate antibiotic/anti-inflammatory creams

Neoplasms of the Skin

• Melanocytic Nevi (Moles): Atypical or dysplastic moles need further evaluation due to potential for melanoma. (ABCDEs: A=asymmetry, B=borders, C=color, D=diameter, E=evolving).
• Malignant Melanoma: UV light exposure = primary cause, fast growing, metastases, early detection crucial for high survival rate.
• Basal Cell Carcinoma (BCC): Most common skin cancer, never metastasizes, appears as a pearly white nodule, 100% 5-year survival rate if detected early.
• Basosquamous Carcinoma (BSC): Rare, aggressive cancer, BCC with mutation/differentiation, high risk of UV exposure.
• Sebaceous Neoplasm: Often benign, but may be malignant, may mimic other tumors.
• Cutaneous Papilloma (Skin Tag): Benign skin growth, common in regions where skin rubs, may be associated with HPV.
• Massage: All neoplasms are local contraindications. Follow cancer guidelines, observant of new lesions, encourage doctor evaluations.

Ichthyosis:

• Over 30 diseases with similar presentations, involving redness, itchiness, and flaky skin.
• Etiology: Genetic mutation /inheritance.
• Symptoms: Varying, but commonly involve redness, pruritus, flaky/leathery skin, large/hard plates.
• Treatment: Varies depending on the type. Typically involves skin moisturizing creams.
• Massage: Not contraindicated, but may be sensitive skin.

This quiz covers the inflammatory skin condition known as psoriasis, including its etiology, epidemiology, signs and symptoms, and common comorbidities. It also discusses diagnosis and treatment options available for managing this chronic autoimmune disease.