Junior teaching

presented by
Mr. vinay kumar
M.Sc. Nursing 1st year
HCN, SRHU

Anatomy and Physiology of
The Integumentary System

STRUCTURE OF SKIN
• The skin is the largest organ in the body,
it includes glands , hair, and nails .
• The two main layers of skin:
1. Epidermis
2. Dermis
3. Between the skin and underlying
structure subcutaneous layer, which
composed of areolar tissues and
adipose tissues.

EPIDERMIS
Thinner and more superficial layer
of the skin.
The epidermis is made up of 4 cell
types:
A. Keratinocytes
B. Langerhans Cells
C. Melanocytes
D. Merkel cells

(A)Keratinocytes– Produce a fibrous protein, keratin, which
protect the skin.
(A) Melanocytes- Gives colour to skin and hair and protects
the body from ultraviolet sunlight.
More melanin results in darker skin colour
(C) Langerhans Cells– participate in immune response.
(D) Merkel cells- participates in the sense of touch.

LAYERS OF EPIDERMIS
Stratum Basale: Bottom layer, and has
column-shaped cells.
single row of cells attached to dermis.
Stratum spinosum: Squamous cell layer,
and thickest layer of the epidermis.
Made up of bundles of keratinocytes
protein, and also contains Langerhans
cells that help prevent infection.

LAYERS OF EPIDERMIS
Stratum granulosum:This
layer contains more keratinocytes.
Stratum lucidum:
This layer exists only on the palms of
the hands and soles of the feet.
Stratum corneum: Outermost or top
layer of the epidermis.
It's made of dead, flat keratinocytes that
shed approximately every two weeks.

NOTE:
• The stratum spinosum and stratum Basale collectively form
the so called germinative zone (where new cells are
germinated).
• The stratum corneum , stratum lucidum , and stratum
granulosum combinedly form the so called cornified zone.

DERMIS
Deeper, and thicker layer composed by
connective tissue, blood vessels, nerves, glands
and hair follicles.
• There are two main layers of the dermis:
• Papillary layer formed of loose areolar
connective tissue containing bundles of
collagen, and elastic tissues.
• Reticular layer Made up of dense irregular
connective & adipose tissue, contains sweat
glands, sebaceous glands, & blood vessels.

STRUCTURE OF DERMIS
• The dermis contains several specialized cells and structures,
including:
• Receptors
• Blood vessels
• nerve endings
• Hair follicles
• Sebaceous glands

SENSORY RECEPTORS OF SKIN
 Meissner’s Corpuscle:
light pressure
 Pacinian Corpuscle:
deep pressure
 Free nerve ending :
pain

BLOOD VESSELS AND NERVE ENDINGS
BLOOD VESSELS
Arterioles from fine network with capillary
branches supplying blood to sweat glands ,
sebaceous glands , hair follicles and the
dermis.
SENSORY NERVE ENDINGS:
• They are sensitive to pain, touch,
temperature, pressure and pain.

Hair follicles
 part of the skin, which grows a hair
 Hair grows on most of the body except
lips, the palms of the hands, and the
soles of the feet.
 The colour of the hair is a result of
heredity and is determined by the type
and amount of melanin in the hair
shaft.
 • Hair grows approximately 1 cm per
month.
 • On average 100 hairs are lost each
day

SEBACEOUS GLAND
 Glands are distributed over
the entire body except palms
of the hands and the soles of
the feet.
 Most abundant on the scalp
and face.

NAILS
Nails are plates of tightly packed,
hard, keratinized epidermal cells.
The nail consists of:
nail root: -the portion of the nail
under the skin,
nail body: -the visible pink
portion of the nail, the white
crescent at the base of the nail is
the lunula.
free edge: -the white end that may
extend past the finger.

FUNCTIONS OF SKIN
• Thermoregulation
• Cutaneous sensation
• Vitamin D production
• Protection
• Absorption & secretion
• Wound healing

Introduction
• The word psoriasis is derived from Greek word ‘psora’ means ‘itching’
and iasis, means "action, condition”.
• Chronic skin disease result in red patches on skin that covered with the
silvery scales.
• These patches are referred as plaque which usually occur on the elbow,
knees, legs, scalp, lower back, face, palm and sole of the feet, nails too

Definition
According to www.mayoclinic.com,
“ psoriasis is defined as a persistent
skin disease causes cell to build
rapidly on the surface of the skin,
forming thick silvery scales, itchy, dry
and red patches.”

Dry flakes of skin scales is due to excessively rapid hyperproliferation
of the keratinocytes cells in the epidermis skin.
Hyperproliferation is triggered by inflammatory chemicals produced by
specialized white blood cells called T-lymphocytes.
Injury to the skin can trigger psoriatic skin changes at that spot, which
is known as the Koebner phenomenon
Psoriasis varies in severity from small, localized patches to complete
body coverage.

1-3% and in America and western.
 Lower rates are found in Japanese and psoriasis is rare in
West Africans.
 Psoriasis first appears during 2 peak age ranges:The first peak occurs
in persons aged 16-22 years, and the second occurs in persons aged
57-60 years.
INCIDENCE

CAUSES RISK FACTORS
Idiopathic Genetics
Autoimmune reaction
chronic Infection
 Injury to skin
Vitamin D deficiency
Lifestyle
stress, and changes in season
and climate.

Others condition include-
 hot water,
scratching psoriasis skin lesions,
skin dryness,
excessive alcohol consumption,
cigarette smoking, and obesity
Medication: lithium
antimalarial medications,
NSAID- indomethacin

Etiological factor
HYPERACTIVE OF T-CELLS
EPIDERMIS INFILTRATION AND KERATINOCYTE HYPER
PROLIFERATION
DEREGULATED INFLAMMATORY PROCESS

LARGE PRODUCTION OF VARIOUS
CYTOKINES ( INTEFERRON, INTERLEUKIN-12
SUPERFICIAL BLOOD VESSEL DILATED
AND VASCULAR ENGORGEMENT
EPIDERMAL HYPERPLASIA AND IMPROPER
CELL MATURATION

FAILS TO RELEASE ADEQUATE LIPIDS WHICH LEAD TO
FLAKING, SCALING PRESENTATION OF PSORIASIS
LESION
SILVER SCALING OF
SKIN

CLASSIFICATION
Types of psoriasis include: -
1. Plaque psoriasis
2. Guttate psoriasis
3. Inverse psoriasis
4. Pustular psoriasis
5. Erythrodermic psoriasis
6. Nail psoriasis
7. Psoriatic arthritis

 Most common type of
psoriasis.(85%–90% of people)
 Also known as psoriasis vulgaris,
 Inherited systemic inflammatory
disease of immune dysfunction that
causes plaques of elevated, scaling,
inflamed skin that is quite itchy.
PLAQUE PSORIASIS ("vulgaris" means common)

Appearance- raised, inflamed, red
skin covered by silvery patches or
scales.
Signs and symptoms-
 severe itching, swelling, and
pain
 small scaly, red bumps.
 These bumps generally join
together into elevated plaques of
skin

 Occurs in those who have inherited genetic predisposition of
psoriasis
 Triggering condition is streptococcal bacterial (throat) infection
followed within two to three weeks of skin eruption.
 The disease may recur if the person is a strep carrier -(recurrent
streptococcal bacterial infection in respiratory system).
GUTTATE PSORIASIS (Latin Gutta=drop)

Appearance-
Small, pink dot like lesion. 0.5 to 1.5 cm.
Round to oval lesion over the upper trunk and
proximal extremities.
The number of lesions can range from 5 to
over 100.
Sign and symptoms- Dry red spot with mild
itching.
If dry skin is removed, then red skin beneath
with white, dry areas marking where flakes of
dry skin is appear.
Sites: usually occurs on the trunk, arms, or legs.

 Also known as intertriginous psoriasis.
 commonly seen in obese client.
 Painful and irritating, due to friction between skin
folds.
Appearance Scaling is usually minimal or absent, and
the lesions appear glossy, smooth and bright red.
Sites Skin folds, such as the axilla, inguinal behind the
knee, under the arm or in the groin
INVERSEPSORIASIS -(skin folds)

 Usually uncommon.
 serious in all type of psoriasis.
 Children 2-10 years of age and in young below
50 year can affected
Appearance raised bumps that are filled with a
white, thick fluid composed of white blood cells.
Sites mostly at hands and feet.
֍ Serious condition so immediate medical
attention is required.
PUSTULARPSORIASIS

least common type of psoriasis.
Large area of the skin becomes bright red,
inflamed, and scaly.
Appearance skin covered in a red, peeling rash.
The rash usually itches or burns.
Sites it may affects all body sites
Causes: sun burn, allergic reaction, strong coal
product use.
ERYTHRODERMIC PSORIASIS

 It is a disease in which a person may
have both psoriasis and
inflammatory arthritis.
 Psoriatic arthritis is a potentially
destructive and deforming form of joint
disease.
 Rarely, a person can have psoriatic
arthritis without having skin psoriasis.
PSORIATICARTHRITIS

Count……
The most distinctive features of
psoriatic arthritis are -
• Distal interphalangeal joint
arthritis
• Dactylitis (inflammation of an
entire digit (a finger or toe), and it
can be painful

 The blue arrow = a normal joint
space
 Red arrow = “cup and saucer”
effect of the fourth metatarsal
bone being jammed into the base
of the fourth toe
 The yellow circle = “Pencil
appearance” destruction
characteristic of the disease

 Commonly seen with psoriatic arthritis.
 Affect the fingernails and toenails.
 It cause a number of changes to the nail area.
Clear yellow-red nail, discolouring that looks
like a drop of oil under the nail plate may occur.
 Little pits may form in the nails. These pits
develop when cells are lost from the nail's
surface
 Treated by steroid injected- into nail or light
therapy
NAIL PSORIASIS

 Pain
 Itching
 Burning
 Restricted joint motion or pain
 Cracked and bleeding skin
 Dandruff on scalp Pus filled blisters Genital lesions in males.
 Pitting, small depression on the surface of the nail Yellow,
discoloured nail Koebner phenomenon
 Arthritis

• History collection
Present health history
Past health history
• Physical examination
• CBC (complete blood count)

• Skin biopsy
• Joint radiographs: Can facilitate the diagnosis of psoriatic arthritis
• Radiographs of affected joints: Can be helpful in differentiating
types of arthritis
• Bone scans: Can identify joint involvement early
• Dermatologic biopsy: Can be used to make the diagnosis when
some cases of psoriasis are difficult to recognize (e.g. pustular
forms)

Medical management
Aim
• Interrupt the cycle that cause an increased production of skin
cells thereby reducing inflammation and plaque formation.
• - Remove scales and smooth skin, which is particularly remove
by topical treatment.

Psoriasis treatment is divided into three main type:
• Topical treatment
• Light therapy
• systemic medications
• Alternative medicine

A- TOPICAL
1. Topical steroid
2. Vitamin d analogous
3. Coal tar
4. Topical retinoid
5. Immunomodulating agent
6. Emollients

1- STEROIDMEDICATION
First-line therapy in mild to moderate psoriasis
Improvement is usually achieved within 2 to 4 weeks.
They slow the cells turnover by suppressing the immune
system which reduce inflammation and relieves
associated itching.

Strong corticosteroids use for smaller area of skin like hands
and feet.
Long term use may cause thinning of skin and resistance.
 Low potency steroids are recommended and treating wide
spread patches damage skin.

 To avoid systemic effects of
glucocorticoid, a maximum dose of
50mg ointment may be used per week
 For small plaques (< 4cm),
triamcinolone acetonide aqueous
suspension 10 mg/ml diluted with
normal saline is injected into the
lesion

Calcipotriene “(calcipotriol) Betdaivonex”
Potent topical corticosteroids are superior to calcipotriene.
The efficacy of calcipotriene is not reduced with long-term treatment
Calcipotriene is applied twice daily
Salicylic acid inactivates calcipotriene
2- Vitamin D Analogues

Hypercalcemia is the only major concern
When the amount used does not exceed the recommended 100
g/week, calcipotriene can be used with a great margin of safety
 Used in combination with or in rotation with topical
corticosteroids for maximize therapeutic effectiveness while
minimizing steroid related skin atrophy.
Other vitamin D analogues are tacalcitol and maxacalcitol

The use of tar to treat skin diseases dates back nearly 2000
years
 Tar is the dry distillation product of organic matter heated in
the absence of oxygen
In 1925, Goeckerman introduced “The Goekerman
technique” which uses crude coal tar and UV light for the
treatment of psoriasis.

3- Coal Tar
The use of coal tar to treat skin diseases dates
back nearly 2000 years
dry distillation product of organic matter heated
in the absence of oxygen.
In 1925, Goeckerman introduced “The
Goekerman technique” which uses crude coal
tar and UV light for the treatment of psoriasis.
5- 20% concentrations can compounded in
creams, ointments, shampoos and in pastes.

Often combined with salicylic acid (2-
5% ), which by its keratolytic action
leads to better absorption of the coal
tar.
Disadvantages include:
allergic reactions,
 folliculitis, it has foul smell and
appearance and can stain clothing and
other items.
 Coal tar is carcinogenic.

4-TOPICAL retinoid
Tazarotene (zar, Zarotex)
• Third-generation retinoid
• Reduces mainly scaling and plaque thickness,
• Available in 0.05 percent and 0.1 % gels, and a cream.

5- IMMUNOMODULATING AGENT
Topical Calcineurin Inhibitors (Tacrolimus” Tarolimus” &
Pimecrolimus” Elidel”)
They inhibit activation of T Cells which in turn reduces inflammation
and plaque build-up.
Not effective in plaque psoriasis. However, for treatment of inverse
and facial psoriasis, very effective treatment.

6-Emollients
 Between treatment periods, skin care with emollients should be
performed to avoid dryness.
 Emollients reduce scaling, may limit painful fissuring, and can help
control pruritus.
 They are best applied immediately after bathing or showering.
 The use emollients in combination with topical treatments improves
hydration while minimizing treatment costs.

 Bath salts or bathing in high-salt-
concentration waters like the Dead Sea, along
with careful exposure to sunlight
 Moisturizers Moisturizing creams alone
won't heal psoriasis, but they can reduce
itching, scaling and dryness.
• Apply immediately after a bath or shower to
lock in moisture.

B- PHOTOTHERAPY
This treatment uses natural or artificial ultraviolet light.
Simplest and easiest form of phototherapy involves exposing your
skin to natural sunlight.
 There are many type of phototherapy.

1- sunlight
Exposure to ultraviolet (UV) rays in sunlight or artificial
light slows skin cell turnover.
When exposed to the UV light, is activated t– cell in the
skin are destroy that 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 treatment.

2- broadband UVB phototherapy
 Also called UVB (290 to 320 nm).
UVB Phototherapy used for skin eruptions using artificial ultraviolet
light.
Initially three times a week, first few exposures will be short (less
than 5 minutes).
The length of exposure is gradually increased, according to the
patient's response, up to a maximum of 30 minutes per session.

Few patients require such long exposures, most being
controlled with shorter times.
Most psoriasis patients will have their psoriasis cleared or much
improved after 12 to 24 treatments.
At this stage treatments will usually be discontinued.
However, the psoriasis may later flare up again, and further
UVB treatment may be necessary.

3- Narrow band UVB phototherapy
(311-312 nm)
It is for two to five times weekly. and
then maintenance may require only
weekly sessions.
If whole-body treatment is
recommended.
Patient is placed in a specially
designed cabinet containing fluorescent
light tubes.

Patient stands in the centre of cabinet,
undressed except for underwear, and
wears protective goggles.
Usually the whole body is exposed to the
UVB for a short time (seconds to
minutes). The amount of UV is carefully
monitored by the phototherapy staff.
It is depending on the individual's skin
type, age, skin condition and other factors.

Result of narrowband UVB-
The skin may remain pale or turn slightly pink (the Minimal
Erythemal Dose) after each treatment.
Tell to therapist if you experience any discomfort.
 Patches of psoriasis generally start to become thinner after five to
ten treatments.
Most patients with psoriasis require 15 to 25 treatments to clear.
Results vary.

Compared with broadband UVB-
Exposure times are shorter but of higher intensity.
The course of treatment is shorter.
It is more likely to clear the skin condition.
Longer periods of remission occur before it reappears.

4- Psoralen plus ultraviolet A (PUVA)
If resistant to UVB then another form of ultraviolet treatment
called PUVA.
 This 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.
Side effect: nausea, headache, burning and itching, wrinkle skin or skin
cancer.

5 - Excimer laser
This form of light therapy, used for mild to moderate psoriasis,
treats only the involved skin without harming healthy skin.
A controlled beam of UVB light is directed to the psoriasis
plaques to control scaling and inflammation.
It requires fewer sessions than does traditional phototherapy
because more powerful UVB light is used.
Side effects: can include redness and blistering.

6- Goeckerman therapy
Regimen for treatment of moderate to severe plaque psoriasis using a
combination of crude coal tar and artificial ultraviolet radiation.
Specialized form of light therapy.
First formulated in 1925 by American dermatologist William H.
Goeckerman (1884–1954), Goeckerman therapy continues to be used
due to its efficacy and safety profile.
 Individual institutions have modified the Goeckerman regimen and
developed their own protocols.
 Standard therapy includes use of 2–4% crude coal tar in
a petroleum base applied daily to the psoriatic plaques.

Minimum period of time for tar application is 2-hours, more duration
periods of time produce better results.
The patient is then exposed to broad-band ultraviolet B (UVB)
radiation, although narrow-band UVB may also be used.
 Laboratory studies have shown that the combination of coal
tar and UV light reduces epidermal DNA synthesis.

7- Determination of the minimal erythema dose (MED)
Patient wears a thick cotton shirt which
has 10 small, holes on its back.
 Patient is exposed to 50 mj of UV on the
back while all the holes are opened.
Then first hole is closed and remaining
holes exposed at that time skin under
first hole was exposed to 50 mj of UV.
And skin under the second hole was
exposed to 100 mj

Then second hole is closed and the procedure is
repeated in the same way (closing an hole and
giving a dose) for all the holes
After 24-72 hours the back area skin is examined
and the first skin area showing well-defined
erythema is determined and the amount of UV
causing it is called "the minimal erythema dose"

C- SYSTEMIC THERAPY
Cyclosporine A
Neoral 100mg/ml Suspension & 100 mg capsules
Action Binds cyclo-philin producing a complex that blocks calcineurin,
reducing the effect of the NF-AT in T cells, resulting in inhibition of
interleukin 2
Dosage High-dose method: 5 mg/kg daily, then tapered
Low-dose method: 2.5 mg/kg daily, increased every 2-4 weak up to 5
mg/kg daily, then tapered

Side effect
Nephrotoxicity,
Hypertension,
Immuno-Suppression,
Neurotoxicity,
Increased risk of malignancy
Contraindication:
• Prior bone marrow depression, Pregnancy, Lactation, Renal
abnormalities

METHOTREXATE
Dose: 2.5 mg tab & 50 mg/ml vial
Action: Blocks dihydrofolate reductase leading to inhibition of purine
and pyrimidine synthesis. Leading to accumulation of anti-inflammatory
adenosine
Dosage: Start with a test dose of 2.5 mg and then gradually increase dose
until a therapeutic level is achieved (average range, 10-15 mg weekly;
maximum, 2530 mg weekly

Side effect: Chronic use may lead to
hepatic fibrosis,
Fatal abnormalities or death,
Pulmonary fibrosis
Contraindication:
Liver Toxicity
Pregnancy

ACITRETIN
Dose: 25 mg daily.
Action Binds to retinoic acid receptors. May contribute to
improvement by normalizing keratinization and proliferation
of the epidermis.
Side effect:
 Hepatotoxicity,
 Lipid abnormalities,
Alopecia,
Fatal abnormalities or death,
Contraindication:
 Severe, infections, Malignancy

D- Alternative medicine
Aloe Vera
Taken from the leaves of the Aloe Vera plant, extract cream may
reduce-
Redness
Scaling
Itching and inflammation
You may need to use the cream several times a day for a month or more
to see any improvements in your skin.

Fish oil
 Omega-3 fatty acids found in fish oil
supplements
It reduce inflammation associated
with psoriasis, although results from
studies are mixed.
 Taking 3 grams or less of fish oil
daily is generally recognized as safe,
and you may find it beneficial.

Oregon grape- Also known as barberry,
topical applications of Oregon grape may
reduce inflammation and ease psoriasis
symptoms.
High-fibers foods — It keep your
digestive system healthy, which helps
avoid constipation and keep your natural
detoxification processes on track.

Foods high in antioxidants-
Foods high in zinc-

• These are excellent sources of
vitamin D as well as omega-3
fatty acids, which help improving
psoriasis.
• fish should be the new
leading protein diet rather than
meat and conventional dairy
products.
Wild-caught fish
Salmon
Herring
Mackerel
Sardines

Foods high in vitamin A
• It is critical for skin healing.
• Sources of vitamin A
includes orange, yellow and dark
leafy green vegetables, cantaloupe,
carrots, tomatoes, kale, collard
greens and watermelon.
• Raw dairy — Raw milk is a much
healthier choice than conventional
milk. Rich in vitamin D and
enzymes, raw dairy products can be
therapeutic to psoriasis.
mango

Lifestyle and home remedies:
Take daily baths.
It helps remove scales and calm
inflamed skin.
 Add bath oil, colloidal oatmeal,
Epsom salts or Dead Sea salts to the
water and soak.
Avoid hot water and harsh soaps, which
can worsen symptoms, use lukewarm
water and mild soaps.
• Soak about 10 minutes then gently pat
dry skin.

Use moisturizer.
• After bathing, apply a heavy, ointment-based moisturizer
while your skin is still moist.
• For very dry skin, oils may be preferable they have more
staying power than creams or lotions do and are more
effective at preventing water from evaporating from your
skin.
• During cold, dry weather, you may need to apply a
moisturizer several times a day.

Expose your skin to small
amounts of sunlight.
A controlled amount of sunlight
can improve psoriasis, but too
much sun can trigger or worsen
outbreaks and increase the risk of
skin cancer.
First ask your doctor about the best
way to use natural sunlight to treat
your skin.

Avoid psoriasis triggers, if possible-
• Try to find out what triggers, if any, worsen your psoriasis
and take steps to prevent or avoid them.
• Infections, injuries to your skin, stress, smoking and intense
sun exposure can all worsen psoriasis.
Avoid drinking alcohol-
• Alcohol consumption may decrease the effectiveness of some
psoriasis treatments. If you have psoriasis, avoid alcohol.
• If you do drink, keep it moderate.

1-Impaired skin integrity r/t lesion and inflammatory response as
evidence by itching all over body.
Goal- Maintaining the integrity of the skin
Intervention-
• Protect client’s skin healthy from the possibility of maceration
(excessive hydration of the stratum carenum) when installing wet
bandage.
• Take care to avoid thermal injury due to the use of warm compresses,
the temperature is too high, and as a result of injuries that did not feel
the heat (heating pads, radiator)
• Advise the client to use cosmetics and sunscreen preparations.

2- Acute pain related to inflammation as evidence by
verbalisation of patient.
Goal- To Relieves pain
Intervention-
• Find the cause of the pain / itching.
• Record the results of observations in detail.
• Maintain moisture, use a humidifier.

3- Disturbed body image related to the appearance of the
skin that is not good
Goal-To reduce the scalp
Intervention-
• Provide emotional support
• Council the patient
• Administer prescribed Medication for removing scalp.

 Infection
 Fluid and electrolyte imbalance Low self esteem
 Depression Stress
 Metabolic syndrome Hypertension
 Joint damage
COMPLICATIONS

 Take daily bath Use moisturizer
 Expose small amount of skin to sunlight
 Cover the affected area over night
 Apply medication cream or ointment
 Avoid drinking alcohol and smoking
 Eat healthy diet
HEALTHEDUCATION

Junior teaching

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Semelhante a Junior teaching

Semelhante a Junior teaching (20)

Último

Último (20)

Junior teaching