CASE PRESENTATION ON

Erythrodermic Psoriasis

By Rumana Hameed

170310820021

Psoriatic erythroderma represents the generalized form of the disease that affects all body sites including the face, hands, feet, nails, trunk, and extremities.

Although all the symptoms of psoriasis are present, erythema is the most prominent feature, and scaling is different compared with chronic stationary psoriasis.

ERYTHRODERMIC PSORIASIS

Instead of thick, adherent, white scale there is superficial scaling.

Patients with erythrodermic psoriasis lose excessive heat because of generalized vasodilatation, and this may cause hypothermia.

Patients may shiver in an attempt to raise their body temperature.

Psoriatic skin is often hypohidrotic due to occlusion of the sweat ducts and there is an attendant risk of hyperthermia in warm climates.

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Name:ABC D.O.A:1-05-2015 Age:6oyrs Reg no:1659/15 Sex:M Dept: DVL-IV,MSW Adrs:HYD

Occupation:shopkeeper

SUBJECTIVE

Complaints: c/o redness,scaling and itching all over the body

since 2o days.History of present illness: Patient was apparently asymptomatic 20 days

back then he developed erythema and scaling over trunk extremities,face,neck ,scalp and also including palms,soles and genitelia with itching.

No H/O joint pains,fever and chills.

Past medical history: patient is a known hypertensive since 9 months on

irregular medication. Known Psoriatic since 10 years. No H/O DM,TB,Asthma,Epilepsy.

Family history : no family history of psoriasis

Personal history: Appetite :normal Sleep :disturbed Diet :normal CHRONIC ALCOHOLIC AND SMOKER SINCE 20 YEARS

OBJECTIVE

Vitals DAY 1 DAY 2 DAY 3 DAY 4

BP/mmHg 130/90 120/80 120/80 110/70

Pulse Rate/min

84 80 84 82

Temp normal normal normal normal

Vitals

RBS:80mg/dl Serum urea: 24mg/dl Serum creatinine:1.0 mg/dl Sodium:133meq Potassium:4.0meq Serum protiens:6.8 Serum albumin: 3.6 T.Bilirubin:0.9 mg/dl

Laboratory Data

•B/L symmetrical diffuse erythma,scaling associated with itiching present over trunk,face,scalp and all extemities.•Palms,soles and genetilia was also involved.

Cutaneous Examination

Cutaneous Examination

•Pitting is seen•Nails have become brittle.•Oil drop or salmon patch is present.•Onycholysis is also seen.

Nails Examination

Hb:14.0 gm/dl WBC:8,200 cells/cmm Neutrophils:66% Lymphocytes:30% Esinophils:02% Basophils:00% Monocytes:02% Platelets:Adequate ESR:0.5mm Few Reactive Lymphocytes:+ Blood picture : NormocyticNormochromic

Complete Blood Picture

Urine: Yellow Albumin: + Sugar: Nil Pus cells:1-2/hpf Epithelial cells:2-3/hpf

Urine Examination Report

RESULT: Microscopic Examination of the section revealed

skin showing psoriform epidermal hyperplasia Confluent parakeratosis layered with neutrophils Spongiform pustules Hypogranulosis Dilated tortuous papillary blood vessels IMPRESSION: Suggestive of psoriatic eryhtroderma.

Skin Biopsy

Based upon the cutaneous examination and skin biopsy report the disease was diagnosed as psoriatic erythroderma.

ASSESSMENT

Goal: Restore and maintain body fluids and

temperature, followed by antibiotics as prophylactic to infections and symptomatic treatment.

Plan

MEDICATION DOSE

ROUTE

FREQ Generic Name

INDICATION

IVF IV

INJj.Monocef 1gm IV BD ceftraixone Antibiotic

INJ.Rantac 2cc IV BD ranitidine H2RB

INJ .Avil 2cc IV BD Pheneramine malate

Anti histamine

Tab.Mext-F 2.5mg

oral Once weekly

methotrexate Immunosupressant

Tab.Folic acid oral On rest of days

Folic acid supplement

Tab. MVT 1 Tab oral OD Multi vitamin Vitamins

Tab.BC 1Tab oral OD B complex Vitamin

Tab.Enam 5mg oral OD Enalapril Anti HTN

Tab.calcium 1Tab oral OD Calcium Supplement

Liquid Paraffin E/A mrng Liquid paraffin Emollient

Betamethasone cream

E/A night Betamethasone

Anti inflammatory

Pharmacological TREATMENT

PATIENT COUNCELLING

NON - PHARMACOLOGICAL

TREATMENT

Psoriatic erythroderma represents the generalized form of the disease that affects all body sites,including the face, hands, feet, nails, trunk, and extremities.

A particularly inflammatory form of psoriasis that often affects most of the body making skin look burned.

Regarding diseased state

Methotrexate: Immunosuppresant Folic acid: folate supplement Monocef: antibiotic as prophylaxis Avil: Anti histamine Rantac:Antacid Liquid paraffin :Emollient Betamethasone cream:anti inflammatory Enam :anti hypertensive

Regarding medication

SMOKING: Smoking (more than 20 cigarettes daily)has also been

associated with more than a twofold increased risk of severe psoriasis.smoking appears to have a role in the onset of psoriasis .Recently, a gene–environment interaction has been identified between low activity of the cytochrome P450 gene CYP1A1 and smoking in psoriasis.

Avoid alcohol and smoking as it may trigger the psoriasis. Take oatmeal baths they can help loosen the scaling and

reduces itching. Bathing in very hot water or using abrasive cleaners can

also make your psoriasis flare up.  Avoid stressful situations when you can, and take extra

steps to take care of yourself such as eating well, exercising, and getting enough sleep.

Regarding lifestyle modification

Dry skin is more susceptible to outbreaks of psoriasis, so keep your skin well lubricated. After bathing or showering, seal in moisture by applying a generous amount of moisturizing cream or oil to your skin.

Use talcum powder to prevent oozing skin from sticking.

Minimize sun exposure.

No serious drug interactions were found in the plan.

Methotrexate-Enalapril: Methotrexate may cause liver problems, and using

it with other medications that can also affect the liver such as enalapril may increase that risk.

Avoid or limit the use of alcohol while being treated with these medications.

Drug-Drug Interaction

What Causes Psoriasis? Psoriasis is a skin disorder driven by the

immune system, especially involving a type of white blood cell called a T cell. Normally, T cells help protect the body against infection and disease. In the case of psoriasis, T cells are put into action by mistake and become so active that they trigger other immune responses, which lead to inflammation and to rapid turnover of skin cells.

Drug Information Query

At the time of initiation of treatment Present picture

All pictures are taken with the permission of patient.

At the time of initiating the treatment Present picture

THANK YOU