A CASE STUDY ON SKIN DISORDER

EXPERIMENT 14 (PH 4Y1-5)

Jacinto, Adrien kyle m.

Tonog, Yasmin joy R.

Adrien Kyle M. Jacinto, RPh (Confidential File)

CASE 1

• A 35-year old mother of two has moderate psoriasis. She tells you that her mother had a similar condition 3 years ago and was successfully treated with the agent Acitretin She has come to you because her regular physician refused to write her a prescription for Acitretin, and she is very uncomfortable with her skin condition. You tell her that there is a serios risk of teratogenicity if she should become pregnant. She informs you that she is taking oral contraceptive and that the possibility of pregnancy is very low. What would you advise her regarding her problem?

Adrien Kyle M. Jacinto, RPh (Confidential File)

Medical terminologies and abbreviations

• Psoriasis- A inflammatory skin disorder that causes the skin to grow quickly, resulting in thick, white, silvery or red patches (plaques)of /scaly skin.

• Teratogenicity- Is the ability to cause developmental abnormality in embryo or fetus

Adrien Kyle M. Jacinto, RPh (Confidential File)

• New skin cells move to the outermost layer of skin too quickly.

• Dead skin and white blood cells can’t slough off quickly enough and build up in thick, scaly patches on the skin’s surface.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Symptoms

• Expoliative dermatitis

• Erythematous scaly area

• Long term rash

• Pruritus

• Psoriatic arthritis (nails -Discoloration and pitting & joints are Involved.

*Knees, elbows, wrists, and ankles could be involved

Adrien Kyle M. Jacinto, RPh (Confidential File)

Diagnosis

• Moderate Psoriasis- red, scaly patches (plaques) cover less than 5 -10% of your body.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Etiology

• Emotional stress and trauma

• Streptococcal infection

• Medications e.g. Beta blockers, Antimalarial, Lithium, ACEI and Ibuprofen

• Smoking

• Alcoholism

• Trauma

• Sunlight

• Hereditary

Adrien Kyle M. Jacinto, RPh (Confidential File)

Laboratory Test

Erythrocyte sedimentation rate (sed rate or ESR) is a test that gives a rough index of inflammation. The sed rate is not specific and can be elevated with many other conditions such as other autoimmune syndromes, infection, tumor, liver disease, or pregnancy.

Skin biopsy. Rarely, your doctor may take a small sample of skin (biopsy) that's examined under a microscope to determine the exact type of psoriasis and to rule out other disorders. A skin biopsy can generally be done in a doctor's office after application of a local anesthetic.

Adrien Kyle M. Jacinto, RPh (Confidential File)

• Hormonal changes

*Psoriasis in women tends to be worst during puberty and during the menopause. These are times when there are some major changes in female hormone levels. Some pregnant women with psoriasis find that their symptoms improve when they are pregnant, but it may flare up in the months just after having a baby. Again, this is thought to be related to changes in hormone levels.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Identified predisposing factors

• Primary: Hereditary (Family history of Psoriasis)

• Secondary:

Age 35 (pre-menopausal)- Decrease hormone production

Stress- (Mother)

Adrien Kyle M. Jacinto, RPh (Confidential File)

Can cause hormonal imbalance but helpful in treatment of Psoriasis:

• Taking oral contraceptives (Progestin)

• Pregnancy- Estrogen and Progesterone levels both increases.

*Increase in Estrogen and decrease in Progesterone can lead to psoriasis

Adrien Kyle M. Jacinto, RPh (Confidential File)

Medications and Rationale

• Oral contraceptive

• Content: Progesterone (w/ or w/o estrogen)

• Corticosteroids (specifically the topical agents) are the first line treatment for psoriasis. Since increase in progesterone is beneficial in patients with psoriasis, using this can improve the condition.

• Progesterone is a hormone that can inhibit ovulation (release of egg cells), thereby preventing pregnancy.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Why is it not possible to use Acitretin especially when taking Oral contraceptives

• Acitretin, just like oral contraceptives, may harm the fetus.

• Also, there is an underlying drug interaction:

• Acitretin may decrease the effectiveness of certain hormonal contraceptives, e.g. low-dose progestin only birth control pill or minipill.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Advise:

• When pregnant or planning to become one, Stop taking oral contraceptives and don’t try Acitretin since it can affect pregnancy. Instead, use

• Topical corticosteroids (-betasol, betamethasone)- first line tx. For Psoriasis. Do not cause birth defects but, still needs to be monitored.

• Calcipotriene- A vitamin D analog for moderate plaque psoriasis. Does not cause long term skin thinning or systemic effect. FDA category C. Foam version, Sorilux is also available. Or,

• Adalimumab- A TNF inhibitor which is effective for moderate to severe psoriasis and psoriatic arthritis. Safe to use in pregnancy (FDA category B) and do not cause immunosuppression.

Adrien Kyle M. Jacinto, RPh (Confidential File)

• Coal tar-

• inhibits epidermal proliferation and dermal infiltration

• Messy application (2nd line) except shampoo

• Do not injure normal skin

• Useful when combined with oral corticosteroids.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Chronic Stationary psoriasis ( Psoriasis vulgaris)

Most common type of psoriasis, involves the

scalp extensor surface, genitals, umbilicus and

lumosacral regions.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Plaque psoriasis

Characterized by raised, inflamed lesions covered with a

silver white scale.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Guttate Psoriasis

Small salmon pink papule predominantly on the trunk.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Inverse psoriasis

Smooth, inflamed lesions without scling due to the moist nature

of the area where this type of psoriasis is located.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Pustular psoriasis

Sterile pustules appering on the palm and sole or diffused

all over the body (Zumbusch variant). Acrodermatitis

continua o hallopeau-hands and feet affection.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Erythodermic psoriais

With generalized erythema,pain ,itching and fine scaling encompassing nearly the whole body.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Scalp psoriasis

Affect approximately 50% of the patient.

Erythematous raised plaques with silver white

scales on the scalp.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Nail psoriasis

• Cause pits of the nails, which become thickened

• and yellowish color.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Psoriatic arthritis

Usually in the hands and feet and large

joint.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Oral psoriasis

• Whitish lesion on the oral mucosa which may appear to

change in severity daily. May also present as severe

cheliosis crossing the vermillion border.

Adrien Kyle M. Jacinto, RPh (Confidential File)

Types of Psoriasis

• Eruptive psoriasis

Involves the upper trunk and upper extremities,most

often seen in younger children.

Adrien Kyle M. Jacinto, RPh (Confidential File)