Holla at your Psoria-sister

     That headline hurt to write, but I once tattooed the initials of a PA I worked for into my leg for a practical joke. Thankfully for my relationship with my fiancé, they were covered up. Psoriasis is the definition of a gnarly disease; a chronic inflammatory autoimmune disease that patients have described with a wide variety of colorful language. Hellish, burning, painful, like knives, and I would be better off dead are just a few of what I have heard. It effects the skin and psyche.

    The patient is a middle aged female who presented to the ED after 1 week of a full body rash that couldn't be confirmed as psoriasis (but really it was, seriously). The issue was that aside from her 85% BSA affected by the plaques, the weeping wounds, and the pruritus and pain; her dermatologist would not give her anything until the biopsy came back. So here she was, cellulitis on top of the psoriasis because she, like any of us would, scratched too much. 

    So I called the doc to get her some topical steroids and she improved, at least as far as her itching, which meant she could sleep at last. I wasn't able to follow up on the patient but it got me thinking about the paradox we have when treating this skin fire: Almost all commonly used psoriasis medications such as biologics, steroids, and methotrexate increase the risk for infection and malignancy with long term usage. So? This is in my mind, which is a scary place, in an exercise in risk-benefit balancing. A study in Health & Medicine Week reports there is a 12%, 18%, and 24% increase in all malignancies except NMSC, lymphoma, and NMSC respectively. The numbers per 10,000 person-years were 142, 12.9, and 180 while using nonbiologic, adalimumab, etanercept, infliximab, or phototherapy. An older study from 2014 in the British Journal of Dermatology showed an overall increase in malignancies of 20% and 65% for NMSC.

    I think of two things, look for signs of malignancy. In my short medical career thus far I have seen blisteringly fast progression of cancer in patients. As a nurse, we should note and take seriously what the patients tell us and make sure that is communicated to the providers along with the increased risk from the above listed meds. We can't catch everything and it is fiscally American, I mean wasteful, to test every suspicious we have, but unlike our government, use some discretion when spending the patient's money on tests. 

    Finally, wash your hands, these folks already have compromised skin integrity. Lets not make that any worse for them. 

References

Biologics in Psoriasis: Updated Perspectives on Long-Term Safety and Risk Management from Psoriasis July 2022

Image of psoriasis on the arms from Cleveland Clinic @ https://my.clevelandclinic.org/health/diseases/6866-psoriasis

Incidence rated of malignancies and hospitalized infectious events in patients with psoriasis with or without treatment and a general population in the U.S.A: 2005-09 from the British Journal of Dermatology February 2014. 

Papulosquamous Skin Diseases; Study Data from A.B. Kimball and Colleagues Update Understanding of Psoriasis from Health & Medicine Week 2016.