Q-1
Psoriasis is a chronic inflammatory skin disease, and the most common subtype is chronic plaque psoriasis. It is a multisystem inflammatory disorder associated with multiple comorbidities. Therefore, it’s more common in adults than children as the peak onset ages are between 30-39 years and between 50-69 years (Micali et al., 2019).
Etiology: The cause is unknown, but family history is present in 1/3 of the cases (Micali et al., 2019). Risk factors for psoriasis include genetics and environmental and behavioral factors, such as smoking, obesity, and alcohol use. Other risk factors include streptococcal infection, stress, sunburn, and drugs, including beta-blockers and systemic steroids.
Presentation: Patients with chronic plaque psoriasis typically present with symmetrically distributed plaques, typically, located on the scalp, elbows, knees, fingernails, palms, soles of feet, and gluteal cleft. It is characterized as well-demarcated, erythematous plaques with thick, silvery scales (Micali et al., 2019). Classic signs are the Auspitz sign, which is pinpoint bleeding after removal of a scale overlying a psoriatic plaque, and intergluteal pinking.
Differential diagnosis: Differential diagnoses include seborrheic dermatitis, lichen simplex chronicus, and atopic dermatitis. Clinical features help differentiate psoriasis from other skin disorders. For instance, clinical features of seborrheic dermatitis are fine, greasy scales that are commonly located on the eyebrows, nasolabial folds, central chest, and postauricular area (Alhammad et al., 2021).
Diagnostic work-up/screening tools: Diagnosis is typically made by history and physical examination. It is important to examine the scalp, nails, ears, elbows, and knees and identify characterizations of psoriasis. ESR and CRP would be elevated to due chronic inflammation (Alhammad et al., 2021). A skin biopsy may also be helpful for difficult cases. However, no laboratory tests can confirm the diagnosis.
Treatment plan: Nonpharmacologic management include warm soaks, solar/ultraviolet radiation, oatmeal bath for itching, and skin hydration with emollients. Topical steroids should be considered, but high potency steroids should be limited to <2 weeks (Alhammad et al., 2021). Systemic treatments include methotrexate, cyclosporin, Humira, and Stelara.
Preventative measures: Patients should precipitants that may trigger exacerbations including sunburn, sudden withdrawals of steroids, and medications.
Referrals: For severe cases and/or slow response to treatment, a referral should be made out to a dermatologist.
Geriatric considerations: Various comorbidities, such as cardiovascular disease, diabetes, hypertension, metabolic syndrome, and/or autoimmune disorders, may increase the prevalence of psoriasis. This may be due to the effects of immune-mediated chronic inflammation and the adverse effects of systemic therapies (Micali et al., 2019).
References
Alhammad, I. M., Aseri, A. M., Alqahtani, S. A. M., Alshaebi, M. F., Alqahtani, S. A., Alzahrani, R. A., Alhaji, A. A., Alamoudi, M. K., Bafarat, A. Y., & Jad, A. Y. (2021). A review on updates in management and treatment of psoriasis. Archives of Pharmacy Practice, 12(1), 74.
Micali, G., Verzì, A. E., Giuffrida, G., Panebianco, E., Musumeci, M. L., & Lacarrubba, F. (2019). Inverse psoriasis: From diagnosis to current treatment options. Clinical, Cosmetic and Investigational Dermatology, 12, 953-959. https://doi.org/10.2147/CCID.S189000
Q-2
Diabetic foot wounds are common in diabetic patients who have their diabetes uncontrolled (Sunarmi, Isworo & Sunarko, 2021). Diabetics also have a prolonged healing phase, which is caused by many factors, most notably the thinning of the subcutaneous layers of the skin in the legs which also has slowing blood flow due to microangiopathies and neuropathy (Sunarmi, Isworo & Sunarko, 2021).
There are three stages of development in a diabetic foot ulcer, the first state is the development of a callus, second is drying of the skin from autonomic neuropathy, and finally, frequent trauma of the callus leads to subcutaneous hemorrhage and eventually leading to erosion and ulceration (Oliver & Mutluoglu, 2019).
A good history and physical with emphasis on the history of their diabetes and glycemic control is imperative here (Oliver & Mutluoglu, 2019). The examination should focus on the pulses of the feet, the presence of callus, vascular insufficiency, hair loss, muscle atrophy, and the overall location of the ulcer (Oliver & Mutluoglu, 2019). Most commonly the ulcers appear on weight-bearing areas such as the plantar metatarsal head, heel, tips of hammer toes, and other prominent areas of weight-bearing activity (Oliver & Mutluoglu, 2019). This does not rule out other parts of the leg where trauma can occur and insufficient healing follows which can lead to a diabetic ulcer (Oliver & Mutluoglu, 2019).
Treatment of a diabetic ulcer includes a few steps. Most importantly, it is imperative to rule out any signs of occurring infection (Oliver & Mutluoglu, 2019). We can obtain this by visual inspection of the wound, assertation of any history of fever, chills, or any current drainage that was noted, pain, redness, or any swelling (Oliver & Mutluoglu, 2019). If the patient has positive findings for an infection, the most common organisms that occur are Staph A, Streptococcus, Pseudomonas aeruginosa, and rarely E. Coli (Oliver & Mutluoglu, 2019). A typical outpatient antibiotic regimen includes oral cephalosporins and amoxicillin-clavulanic acid combinations (Oliver & Mutluoglu, 2019).
Some therapies that can help are vacuum-assisted closure, local debridement, immobilization, or hyperbaric oxygen therapy only in wounds failing to heal in 30 days (Oliver & Mutluoglu, 2019).
At this point, it is also is important to realize the patient’s ability to take care of themselves (Oliver & Mutluoglu, 2019). We would have to determine if this patient is able to take care of the ulcer at home, or if they would need inpatient admission to evaluate and treat the wound (Oliver & Mutluoglu, 2019).
Staging is important of the wound which includes stages 1-5 (Oliver & Mutluoglu, 2019). With 1 being a superficial ulcer, 2 being a deep ulcer involving tendons, bone or joints, 3 being a deep ulcer with abscess or osteomyelitis, 4 being gangrene involving the forefoot, and 5 being gangrene involving the entire foot (Oliver & Mutluoglu, 2019).
Some consultations would be dependent on the severity of the wound but include internal medicine, podiatrist, endocrinology, vascular surgeon, and infectious disease (Oliver & Mutluoglu, 2019).
References:
Oliver, T.I., Mutluoglu, M. (2019). Diabetic Foot Ulcer. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK537328/
Sunarmi, Isworo, A., & Sunarko. (2021). Combination of Wound Treatment and Massage for Healing Diabetic Foot Ulcers. International Journal of Nursing Education, 13(1), 137–140. https://doi-org.lopes.idm.oclc.org/10.37506/ijone.v13i1.13330
Q-3
Venous ulcers occur from the pooling of venous blood traps leukocytes which release proteolytic enzymes and increased venous pressure widens inter endothelial pores with deposition of red blood cells, fibrin, and other macromolecules making them unavailable for repair and promoting inflammation (McCann, & Huether, 2019). Venous ulcers present as stasis dermatitis usually occur on the legs from venous stasis and edema associated with varicosities due to incompetent venous valves, phlebitis, and vascular trauma (McCann, & Huether, 2019). Edema evolves to erythema and pruritis with progression to scaling, petechiae, and hyperpigmentation and progressive lesions become ulcerated on ankles and tibia. Venous ulcers typically have an irregular shape and well-defined borders, heaviness of the limb, pruritis, pain, and edema that worsens throughout the day and improves with elevation (Millan, Gan, & Townsend,2019). Usually located over bony prominences such as gaiter area over the medial malleolus, dilated vein around the ankle and foot, atrophic, lipodermatosclerosis, white scarring, and inverted champagne-bottle deformity of the lower leg.
Differential diagnoses in any ulcers were pressure ulcers, arterial occlusive disorders such as peripheral arterial disease and insufficiency, malignancy (Merkle cell carcinoma), lymphedema, sickle cell disease, ulcer due to diabetic neuropathy, pyoderma gangrenosum, and other inflammatory ulcers, vasculitis, calciphylaxis or autoimmune disease.
Typical diagnostic tests by doing an arterial pulse examination and measurement of ankle-brachial pressure index (ABPI) < 0.5 which is evidence of arterial occlusive disease, basic EKG and an echocardiogram and BNP to rule out any cardiac pathology such as heart failure, CBC CRP, ESR to rule out any anemia and infectious and inflammatory process. Venous Doppler ultrasound of the lower extremities to rule out any DVTs. Color duplex ultrasonography to assess deep and superfici8al venous reflux obstruction. Culture of the wound to rule out infection of the wound and biopsy in suspicious chronic nonhealing wound ulcer.
The treatment plan includes elevating the legs as often as possible, refraining from wearing tight clothes around the legs, compression stockings, avoid standing for long periods (McCann, & Huether, 2019). Specific treatment of infections with antibiotics and chronic lesions with ulcerations with moist dressings, external compression/dressings, and vein ablation surgery (McCann, & Huether, 2019). Pentoxifylline improves healing with or without compression therapy, wound debridement benefit ulcer healing, endogenous ablation increases healing rates and prevent recurrences, skin grafting for large ulcers and non-healing ulcers (Millan, Gan, & Townsend, 2019). Compression therapy is the standard of care for patients with venous leg ulcers who do not have arterial insufficiency (De Carvalho, Peixoto, Silveira, & Oliveria, 2018). Referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance.
Preventive measures are by lifestyle changes such as reduction and cessation of smoking/drug abuse, physical activity and rest, the elevation of lower extremities, nutrition, hydration, cleansing, and moisturizing the skin are necessary for wound healing and prevention of complications (Domingues, Kaizer, & Lima, 2018). Managing comorbid conditions such as heart failure, kidney failure, liver failure, skin conditions such as eczema and psoriasis, blood disorders, avoid trauma to skin and veins, knowledge and understanding of venous ulcers, and promotion of self-care supplements for the prevention of venous ulcer prevention. Special consideration to geriatrics in venous ulcers will be due to presence of comorbidities and risk factors, delayed healing and immunity, anemia of chronic disease, malnutrition, and poor personal hygiene, and accessibility to health care all need to be investigated.
References.
McCann, S.A., & Huether, S.E. (2019). Structure, function and disorders of the integument. In V.L Brashers and N.S. Rote (8th Eds.). Pathophysiology: The biologic basis for disease in adults and children. (pp 1507). Missouri: Elsevier.
De Carvalho, M. R., Peixoto, B. U., Silveira, I. A., & Oliveria, B. G. R. B. (2018). A meta-analysis to compare four-layer to short-stretch compression bandaging for venous leg ulcer healing. Ostomy Wound Manage, 64(5), 30-37. Retrieved from www.o-wm.com
Millan, S. B., Gan, R., & Townsend, P. E. (2019). Venous ulcers: diagnosis and treatment. American family physician, 100(5), 298-305. Retrieved from https://www.aafp.org/afp/2019/0901/p298.html
Domingues, E. A. R., Kaizer, U. A. O., & Lima, M. H. M. (2018). Effectiveness of the strategies of an orientation programme for the lifestyle and wound‐healing process in patients with venous ulcer: A randomised controlled trial. International wound journal, 15(5), 798-806. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/iwj.12930