Skin Rash discussion from an FNP perspective

Sally is 18 years old and recently became bothered by a rash that is itchy, red, inflamed, and dry. She also has scaly areas that she says are getting worse.The rash is only around her umbilicus and on her elbows. Both of her parents have psoriasis, but she doesn’t believe this is the problem, because it appears different from her parent’s lesions. She lives in Florida, is under a lot of stress in high school, and just recovered from a lingering upper respiratory infection (URI).

Questions:

1. What do you anticipate the rash will look like? Using the internet search engine find an image that reflects what the patient is reporting and attach for all to see.
2. What are the risk factors for Sally getting psoriasis?
3. What diagnostic test might you order as an FNP?
4. Name your top three differentials?
5. What is the goal of therapy?
6. What would you order first to treat?
7. What follow up or referral is needed?

Answer each section.Include in text-citations, APA format, use at least 2 peer review journals

Part2:Post a response to each classmate. No more than 100 words include in-text citations and at least 1 reference APA style. Please be respectful.

April’s Response:

Psoriasis image.JPG

Plaque Psoriasis

From the information provided, it sounds like Sally is presenting with a classic case of plaque psoriasis. Psoriasis, a chronic inflammatory skin disorder, is characterized by well-defined patchy areas of erythematous plaque and scaling (Feldman, 2018).

The image I chose to share is from the JAMA Network website. After looking at a number of images online, I chose this one because it shows both the typical plaque psoriasis rash and the areas of the body that are most commonly affected. Although this image is a sketch and not an actual photograph, I feel it is well done and is an accurate depiction of a psoriasis rash (Armstrong, 2017).

Risk Factors for Psoriasis

Sally has a number of risk factors for developing psoriasis, perhaps the most contributory being her genetic predisposition for the disorder. Unfortunately for Sally, psoriasis runs on both the maternal and paternal sides of her family with both of her parents affected by the disease. It is common for psoriasis to occur in families, with 40% of patients having a first-degree relative with it as well. In addition to genetics, behavioral and environmental factors are also thought to play a role in the development of psoriasis. Both bacterial and viral infections have been associated with psoriasis flares, and Sally reports just getting over a URI. Stress has long been thought to be a contributing factor and exacerbating factor in psoriasis as well, and Sally reports a high level of stress in her life (Feldman, 2018).

Diagnosing Psoriasis

In most cases, the diagnosis of psoriasis can be made through a comprehensive history and physical examination; however, a skin biopsy can be performed when the clinical examination is not sufficient enough to ruled out other disorders. While a 4mm punch biopsy is recommended, a shave biopsy may be adequate in some cases. The specimen is typically evaluated using a PAS-D stain, with can aid in distinguishing psoriasis from other conditions (Feldman, 2018).

Differential Diagnoses

The differential diagnosis of psoriasis is broad, with one possibility being a superficial fungal infection such as tinea corporis or cutaneous candidiasis. As noted above, a biopsy with PAS-D stain is helpful in differentiating psoriasis from a superficial fungal infection. A KOH preparation can also be helpful in the diagnosis of a fungal infections. Seborrheic dermatitis is another differential diagnosis that typically can be ruled out by certain characteristics of the rash. For example, the rash associated with seborrheic dermatitis is typically fine and greasy and routinely occurs in specific areas such as the eyebrows, nasalabial folds, and behind the ears. Lastly, lichen simplex chronicus can occur along with psoriasis secondary to excessive scratching (Feldman, 2018).

Treatment Goal and Initial Plan

The primary goal of psoriasis treatment is control of disease and symptoms (Feldman, 2018). Treatment choice is often based on the severity of the disease. Fortunately, Sally’s case seems mild. My plan would be to prescribe both a topical corticosteroid and topical vitamin D, as both medications are indicated for the treatment of mild, localized psoriasis (Armstrong, 2017). Current research has also shown that when used in combination, topical corticosteroids and vitamin D analogs are more effective than when either is used alone for monotherapy (Feldman, 2018).

Follow up and Referral

I would plan on seeing Sally again for follow up within one week, as timely follow up can lead to increased adherence with topical treatments. If no improvement is noted with the prescribed treatment regimen within one month, I would consider referring her to a dermatologist for further evaluation. Referral would also be warranted in the case of worsening or widespread disease or when other treatment modalities such as phototherapy and systemic immunosuppressive medications are required (Feldman, 2018).

References

Armstrong, A. W. (2017). Psoriasis. JAMA Dermatology, 153, 956. doi:10.1001/jamadermatol.2017.2103

Feldman, S. R. (2018, May 31). Epidemiology, clinical manifestations, and diagnosis of psoriasis. Retrieved from https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-psoriasis#subscribeMessage

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