Psoriasis & Atopic Eczema — GCC Nursing Guide

Dendritic cells present antigens → activate CD4+ Th1 and Th17 cells → IL-17 & IL-23 drive inflammation cascade. CD8+ T-cells in epidermis amplify response.

IL-23 (p19/p40) drives Th17 differentiation. IL-17A is the key effector cytokine stimulating keratinocytes to produce chemokines and antimicrobial peptides, perpetuating inflammation.

Normal skin turnover: 28 days. Psoriatic skin: 3–5 days (10× normal rate). Immature keratinocytes accumulate → silvery scale. TNF-α also contributes to NF-κB activation.

Well-demarcated, erythematous plaques with adherent silvery-white scale. Sites: extensor surfaces (elbows, knees), scalp, lumbosacral, nails. Auspitz sign: pinpoint bleeding on scale removal.

Drop-shaped (<1cm) lesions on trunk/limbs. Often in children & young adults. Triggered by Group A Streptococcal pharyngitis (2–3 weeks prior). May resolve spontaneously or evolve to plaque type.

Generalised (Von Zumbusch): sterile pustules on erythematous skin, fever, systemic illness. Admit immediately. Monitor FBC, LFTs, U&E. Palmoplantar pustulosis: localised — strongly associated with smoking.

Generalised erythema >90% BSA. Risk: hypothermia, high-output cardiac failure, hypoalbuminaemia, sepsis. Avoid abrupt withdrawal of systemic steroids as a trigger. Requires IV fluids, temperature management, supportive care.

Affects intertriginous areas: axillae, groin, submammary folds, umbilicus. Smooth erythema, minimal scale due to moisture. Risk of Candida superinfection. Use only mild topical corticosteroids.

Nail psoriasis is a strong predictor of psoriatic arthritis development.

Koebner Phenomenon

Group A Streptococcus (guttate trigger), HIV (severe, refractory psoriasis), staphylococcal infection

Lithium · Beta-blockers · Antimalarials (chloroquine/hydroxychloroquine) · NSAIDs · ACE inhibitors · IFN-alpha · Abrupt systemic corticosteroid withdrawal

Psychological stress · Smoking (especially palmoplantar pustulosis) · Alcohol excess · Obesity · Trauma (Koebner)

Puberty, menopause, pregnancy (may improve or worsen). Sunburn can trigger flare despite UV generally benefiting psoriasis.

Nursing Assessment Mnemonics

PASI Score (0–72)

DLQI (0–30)

BSA & Other Scores

Apply liberally and frequently (minimum 250g/week). Restore skin barrier. Use as soap substitute. Apply topical treatments after (not before) emollient.

Calcipotriol (Dovonex): antiproliferative, once or twice daily. Max 100g/week (hypercalcaemia risk). Avoid on face and flexures. Calcitriol: gentler, suitable for flexures/face.

Potency appropriate to site. Use FTU guide. Weekend-only regimen for maintenance. Avoid prolonged use — risk of atrophy, striae, telangiectasia, rebound flare. See Steroid Guide tool in Tab 5.

Dovobet (calcipotriol + betamethasone dipropionate) ointment — once daily, max 4 weeks continuous.
Enstilar foam formulation — better penetration for scalp/hairy areas, aerosol delivery.

Coal tar: antipruritic, antiscaling. Messy, odorous — poor adherence. Shampoo for scalp.
Dithranol: stains skin/fabric, irritating. Short-contact therapy 30 min. Start 0.1%, increase gradually.

Phototherapy (2nd line)

Conventional Systemics

Biologics — Criteria: PASI >10 + DLQI >10 + Failure of ≥2 Systemics

Most common pattern. <5 joints. Patchy distribution. Sausage digits (dactylitis).

Resembles RA but RF negative. MCP and PIP joints. Distinguish by nail changes and skin disease.

Distal interphalangeal joints. Associated with nail psoriasis. Key differentiator from RA (RA spares DIP).

Inflammatory back pain, sacroiliac joint involvement. HLA-B27 positive in 50%. Morning stiffness >45 min, improves with exercise.

Most destructive form. "Telescoping" fingers (opera glass deformity). Osteolysis of phalanges. Severely disabling.

CASPAR Criteria (≥3 points required)

Disease Activity Scores

Treatment

Step 1: NSAIDs (naproxen, diclofenac) — symptomatic relief, peripheral disease

Step 2: csDMARDs: Methotrexate (especially with skin disease), sulfasalazine, leflunomide

Step 3 — Biologics: Anti-IL-17 (ixekizumab, secukinumab) and Anti-IL-23 now first-line biologic for PsA with significant skin disease. Anti-TNF: etanercept, adalimumab, certolizumab.

JAK inhibitors: Upadacitinib (Rinvoq), tofacitinib — for refractory PsA. Note cardiac/malignancy safety monitoring.

Inflammation at tendon/ligament insertions. Heel pain — Achilles enthesitis or plantar fasciitis. Assess with ultrasound (power Doppler). Leeds Enthesitis Index (LEI).

Ocular involvement occurs in PsA/SpA. Red eye, photophobia, blurred vision — URGENT ophthalmology referral. Often anterior uveitis. Treat with topical steroids/mydriatics.

Pathophysiology — Skin Barrier Defect

Filaggrin gene (FLG) mutation → defective skin barrier protein production → impaired epidermal barrier

Increased transepidermal water loss (TEWL) → dry, irritable skin

Allergen & irritant penetration through disrupted barrier → Th2-driven inflammation

Th2 cytokines (IL-4, IL-13, IL-31): IgE production, eosinophil recruitment, pruritus (IL-31)

Chronic scratching → lichenification → perpetuates itch-scratch cycle

Prevalence

Facial distribution (cheeks, forehead), scalp. Weeping, crusting. Often spares nappy area. Extensor surface involvement common.

Flexural distribution: antecubital fossae (elbow creases), popliteal fossae (back of knees), neck, wrists, ankles. Intensely pruritic. Chronic relapsing course. Lichenification in chronic disease (thickened, leathery skin).

Itchy skin condition PLUS ≥3: onset <2 years, flexural involvement, visible flexural eczema, dry skin, personal history of asthma/hay fever.

Common Triggers

Copious, regular application (min 500g/week in children). Use as soap substitute. Emollient pump at sink. Apply with downward strokes along hair follicle direction. Avoid flare triggers.

Potency by site and age. Mild (hydrocortisone 1%) for face/flexures. Moderate–potent for body. Apply once/twice daily during flares. Weekend maintenance therapy for frequent flares. Proactive therapy.

Tacrolimus 0.03% (children ≥2y) / 0.1% (adults) — safe for face/neck long-term. Pimecrolimus 1% — milder, face safe. No atrophy risk. Initial burning sensation common. No steroid phobia concern.

NBUVB phototherapy. Systemic immunosuppressants (ciclosporin, azathioprine, methotrexate). Referral to specialist.

Dupilumab (Dupixent): anti-IL-4Rα (blocks IL-4 and IL-13). SC injection. For moderate-severe adult eczema failing systemics. Expanding to adolescents/children 6+. Main SE: conjunctivitis (manage with lubricating drops), injection site reactions. Excellent safety profile. New: Tralokinumab (anti-IL-13), Lebrikizumab.

Fingertip Unit (FTU) Guide

Steroid Potency Ladder

Wet Wrap Technique (Severe Eczema)

NBUVB Phototherapy — Nursing Protocol

Before: Review photosensitising medications (tetracyclines, thiazides, phenothiazines, NSAIDs, St John's Wort). Check cumulative dose log. Skin type (Fitzpatrick 1–6). Consent.

During: Protective goggles (UVR eye damage). Male genital shield. Expose only treatment area. Start minimum dose MED (minimum erythema dose).

After: Document cumulative dose (J/cm²). Monitor for erythema 24–48h. Report blistering. Lifetime dose limit awareness (SCC risk with PUVA).

PUVA — Additional Requirements

Biologic Monitoring

Pre-initiation: TB screening (IGRA/Mantoux), HBV/HCV serology, FBC, LFTs, varicella immunity, pregnancy test, up-to-date vaccinations (NO live vaccines on biologics).

Injection site reactions: Common with SC biologics — erythema, swelling, mild pain. Usually resolve within days. Rotate sites (abdomen, thigh, upper arm).

Infection surveillance: Educate patient — report fever >38°C, URTI, UTI promptly. Hold biologic during serious infection. Opportunistic infection risk (esp. anti-TNF).

Dupilumab (eczema): Conjunctivitis in 10–28% — lubricating eye drops, ophthalmology referral if persistent.

Patient Education

Eczema Action Plan: Written plan — emollient routine, flare management, escalation guide, when to seek help.

Steroid phobia: Very common barrier to treatment. Explain: correct potency for site/duration is safe. Untreated eczema more harmful than appropriate steroid use.

Itch-scratch cycle: Scratching releases histamine → more itch → more scratching. Strategies: cool compresses, antihistamines at night (sedating), keep nails short, cotton gloves at night for children.

Emollient timing: Moisturise within 3 minutes of bathing (before water evaporates from skin). Pat dry — do not rub.

Epidemiology in GCC

Sand and dust storms (haboob) — particulate irritants triggering eczema flares. Extreme dry heat → TEWL → dry skin barrier. Heavily air-conditioned indoor environments → additional skin drying. Seasonal variation less pronounced than temperate climates.

Extensive use of chlorinated swimming pools in GCC — chlorine is a major skin irritant for eczema patients. Counsel: shower immediately after swimming, apply emollient within 3 minutes of bathing, consider waterproof emollient barrier pre-swimming.

Key point for GCC nursing: Applying emollient/topical medications externally (on skin) is permissible during Ramadan fasting — it does NOT break the fast. Reassure patients explicitly. Oral medications during fasting: discuss timing adjustments (suhoor/iftar). Document in nursing notes.

Potent steroid creams (including clobetasol) available OTC in some GCC pharmacies without prescription. Widespread misuse for skin lightening, acne, general rashes. Consequences: steroid rosacea, skin thinning/atrophy, perioral dermatitis, HPA axis suppression, steroid-induced acne. Always take full medication history including non-prescribed creams.

Many skin lightening products sold informally contain undisclosed potent corticosteroids (often clobetasol) + mercury + hydroquinone. Chronic use → severe skin atrophy, stretch marks, systemic absorption, mercury toxicity. Patient education priority.

Traditional natural henna (safe). Black/chemical henna contains para-phenylenediamine (PPD) — a potent contact allergen. Can cause severe allergic contact dermatitis: blistering, scarring, post-inflammatory hypopigmentation. Cross-reacts with hair dye, rubber, local anaesthetics. Patch test if henna exposure history. Document as allergy.

Rapid expansion of biologic dermatology clinics in UAE, KSA, Qatar, Kuwait. DHA (Dubai Health Authority) and DOH (Abu Dhabi Department of Health) approved protocols for dupilumab, IL-17/IL-23 inhibitors. SCFHS (Saudi Commission) nurses require knowledge of biologic eligibility criteria and monitoring protocols.

High-Yield Exam Topics

Commonly Tested Clinical Facts

Regulatory Standards