Physiotherapy in Skin conditions

A.THANGAMANI RAMALINGAM PT, MSc(PSY),PGDRM, ACspss, MIAP

Functions of the skin

Protection from external injuryCovering the organsUsed in fluid balance excretory function

Sensory functionControls temperatureAbsorption

Metabolizes vitamin DGateway for drug deliveryCosmetic function

Skin conditions

Acne vulgaris is a common chronic skin disease involving blockage and/or inflammation of hair follicles

Alopecia - It is a type of hair loss that occurs when the immune system mistakenly attacks hair follicles

Psoriasis -It is a papulo-squamous disorder of skin. Characterized by erythemato-squamous lesions, vary in size from pinpoint to large plaques. May be localized or generalized with pustular eruptions. It may affect the joints/nails.

Leucoderma / Vitiligo-These are white patches of the skin.Hyperhidrosis is a condition characterized by abnormally

increased sweating

Acne vulgaris

Open comedones (black heads)

Closed comedones (white heads)

PapulesEnlarged pores of hair

folliclesCystsPustulesScars (occassionally)

ComedolyticsChemotherapy ExfoliantsCryotherapy

Alopecia

TypesAlopecia areata – local

patchesAlopecia totalis –

whole scalpAlopecia universalis –

scalp and body

Topical steroidsPUVA therapy

Hyperhidrosis

primary hyperhidrosis or focal hyperhidrosis.

generalized hyperhidrosis or secondary hyperhidrosis

palmoplantar hyperhidrosis 

Gustatory hyperhidrosis

overactivity of the sympathetic nervous system

inherited as an autosomal dominant genetic trait

certain types of cancer, disturbances of the endocrine system, infections, and medications

Psoriasis - papulosquamous disorder

Five main types of psoriasis: plaque, guttate, inverse, pustular, and erythrodermic.

nonpustular and pustular types

Psoriatic plaque - a silvery center surrounded by a reddened border.

Genetic disease Defect in regulatory T cells, and

cytokine interleukin-10 Skin cells are replaced every 3–5

days(normal 28-30 days) scaly, erythematous plaques, papules,

or patches of skin that may be painful and itchy.

Psoriatic arthritis Treatments may include steroid

creams, vitamin D3 cream, ultraviolet light, and immune system suppressing medications such as methotrexate

Mild psoriasis has been defined as a percentage of body surface area (BSA)≤10, a Psoriasis Area Severity Index (PASI) score ≤10, and a dermatology life quality index (DLQI) score ≤10.

Moderate to severe psoriasis was defined by the same group as BSA >10 or PASI score >10 and a DLQI score >10.

Five forms of Psoriatic Arthritis

Asymmetric oligo-articular arthritis (70% of cases) Joints involved - DIP, PIP, MCP mostly -Tenosynovitis -Hip/Knee occasionally

Symmetric rheumatoid like arthritis (15% of cases) Classical psoriatic arthritis (5% of cases)

DIP mostly involved Arthritis multilans (5% of cases)

Osteolysis with severe destruction/deformation of bonesEven dissolution of the phalanges

Ankylosing spondylitis with or without peripheral joint involvement (5% of cases)

Vitiligo

Tissue biopsy cytokine interleukin-1β.

Immune suppressing medications including glucocorticoids (such as 0.05% clobetasol or 0.10% betamethasone) and calcineurin inhibitors (such as tacrolimus or pimecrolimus) are considered to be first-line vitiligo treatmentsSteroid Phototherapy(Narrowband ultraviolet B (NBUVB) phototherapy/PUVA)Counselling Skin camouflageDepigmentation (An alternative approach is to eliminate the skin colour from the normal areas using monobenzone cream)

Characterized by patches of the skin losing their pigment

Genetic susceptibility Auto immune disorderTwo main types: segmental and non-segmentalNon segmental- Generalized Vitiligo: the most common

pattern, wide and randomly distributed areas of depigmentation

Universal Vitiligo: depigmentation encompasses most of the body

Focal Vitiligo: one or a few scattered macules in one area, most common in children

Acrofacial Vitiligo: fingers and periorificial areas

Mucosal Vitiligo: depigmentation of only the mucous membranes[

Physiotherapy

UVR therapy/phototherapy Joint and muscle integrity Care of the bony prominences Increase the mobility and

activity Exercise to improve circulation Reduce shear friction force Don’t expose to extreme hot/

cold Lubricate the skin ‘ adequate

fluid intake’ Use appropriate infection

control techniques Maintain hygiene

PT assessment Inspection under good

light General appearance of

the skin Temperature Moisture , dryness, skin

texture Colour size of lesion Palpate the lymph nodes Look for cyanosis Check the pulses

Advanced PT asssessment

The evaluation is based on six indicators: sensory perception, moisture, activity, mobility, nutrition, and friction or shear.

UVR in skin conditions

Ultraviolet radiation therapy is used to obtain one or more of the following effects: increased vitamin D production, stimulation of the skin, sterilization, tanning, hyperplasia, and exfoliation (peeling).

The use of UVR is indicated for treatment of infectious and noninfectious skin diseases and for the excitation of calcium metabolism.

The development of antibiotics and other medications has greatly reduced the clinical use of UVR.

Today the most common use of UVR is in the treatment of dermatologic conditions such as psoriasis and acne and hard to cure infectious skin conditions such as pressure sores.

UV treatments

Goeckerman’s regimen : Apply coal tar for 24 hrs Remove it with mineral or vegetable oil Exposure to UV Rays to induce mild erythema A bath with soap and water to wash of scales Tar is reapplied after bath. 

Ingram’s regimen: Coal tar application and dry it After drying, UVB radiation to sub erythema dosage Cover up the lesions with Dithranol (0.4% paste) Powder is applied and the lesion covered with Stockinette Patient comes after 24 hrs for treatment. (A short regimen is also available for 30minutes to 2hrs)