Traditional Chinese Medicine nursing protocols for psoriasis vulgaris Editorial Board of Nursing of Integrated Traditional Chinese and Western Medicine

ABSTRACT: Psoriasis is a common chronic inflammatory skin disease with a spectrum of clinical phenotypes including psoriasis vulgaris, pustular psoriasis, guttate psoriasis and erythrodermic psoriasis, in which psoriasis vulgaris is most common. In recent years, Traditional Chinese Medicine (TCM) has attracted widespread attention in the treatment of psoriasis because of better efficacy and a lower incidence of adverse reactions. In TCM, psoriasis is considered to be caused by blood heat and the stagnation of Qi and blood. This article primarily investigated the key points of common syndromes, TCM nursing methods and healthy guidance of psoriasis vulgaris, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

KEY WORDS: psoriasis vulgaris; skin lesion; desquamation; traditional Chinese medicine nursing; syndrome differentiation

Psoriasis is a common chronic inflammatory skin disease with a spectrum of clinical phenotypes, characterized by scaly and sharply demarcated papules and plaques on the skin and scalp[1-2]. It can occur in all age groups and has a higher prevalence in adults compared with children[3]. The prevalence of this disease is different across countries, such as 0.73%-2.90% in Europe, 0.70%-2.60% in the United States and 0-0.50% in Latin America, Africa, and Asia[4]. Psoriasis can be classified into four major clinical phenotypes, namely psoriasis vulgaris, pustular psoriasis, guttate psoriasis and erythrodermic psoriasis, in which psoriasis vulgaris is most common, approximately accounting for 90% of all cases[5]. Psoriasis vulgaris can appear all over the body, seriously affecting the patients’ elbows, knees, scalp, lumbosacral area and intergluteal cleft[6]. Although the pathogenesis of psoriasis is not understood fully, it is universally recognized that its occurrence is associated with genetic predisposition, environmental factors and immune regulation disturbance[7-9].

Currently, psoriasis is treated by use of topical agents, ultraviolet light, systemic drugs, and/or biologics. Topical therapy is usually used for mild-to-moderate psoriasis, with minimal systemic effects[10], while systemic drugs for severe psoriasis due to serious side effects[11]. Additionally, traditional Chinese medicine (TCM) has recently attracted widespread attention in the treatment of psoriasis because of better efficacy and a lower incidence of adverse reactions. In TCM, psoriasis is considered to be caused by blood heat and the stagnation of qi and blood. Liu et al.[12]found that the immune function and blood circulation could be improved by the therapy of replenishing Qi to activate blood. A meta-analysis suggested that oral Chinese herbal medicine might have benefits for psoriasis vulgaris, with better safety[13]. In view of this, State Administration of Traditional Chinese Medicine of the People’s Republic of China formulated a TCM nursing protocol for psoriasis vulgaris, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

Keypointsofcommonsyndromes

Blood-heatsyndrome: gradually increased and rapidly extended new papules, flushing skin lesions, argent scales, cribriform bleeding, pruritus, possibly accompanied by yellow urine and dry stool; red tongue with yellow or white thin coating.

Blood-drynesssyndrome: light red skin lesions, dry desquamation, possibly accompanied by rhagadia and dry mouth and throat; light colored tongue with scanty or white thin coating.

Blood-stasissyndrome: dark red, hypertrophic, invasive skin lesions that are difficult to fade away durably and closely adhere to scales, probable presence of dysmenorrhea in women; dark purple tongue or with petechia and ecchymosis.

Nursingforcommonsymptoms/syndromes

Flushingskinlesionswithscales

·Observe the papular location, color, shape, scale, presence or absence of petechia as well as the isomorphic reaction. The doctor should be informed immediately if the following symptoms suddenly occur, such as diffuse flushing all over the body and a large amount of desquamation accompanied by high fever or severe skin pruritus.

·Prohibit scalding the skin with hot water and avoid trauma.

·Conduct TCM hydropathic compress and TCM smearing according to the doctor’s advice.

·It is suitable for the patients with more scales to have a warm water bath before perfrication and to slightly remove the scales. It is appropriate to remove other drugs in the skin lesions using cotton balls with vegetable oil. When the escharosis is thicker in skin lesions, the drugs are smeared after the crusta is softened using vegetable oil or the ointment with the function of clearing heat and detoxification, such as Huanglian paste and the paste for detoxification.·For the skin lesions on the head, it is suitable to cut the hair short before perfrication. The drugs can be smeared by separating the hair using a comb when the female patient is unwilling to cut the hair short.

Lightredskinlesionsanddrydesquamation

·Observe the papular location, color, shape and the scale condition.

·Perform TCM bath, TCM fumigation and TCM smearing following the doctor’s advice.

Hypertrophic,invasiveskinlesions,difficulttofadeawaydurably

·Observe the papular location, color, shape and the scale condition.

·According to the doctor’s advice, conduct TCM smearing and then package the affected part using the plastic thin film or gauze.

·Based on the doctor’s advice, perform TCM bath and cupping which is suitable for the abundant skin.

Pruritus

·Assess the pruritus degree and observe whether there is a scratch, blood crust and infection in the skin and whether the sleep is affected.

·Advise to wear the clean, soft cotton clothes and pat the itching part with hands.

·Keep the skin clean using mild detergents and keep water temperature comfortable.

·According to the doctor’s advice, perform TCM smearing, TCM bath, intermediate-frequency therapy (the points like Quchi, Neiguan, Zusanli, Sanyinjiao, etc.) and acupoint application (the points like Shenque).

Drystool

·Assess the defecation times, quantity and nature.

·Tell the patients to have a habit of regular bowel movements, and guide them to take exercises for abdominal muscles.

·Abdominal massage: take a horizontal position, massage the abdomen clockwise with the navel as a center, 2-3 times per day.

·Based on the doctor’s advice, conduct acupoint massage (the points like Weishu, Pishu, Guanyuan, Zhongwan, Zhigou, Tianshu, etc.) and auricular acupressure (the points like large intestine, rectum, lung, constipation point, etc.).

TCMspecialnursing

Medications

InternalapplicationofChineseherbs

·Medicationtime: Each dose of herbs can be taken generally in twice or three times. The specific medication time depends on the property and function of herbs as well as the patients' pathological condition. Chinese herbs for relieving exterior and clearing heat should be taken 1 h before meals, in which application of exterior-reliving Chinese herbs should avoid wind chill, or putting on more clothes or having some porridge induces diaphoresis. Chinese herbs for promoting digestion, purgation, expelling parasites, tranquilization and tonification are taken respectively after meals, before meals, on an empty stomach in the morning, before sleep and on an empty stomach. Emergency drug use follows the doctor's advice.

·Medicationtemperature: The administered warm is usually adopted. For the patients with special treatment, the herbs should be taken according to the doctor's advice.

·Medicationdose: 200 mL is taken per time for the adult; 100 mL is taken per time for the patients with heart failure and those of controlling the dose. The elderly and children should take herbs according to the doctor's advice.

Injection

·Inquire the history of allergy carefully before medication.

·Make allocation and administration according to the requirements and injection speed recommended in the drug instructions.

·Apply TCM injection alone, and use it right after it was ready.

·Chinese and western drugs should be separated when Chinese and western injections are in combination.

·It is inappropriate to use a venous channel for two or more kinds of drugs except for special instructions.

·Medication reactions are observed closely, especially for the elderly, children, people with liver and kidney dysfunction and those that use TCM injections initially. Medication is suspended, and the doctors should be told to deal with it if adverse reactions occur.

·Nursing for allergic reactions: stop to use the drugs immediately, change the infusion channel and inform the doctor; seal the liquid and channels that cause adverse reactions; do allergic identification and inform patients and their relatives firmly to avoid re-medication; guide the patients to have a bland diet during the treatment of allergic reactions, forbid to eat the food like fish, shrimps, etc.

Specialtechniques

TCMhydropathiccompress

(1) This method is suitable for the patients with red skin lesions. Its operations are as follows: first, make 6-8 layers of gauze dipped into the drug liquid with the temperature of 20-25 ℃; next, squeeze the gauze to dry by picking it up with a double grab or wearing sterile gloves; finally, make the hydropathic compress pad tightly adhered to the affected part, change it once every 20 min, totally 40 min, once or twice per day.

(2) Others.

·According to the doctor’s advice, select the correct drugs and perform TCM hydropathic compress.

·Assess the skin in the part of hydropathic compress. It should be used with caution for the patients with drug/skin allergy and those with rapidly diffused ulcerative abscesses.

·Expose the part of hydropathic compress, and pay attention to keeping warm and protecting the privacy.

·Make the gauze with 5-6 layers dipped into the drug liquid, and keep the humidity of no dripping. Keep the temperature of drug liquid at 38-41 ℃ to prevent empyrosis.

·Observe local skin reactions during operation. Stop the treatment immediately, inform the doctor and take symptomatic treatment according to the doctor’s advice if the symptoms, such as pale skin, ·erythema, blister, pruritus, pain or rupture, occur.

·Implement corresponding nursing following the doctor’s advice if there are special drugs.

·Pay attention to disinfection and isolation to avoid cross infections.

·Record the part, time and temperature of hydropathic compress, as well as patients’ feelings after all the operations are finished.

TCMbath

(1) This method is appropriate for the patients with blood-dryness and blood-stasis syndrome. They have a dipping bath with TCM decoction following the doctor’s advice, 30 min every time, once every day or every other day.

(2) Others.

·Perform TCM bath following the doctor’s advice.

·Nursing assessment: It is forbidden for the patients with acute infectious disease, severe heart, lung and brain disease, severe anemia, soft tissue injury and acute hemorrhage as well as for the women with pregnancy and menstruation. It is used with caution to the patients the patients with drug and skin allergy.

·Before operation, tell the patients the process and notes of medicated bath, and communicate with the medical staff immediately if discomforts occur.

·It is unsuitable for medicated bath on an empty stomach and one hour after meals.

·Keep a warm operation environment, close the door and window, and maintain good indoor ventilation.

·Pay attention to the medicated bath temperature and control of water level.

·Enhance walkaround inspection during medicated bath. Inform the patients with much sweating of taking warm saline water to prevent prostration. Observe the local and systemic condition of patients, and immediately inform the doctor and deal with them according to the doctor’s advice if the symptoms like erythema, itching, palpitation, sweating and dizziness appear.

·Keep the medicated bath for 20-30 min.

·Tell the patients to move slowly to prevent postural hypotension after medicated bath.

·Require a specially-assigned person to accompany the elderly and the weak patients during the whole medicated bath.

·Equip the rescue drugs and things in the medicated bath room.

·Pay attention to disinfection and isolation to avoid cross infection.

·Record the temperature and time of the medicated bath as well as the skin condition and feelings of patients after operation is finished.

TCMfumigation

(1) This method is suitable for the patients with blood-dryness and blood-stasis syndrome. They take a fumigation of 50-70 ℃ with TCM decoction according to the doctor’s advice, and start to wash when the drug liquid decreases to 38-42 ℃, once every day or every other day.

(2) Others.

·Perform TCM fumigation following the doctor’s advice.

·Nursing assessment: the condition of skin in the part of fumigation. It is used with caution to the patients with drug and skin allergy, heart, lung and brain disease, enema as well as the weak and elderly patients. It is unsuitable for pregnancy women and those during menstruation to take a sitz bath or fumigate the vulva.

·Before operation, tell the patients the process and notes of TCM fumigation, and communicate with the medical staff immediately if discomforts occur.

·Keep a warm operation environment, and close the door and window.

·Expose the fumigated part, keep warm and protect the privacy.

·Keep the liquid temperature at 50-70 ℃. Sitz bath and wash can be conducted to prevent empyrosis when the liquid temperature is decreased to 37-40 ℃.

·Keep TCM fumigation for 20-30 min.

·Inquire the patients’ feelings, and regulate the liquid temperature timely.

·Tell the patients to have a rest for 30 min after TCM fumigation, and then go out in order to prevent invasion of exogenous pathogens.

·Observe the local and systemic condition of patients during operation, and immediately inform the doctor and deal with it if discomforts occur.

·Record the temperature and time of TCM fumigation as well as the skin condition and feelings of patients after operation is finished.

TCMsmearing

(1) A thin layer of drug is smeared evenly, once or twice a day. For the patients with blood-stasis syndrome and those with hypertrophic, invasive skin lesions that are difficult to fade away durably, a thick layer of drug should be smeared, and the affected part is packaged after smearing using the plastic thin film or gauze, once or twice a day.

(2) Others.

·Perform TCM smearing following the doctor’s advice.

·Nursing assessment: previous history, allergic history and the condition of skin in the medicated part.

·Wash the local skin before TCM smearing, and conduct the smearing times according to the doctor’s advice.

·The bottle cap should be stuffed up after aqueous solution and tincture are used. The suspension liquid is embrocated after being shaken equably. The cream should be rubbed repeatedly by the palm or fingers to make it penetrate into the skin.

·Don’t smear too much in the local part to avoid clogging pores.

·Prevent the medicine from entering into the mouth and eyes when it is smeared on the face.

·Stop to smear immediately and inform the doctor to deal with it when papule, itching or swelling appears in local skin.

Acupointapplication

(1) Acupoint application is conducted once a day, 6-8 h every time.

(2) Others.

·Conduct acupoint application following the doctor’s advice.

·Nursing assessment: the skin condition in the part of acupoint application; forbid to use it for pregnancy women.

·Expose the part of acupoint application completely, and pay attention to keeping warm and protecting the privacy.

·Keep a proper thickness of plaster (0.2-0.3 cm) and a certain humidity in order to smear easily.

·Observe the local and systemic condition. Stop to use it and inform the doctor to manage immediately if the allergy occurs, such as erythema, pruritus and vesicles.

·Avoid smoking, drinking alcohol, and taking cold, salty and spicy food, seafood, beef and mutton during application.

·Record the application part, time and patients’ feelings after all the operations are finished.

Cuppingtherapy

(1) This method is suitable for the patients with blood-dryness and blood-stasis syndrome. The cupping therapy is performed in the hypertrophic skin lesion based on the doctor’s advice, once a day or every other day.

(2) Others.

·Do cupping following the doctor’s advice, and select the correct cupping parts and methods.

·Nursing assessment: observe the condition of skin in the cupping part and the patients’ tolerance to the pain. Cupping therapy is unsuitable in the parts including skin ulcer, edema, much hair, large blood vessels, and in the lumbosacral part of pregnancy women. It is also unsuitable for the patients with convulsion due to high fever and disturbances of blood coagulation.

·Take a reasonable position to make cupping part exposed completely, and pay attention to keep warm and protect the privacy.

·Check whether there is a break at the edge of jars, and whether it is glossy. Select proper cupping jars according to different parts.

·Observe the adhesion condition and skin color during cupping. Inquiry the patients’ feelings, and take off the jars immediately to avoid empyrosis if discomforts appear.

·Do cupping accurately, rapidly and steadily, and don’t pull the jars when taking off them.

·Keep a comfortable distance for the arrangement of many jars to avoid the pain induced by jar traction.

·Generally, the local flushed or cyanosis (blood stasis) skin is normal after the jars are taken off, and it will disappear spontaneously. It is unsuitable to do cupping in the previous site if local blood stasis is severe. It is unnecessary to deal with local vesicles, but if the vesicles are bigger, the liquid in them should be extracted using the injector after the local skin is sterilized, and the sterilized dressing is covered.

·Record the cupping part, time and patients’ feelings after all the operations are finished.

Auricular-plastertherapy

·Embed beans at auricular points and select acupoints correctly according to the doctor's advice.

·Assess the condition of ear skin and degree of tolerance to the pain; prohibit using them in the inflammatory, ruptured and frozen skin as well as in pregnant women.

·Keep the intensity of probe moderate and accurately seek the sensitive point in acupoint area.

·Scrub the ears with 75% alcohol.

·Observe the patients' condition, stop immediately and inform the doctor to deal with it if discomforts occur.

·Select one ear for routine performance, keep the beans usually for 3-7 days and use them in two ears alternately; guide the patients to press them correctly.

·Observe the fixed degree of auricular point sticking, the improvement condition of symptoms and ear skin (redness, swelling, rupture, etc.).

·Record the bean-embedded location and time at auricular points as well as the patients' feelings after the operation is finished.

Acupointmassage

·Conduct acupoint massage according to the doctor's advice.

·Assess the skin condition around the massage area and degree of tolerance to the pain; prohibit using it in women during menstruation and pregnancy.

·For the operator, trim the fingernails to prevent the skin from injury.

·Keep the strength even and moderate, and pay attention to keep warm for the patients and protect their privacy.

·Observe the patients' reactions closely when the operation is done; stop the massage and take corresponding measures once discomforts occur.

·Record the massage acupoints, techniques and time as well as the patients' feelings.

Healthyguidance

Dailylife

·Keep the bed sheet clean and select soft and cotton products to reduce the friction.

·Protect the skin, trim the nails frequently to avoid scratching and strong stimulation, forbid to use hot water to wash and avoid trauma and abuse of drugs.

·Ensure adequate sleep, avoid over fatigue and invasion of pathogenic wind, dampness and heat.

·Encourage the patients to enhance the fitness and take recreational and sports activities, such as Baduanjin and Taichi health exercises.

Dietaryguidance

·Blood-heatsyndrome:It is advisable to eat the bland food that can clear heat to cool blood, such as snow pear, lotus root starch, lotus seed and watermelon. Dietary formula: Green bean & lily soup and porridge with rehmannia and purslane. The patient should dink much water, and avoid eating the hot-natured food like dog meat, chocolate and mango.

·Blood-drynesssyndrome: It is advisable to eat the food that can regulate spleen and stomach, tonify and nourish yin for moistening dryness, such as the lean, eggs and duck.

·Blood-stasissyndrome: It is advisable to eat the food that can strengthen the spleen to remove dampness and activate blood to dissipate stasis, such as semen coicis, Chinese yam, hawthorn and brown sugar.

·The patients with pruritus should prohibit eating the spicy food and seafood, such as beef, mutton, venison, dog meat, pepper and wild pepper.

·The patients with a large amount of desquamation in the skin lesions should increase intake of proteins and microelements, including birds, domestic animals, eggs, milk and vegetable proteins. Nutrient supplements can be used if necessary.

·The food that may cause or aggravate the disease condition should be told to the patients, and the suspicious food should be avoided.

·It is suitable to use the cooking methods like steaming, boiling and stewing, but not smoking, roasting and frying.

Emotionaladjustment

·Communicate with patients frequently and timely ease the tension through listen, speech, transference, being in harmony with their feelings for resolving depression and suggestive therapy.

·Encourage the relatives to frequently accompany with patients and give them a better family and social support.