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| LETTER TO THE EDITOR |
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| Year : 2014 | Volume
: 7
| Issue : 3 | Page : 253-254 |
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Psoriasis: is a central neuraxial block safe?
Nita Hazarika1, Rahul Kumar2, Rajesh Sood1
1 Professor and Head of Department, Dr. Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
2 Department of Critical Care, Sir Ganga Ram Hospital, New Delhi, India
| Date of Submission | 29-Mar-2014 |
| Date of Acceptance | 19-May-2014 |
| Date of Web Publication | 27-Aug-2014 |
Correspondence Address:
Nita Hazarika
Post graduate student, R-Block, House No. 712, New Rajinder Nagar, New Delhi - 110010
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1687-7934.139530
How to cite this article:
Hazarika N, Kumar R, Sood R. Psoriasis: is a central neuraxial block safe?. Ain-Shams J Anaesthesiol 2014;7:253-4 |
Psoriasis is an inflammatory skin disease. It is the most common chronic disease of the skin, often a debilitating dermatological ailment that affects up to 3% of the world's population. The disease exhibits the characteristics of a high epidermal turnover rate accompanied with epidermal hyperplasia. The dermal papillae and epidermis undergo hypertrophy and form cutaneous lesions that develop thick, loosely adherent scales (chronic plaque psoriasis).
The epidemiology is due to complex genetics and the disease is known to erupt due to many environmental factors including infection, bone marrow transplantation, stress, and malignancy. Lesions usually appear on the scalp, elbows, knees, and the sacral region. In some cases, psoriasis can spread through the entire integument including the oral mucosa, palms, soles, and even finger nails. Symptoms are cyclical, peaking usually during young adulthood (at 16-22 years of age) and during older ages (at 57-60 years of age) [1]. The symptoms of psoriasis can be ameliorated in a variety of ways that can include moderate doses of UV light, tars, psoralen, anthralin, methotrexate, hydroxyurea, and steroids [1].
As anesthesiologists, we are concerned because:
(1) During the preoperative period, as chronic corticosteroid therapy is involved in the psoriatic patients, stress-dose corticosteroids should be provided [1].
(2) Physical examination and laboratories should explore the evidence of any acute infection or inflammation related to psoriasis.
(3) Renal and liver function should be assessed when immunosuppressants and/or methotrexate have been utilized in the psoriatic patient [1].
(4) It has been well documented that psoriatic plaques can be elicited artificially by inducing trauma to the skin. Thus, the anesthesiologist must protect the skin in the areas of the psoriatic lesions. Tape should be used only in the most necessary cases, as even such a noninvasive step as tape stripping has been reported to provoke a psoriatic lesion. Intravenous catheters should be sutured in place or wrapped with gauge roll [1].
(5) Nitrous oxide potentiated the cytotoxic effects of methotrexate on proliferating cells and therefore the use of nitrous oxide before or even during methotrexate administration should be avoided [1].
(6) Erythroderma variant of psoriasis can present a special challenge. In this inflammatory disorder, generalized erythema and scaling occur. Furthermore, this variant form may disturb the cardiovascular, thermoregulatory, and metabolic systems. Increased incidence of vascular diseases such as thrombophlebitis, pulmonary embolism, cerebrovascular accidents, and myocardial infarction has been described. It is therefore recommended that the psoriatic patient undergoes full systemic monitoring throughout the perioperative period. One of the most important preventative steps in management includes evaluation for undiagnosed high-output congestive heart failure. The presentation of systemic scales can cause difficulty in placing ECG electrodes on the patient. Systemic scaling can also complicate endotracheal tube placement and may lead to postoperative dyspnea. For example, pustular psoriasis can be accompanied by relapsing polychondritis; which can complicate intubation due to reasons such as cartilage degeneration and a smaller glottis due to edema [1].
(7) Patients afflicted with psoriasis-related psychological symptoms such as social phobias are often given agents including tricyclic antidepressants or the selective serotonin reuptake inhibitor antidepressants.
Considering the risks associated with general anaesthesia (GA), regional anesthesia is always a preferred option where feasible. However, involvement of the back by the psoriatic plaques may place the anesthetist in the dilemma of deciding whether central neuraxial block (CNB) will be safe or not. Although the lesions of psoriasis, even the pustules, are not infectious per se, the extensive skin involvement is often considered to be at least a relative contraindication to neuraxial blockade in these patients [2]. Pemberton and Callender [2] have successfully used spinal anesthesia for cesarean section in a patient with pustular psoriasis who was admitted 1 week before her elective surgery to treat the lesions locally to decrease their severity.
In addition, anesthesiologists must be aware of the high incidence of pruritus with neuraxial opioids, especially when dealing with psoriatic patients - for pruritus exacerbates their disease. The onset of pruritus after the administration of neuraxial opioids has been a long-standing adverse effect with an incidence ranging from 0 to 100% [1,3]. This incidence of pruritus is lower in epidural opioids versus spinal opioids (8 vs. 46%), and the greatest incidence has been shown when using neuraxial morphine [1]. Opioid-induced pruritus is not only difficult to manage and extremely uncomfortable, but also has a poor response to histamine (H1) blockers and other conventional treatments. However, naloxone and propofol are two drugs proven to be effective against opioid-induced pruritus [1].
No 'miracle' cure exists for psoriasis. CNB is not absolutely contraindicated in psoriasis. The anesthesiologist must take many factors into consideration, such as the severity of the disease, where to place regional anesthesia, and the anesthetic complications associated with certain types of psoriatic medications.
| Acknowledgements | |  |
| References | | |
| 1. | Baluch A, Kak A, Saleh O, Lonadier L, Kaye AD. Psoriasis and anaesthetic considerations. Middle East J Anesthesiol 2010; 20:621-630. 
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| 2. | Pemberton O, Callender C. Caesarean section under spinal anaesthesia for a patient with pustular psoriasis. Anaesthesia 2009;64:803-804.
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| 3. | Mahajan R, Grover VK. Neuraxial opioids and Koebner phenomenon: implications for anesthesiologists. Anesthesiology 2003; 99:229-230.
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