Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Psoriasis


Related Terms

  • Eruptive Psoriasis
  • Erythrodermic Psoriasis
  • Guttate Psoriasis
  • Inverse Psoriasis
  • Plaque Psoriasis
  • Pustular Psoriasis
  • Vulgaris Psoriasis

Differential Diagnosis

Specialists

  • Dermatologist
  • Family Physician
  • Internal Medicine Physician
  • Rheumatologist

Factors Influencing Duration

Disability depends on the severity of symptoms, location of the lesions, and extent of disease. Psoriatic arthritis can increase the length of disability. Complications that develop as a result of the administration of drugs (e.g., liver toxicity, kidney toxicity) may prolong duration of illness.

Medical Codes

ICD-9-CM:
696.1 - Psoriasis, Other; Acrodermatitis Continua; Dermatitis Repens; Psoriasis, Any Type except Arthropathic

Overview

© Reed Group
Psoriasis is an ongoing (chronic) skin disease that appears in many different forms and can affect any part of the body. In psoriasis, new skin cells are produced about 10 times faster than normal, but the rate at which old cells are shed remains unchanged. As a result, the live cells stack up, forming thickened patches covered by dead, flaking skin.

The most common type of psoriasis is called plaque psoriasis. It is characterized by raised, thickened patches of red skin, covered with silvery-white scales. These patches (plaques) generally begin as little red bumps that gradually grow larger and eventually develop scales, becoming itchy and irritated. Any part of the body can be affected, but the scalp, low back, groin, genitals, nails, elbows, knees, arms, and legs are the most common sites. If the nails are affected, they generally will be pitted or thickened. Usually, the same place on both sides of the body is affected. Other types of psoriasis are pustular psoriasis, erythrodermic psoriasis, guttate psoriasis, and inverse psoriasis (see Physical Exam).

Although the exact cause of psoriasis is unknown, heredity is a factor; approximately 71% of the individuals with psoriasis have a close family member who is also affected (Lui). Factors that cause worsening of psoriasis (flares) include local injury or irritation, infection, hormonal changes, physical or emotional stress, sudden withdrawal of certain medications (e.g., steroids), use of certain medications (e.g., antimalarials, some antibiotics, drugs used to control blood pressure or pain), alcohol use, smoking, and climate changes ("Psoriasis").

Incidence and Prevalence: Psoriasis affects more than 3% of population (“Psoriasis”), with 1% to 2% of individuals having plaque psoriasis (Lui). Less than 2% of all individuals with psoriasis have the guttate form (Taylor). Each year, approximately 150,000 to 260,000 new cases of psoriasis are diagnosed in the US (Gordon).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Psoriasis may develop at any age, and occurs in both children and adults. Most commonly, it is diagnosed between the ages of 16 and 22; however, a second peak in diagnosis occurs in individuals between ages 57 and 60 (Lui). Whites are more commonly affected than other races, with the highest prevalence experienced by individuals of Scandinavian and western European descent (Lui). Men and women are affected equally.

Source: Medical Disability Advisor



Diagnosis

History: The signs and symptoms of psoriasis come and go, with varying degrees of severity. Most individuals have stable, slowly growing patches (plaques) of scaly, thickened skin. The patches typically are 1 to several centimeters in diameter and may be itchy or sore (Lui). Attempts to remove the scales may cause pinpoint bleeding (Auspitz sign). Up to 30% of individuals complain of joint stiffness (psoriatic arthritis) (“Psoriasis”). Some will report a history of skin injury or trauma 1 to 2 weeks before the development of skin lesions (Koebner phenomenon). Other individuals report a sore throat or upper respiratory infection 2 to 3 weeks before the skin outbreak; this effect generally is associated with guttate psoriasis (Gordon). Individuals with erythrodermic psoriasis may report chills and malaise.

Physical exam: Findings vary depending on the form of psoriasis. Plaque psoriasis is the most common form, occurring in 90% of individuals. It is characterized by red, raised, thickened patches of skin, covered with silvery-white scales (Lui). Any part of the body may be affected, but the extensor surfaces of the elbows, knees, arms, legs, and nails are the most common sites. Nails are affected in 53% to 86% of cases and may be pitted or thickened and only loosely attached to the nail bed (Li). The scalp is involved in 50% of cases (Gordon). Hair loss in the affected area may be noted.

Pustular psoriasis appears as pus-like blisters that may be localized to the palms or soles but can be present diffusely over the body.

Guttate psoriasis, most often seen in children and young adults, is characterized by small (1 to 10 millimeter) drop-like, scaly spots that typically are a salmon pink color (Taylor). These spots occur all over the body but are most concentrated on the trunk.

Erythrodermic psoriasis is characterized by intense redness and swelling of large areas of the body. It is one of the most severe forms of psoriasis, and in many cases, individuals will present with chills, fever, dehydration, and malaise.

Inverse psoriasis, seen mostly in older adults, involves smooth, red lesions on the flexor surfaces of the body in the folds of the skin, particularly beneath the breasts, on the groin, genitals, and buttocks, and in the armpits.

Tests: Diagnosis usually is made based on the clinical presentation. If diagnosis is uncertain from the history and physical exam, further testing may include a skin scraping examined under a microscope to check for other causes of the rash. If necessary, a skin biopsy will show the characteristic changes of psoriasis. Since many cases are associated with arthritis, blood tests for other diseases that can cause arthritis usually are done.

Source: Medical Disability Advisor



Treatment

Currently, there is no cure for psoriasis. Treatment is directed at elimination of disease triggers when possible (e.g., stress reduction or removal, discontinuation of certain medications that are associated with either exacerbation or development of psoriasis) and control of symptoms. Treatment varies depending on the individual's age, lifestyle, health status, symptoms, and severity of disease. Frequent visits to a dermatologist may be necessary.

Individuals with somewhat limited psoriasis (i.e., when disease is limited to <20% of the body) may be helped by exposure to sunlight or an ultraviolet lamp (actinotherapy). They also may benefit from daily warm water baths followed by application of emollient moisturizing creams and lotions to loosen scales and help control itching. In milder cases, medications to be applied to the skin also may be prescribed. Such medications include emollients, keratolytics (e.g., salicylic acid, anthralin), coal tar, topical steroids, vitamin A derivatives, or vitamin D analogs (calcipotriene). In more involved cases, intralesional steroids, occlusive dressings or tape, and combination treatments of coal tar preparations with ultraviolet light, such as UVB (a treatment called Goeckerman regimen) may be used.

Topical or intralesional steroids should be used cautiously, with attention to the potency of the preparations (based on the extent of involvement) and the duration of the treatment (no more than 3 weeks with a rest period of 1 or 2 weeks). Although steroids can bring about rapid and significant improvement, they may be accompanied by fast relapse. The use of systemic steroids is to be discouraged in any form of psoriasis, since they may precipitate exacerbations or pustular psoriasis.

In generalized psoriasis where more than 20% of the body is affected, topical therapy alone may provide adequate treatment. These individuals may benefit from either phototherapy (UVB or psoralen + UVA [PUVA]) or systemic treatments of either oral or injectable medications.

Treatment with PUVA can either be oral or topical. In oral PUVA treatment, individuals take medications that sensitize the skin to the effects of sunlight (photosensitizers) by mouth before strong ultraviolet light (UVA) is directed at the lesions. In topical PUVA treatment, photosensitizers are applied as a topical preparation (e.g., cream, lotion) before a low dose of UVA is given.

In severe cases, oral psoriasis medication, prescription oral vitamin A-related drugs, oral/injectable immunosuppressive agents (e.g., cyclosporine A), the antimetabolite methotrexate, or biologic response modifiers (antitumor necrosis factor alpha compounds such as etanercept) may be prescribed. If the nails are severely involved, the nail may be removed surgically or chemically.
Arthritis symptoms may be treated with drugs that reduce inflammation (nonsteroidal anti-inflammatory drugs [NSAIDs]) in milder cases and with a disease-modifying antirheumatic agent (etanercept) in more severe cases.

Source: Medical Disability Advisor



Prognosis

Psoriasis is considered a chronic condition, with no permanent cure. However, individual episodes can be relieved with appropriate treatment. In general, psoriasis worsens during winter months and improves during the summer (Taylor). While the signs and symptoms of psoriasis can be extremely bothersome and cosmetically unappealing, most cases of psoriasis do not represent serious medical conditions.

Goeckerman regimen, when used for approximately 30 treatments, can produce a remission within 2 to 3 weeks in 80% of individuals (Ramirez-Fort). When oral PUVA treatment is repeated 2-3 times a week, psoriasis clears in 85% of the individuals within 2 months (Lui). Guttate psoriasis may spontaneously resolve without treatment within several weeks; however, in 33% to 68% of cases, acute guttate psoriasis will progress to the chronic plaque form of psoriasis (Taylor). Out of all types of psoriasis, erythrodermic psoriasis, which is one of the more severe forms of this condition, can lead to a variety of complications involving the entire body and can be life-threatening, requiring hospitalization in some cases.

Source: Medical Disability Advisor



Complications

Intense itching may lead to skin breakdown and secondary infection. Psoriasis can be accompanied by painful swelling and stiffness of the joints (psoriatic arthritis), which occurs in up to 30% of individuals (Gordon, “Psoriasis”). Individuals with psoriasis, especially those who are obese, have an increased risk for cardiovascular disorders such as mitral valve prolapse (Lui, “Psoriasis”).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions and accommodations will depend on the location and extent of the condition, the severity of symptoms, and the nature of the job. Lesions on limbs, knees, elbows, palms, or soles may prohibit certain types of work or limit an individual's ability to perform certain duties.

Individuals with psoriatic arthritis may have difficulty with tasks requiring flexibility and/or dexterity. If the job requires these types of tasks (such as occurs with professional musicians, typists, cashiers, bank tellers), a change in jobs may be required.

In mild cases, no long-term disability is expected, and individuals usually self-administer treatment. In moderate-to-severe forms of psoriasis, when individuals are treated with phototherapy, they may not be able to work full-time, as they would need to go to their doctor's office 2 to 3 times a week to have the treatment administered.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual have any risk factors such as a family history of psoriasis, local injury or inflammation, stress, hormonal changes, alcohol use, smoking, use of medications associated with psoriasis exacerbation or development, or steroid use?
  • Did individual present with symptoms such as intermittent outbreaks of the red, scaly, thickened skin, particularly on the elbows, knees, arms, legs, scalp, nails?
  • Did the physical exam reveal red, scaly, or pustular lesions beneath the breasts, or on elbows, knees, groin, genitals, arms, legs, scalp, buttocks, or armpits?
  • Was the diagnosis confirmed with a skin biopsy?
  • Does the patient have limited (less than 20% of body affected) or generalized (greater than 20% of body affected) psoriasis?
  • Did the diagnostic workup include blood tests to detect other diseases that can cause arthritis?
  • If the diagnosis was uncertain, were other conditions with similar symptoms considered in the differential diagnosis?

Regarding treatment:

  • Was the treatment selected appropriate for patient's severity of disease?
  • If the disease was mild to moderate or limited, was treatment with moisturizers and topical medications tried? If yes, and they have failed, was phototherapy tried? If yes, and phototherapy failed, were oral or injectable medications considered and tried?
  • Was Goeckerman regimen necessary?
  • If the disease was moderate to severe, was treatment with phototherapy tried? If yes, and phototherapy failed, was treatment with oral antipsoriatics, vitamin A-related drugs, immunosuppressive agents (ciclosporin A), methotrexate or biologic response modifiers tried?
  • Did nails need to be removed surgically or chemically?
  • Were symptoms of arthritic pain managed with NSAIDs?
  • If psoriatic arthritis was severe, was a disease-modifying antirheumatic agent prescribed and administered?

Regarding prognosis:

  • Have necessary work accommodations been made so individual can return to work safely?
  • Has individual been compliant with treatment recommendations? If not, are physical restrictions impairing the ability to apply topical treatments?
  • Does individual have any underlying conditions or associated complications that may affect recovery and prognosis?
  • Did patient experience severe adverse effects from phototherapy or oral or injectable drug treatment?

Source: Medical Disability Advisor



References

Cited

"Psoriasis." National Institute of Arthritis and Musculoskeletal and Skin Diseases. Apr. 2009. National Institutes of Health (NIH). 8 Oct. 2009 <http://www.niams.nih.gov/Health_Info/Psoriasis/default.asp>.

Gordon, Richard, and Adam J. Rosh. "Psoriasis." eMedicine. Eds. Dana A. Stearns, et al. 10 Apr. 2009. Medscape. 8 Oct. 2009 <http://emedicine.medscape.com/article/762805-overview>.

Li, Cindy, and Richard K. Scher. "Psoriasis, Nails." eMedicine. Eds. Mark Lebwohl, et al. 8 Nov. 2007. Medscape. 8 Oct. 2009 <http://emedicine.medscape.com/article/1107949-overview>.

Lui, Harvey, and Adam J. Mamelak. "Psoriasis, Plaque." eMedicine. Eds. Mark Lebwohl, et al. 30 Sep. 2009. Medscape. 8 Oct. 2009 <http://emedicine.medscape.com/article/1108072-overview>.

Ramirez-Fort, Marigdalia K., and Alexander Doctoroff. "Goeckerman’s Regimen for Psoriasis." Dermatopedia. 11 Oct. 2009. 8 Oct. 2009 <http://www.dermatopedia.com/goeckermans-regimen-for-psoriasis>.

Taylor, Charles C. "Psoriasis, Guttate." eMedicine. Eds. Mark Lebwohl, et al. 3 Aug. 2009. Medscape. 8 Oct. 2009 <http://emedicine.medscape.com/article/1107850-overview>.

Source: Medical Disability Advisor






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