Psoriasis

What to consider in Primary Care before referring:

General Comments

• Psoriasis is a chronic relapsing condition; mild to moderate involvement can usually be managed in primary care.

• Prior to referral, basic treatment should be tried as outlined.

• Nursing input by an appropriately skilled nurse at this stage will decrease need for referral to Dermatology service.

• Ensure patients understand how and when to use their treatments.

Treatment in primary care

Chronic Plaque Psoriasis

First line therapy:

1. Vitamin D analogues

• Calcitriol (Silkis) - Apply twice daily (up to 210g weekly). NB only available as an ointment.

• Calcipotriol (Dovonex) - Apply generously twice daily (up to 100g weekly) NB only available as a cream.

• Tacalcitol (Curatoderm) - Apply generously once daily.
  (Calcitriol and Tacalcitol generally well tolerated and non irritant. For use in flexures/face. Expect improvement to be gradual, achieving maximum effect over 12 weeks treatment. If useful can be continued long term or intermittently. If used correctly many patients will achieve at least flattening and partial clearance of plaques)

•  Calcipotriol & potent topical steroid (Dovobet ointment) - Apply accurately to plaques once daily for 4 weeks.(Dovobet provides rapid improvement over a 4 week period; use Vitamin D analogues for maintenance therapy in rotation with Dovobet but it can be an irritant)

2. Tar preparations

• Alphosyl cream

• Exorex lotion
  Apply away from flexures twice daily

(Refined tar products are less smelly or messy than old unrefined preparations. May stain clothes or irritate. Expect slow response over 6 – 12 weeks)

3. Dithranol preparations

• Dithrocream

• Micanol
  Start with the lowest strength, applied daily to plaques for 15–30 minutes, then wash off. Increase through strengths weekly unless irritancy occurs.
  Prescribe range:
  e.g.
  Micanol 1% - 3%

Can be used as ‘short contact therapy’ at home, away from face, flexures and genitals.

Often very effective if performed correctly with good remission time but time consuming to do therefore only useful if patient is well motivated and psoriasis localised.

Stains everything including skin, linen, bathroom furniture and may cause irritation of the skin.

Gve adequate quantities of topical preparations appropriate for extent of disease 

4. Topical Retinoid

• Tazarotene
  Apply daily and pre-treat plaque and surrounding skin for one hour with Vaseline/WSP to reduce risk of irritancy.
  Start with 0.05% increasing to 0.1% preparation.

May be useful in fairly limited disease (<10%) with well-defined plaques.

May irritate the skin in which case it can be combined with a moderate potency topical corticosteroid such as clobetasone butyrate 0.05% (Eumovate).

Guttate Psoriasis

(Numerous small lesions, mostly on trunk, generally affecting children/young adults acutely. Often follows sore throat and is self-limiting over 3-6 months)

• Treat with emollients plus trials of tar preparations,

• Vitamin D analogues or moderate potency steroid e.g. Clobetasone Butyrate 0.05%.

• Also tar baths.

If severe, early referral for phototherapy may be the best option.

Scalp Psoriasis

• For moderate scalp psoriasis consider Clobetasol Propionate Shampoo (Etrivex)
  Use daily, apply to dry hair, leave on for 15 minutes and then add water, lather and shampoo out. Review after 4 weeks.

• Generally requires combination of agents. Initially Calcipotriol scalp application plus tar based shampoo e.g. Polytar, Alphosyl or Capasal

If condition extends beyond the hairline or onto the face, Calcitriol (Silkis) is a well tolerated and effective treatment

• If very itchy a topical steroid could be substituted.

• In more severe cases use keratolytic e.g. Cocois or Sebco ointment massaged in and left overnight, washed out in the morning plus topical potent steroid e.g.
  Betamethasone 0.1%
  Betamethasone 0.5% + Salicylic Acid 3%
  Xamiol scalp preparation once daily
  Synalar gel

Cocois or Sebco ointment can be applied for 3-4 hours in the evening and washed out with tar shampoo before bed. Calcipotriol scalp application/Xamiol or a topical steroid could then be applied overnight in addition

Flexural Psoriasis

(Smooth well demarcated areas in axillae, groins, inframammary folds and natal cleft. May occur alone or with chronic plaques elsewhere)

• Use mild to moderate potency steroids combined with antibiotic/antifungals e.g.
  Timodine
  Trimovate creams
  Daktacort cream
  Apply one to twice daily

Facial Psoriasis

• Can be treated with:
  Tacalcitol
  Calcitriol
  Daktacort

Often partial response only is achieved.

Avoid potent steroids to the face.

Referral Threshold

• Extensive/severe or disabling psoriasis – covering 20 % body surface area or more

• Failure to respond to adequate treatment or rapid relapse post treatment

• Extensive acute guttate psoriasis

• Unstable and generalised pustular psoriasis – URGENT REFERRAL

• Diagnostic uncertainty