Psoriasis

By Anna Hodge

19.12.12

Objectives

• Recognise psoriasis

• Know the first line treatments for psoriasis

• Use topical corticosteroids safely

• Know when to refer

Psoriasis

• What is it?

• What does it look like?

• How do I treat it?

• When should I refer?

What is Psoriasis?

• Immune-mediated disease affecting the skin

• Causes over production of new skin cells

• Genetic component and can be triggered by stress

• Also affects nails and joints

What does it look like?

• Red scaly patches• Well defined• Symmetrical

• Plaque psoriasis

• Scalp psoriasis

• Guttate psoriasis

NICE guidance

• Topical therapy is first line

• Offer referral for phototherapy or systemic therapy– Extensive disease (<10% of body affected)– Where topical Rx is ineffective

How to use topical steroids safely

• Risks– Irreversible skin atrophy or striae– Unstable psoriasis– Systemic side effects

How to avoid s/e

• Very potent corticosteroids– 4 weeks max

• Potent corticosteroids– 8 weeks max

• 4 week break between courses• Use non-steroid based Rx in the break eg

Vitamin D or coal tar preparations• Do not use potent or v. potent topical steroid on

face, flexures, genitals• Or in children

Topical Corticosteroids

• Very potent (600x Hc)– Clobetasol dipropionate (Dermovate)

• Potent (100-150x Hc)– Betamethasone Valerate (Betnovate)– Mometasone Furoate (Elocon)

• Moderate (20-50x Hc)– Betamethasone Valerate 1:4 (Betnovate RD)– Clobetason Butyrate (Eumovate)

• Mild– Hydrocortisone

Management

• Step 1– Potent steroid mane– Vitamin D nocte– For 4-8 weeks

• Step 2– Vit D BD– 8-12 weeks

Management continued

• Step 3– Potent corticosteroid BD for up to 4 weeks

• OR

– Coal tar preparation OD or BD

• Offer once daily combined Steroid and

Vit D if this would improve compliance

Reviewing Rx

• Review 4 weeks after starting a new topical treatment– Evaluate tolerability, initial response– Reinforce importance of adherence– Reinforce importance of 4 week break

between potent and v potent steroid courses

• Patients should have annual rv

Review

• Ensure patients understand that relapse occurs in most people after treatment stopped

• Topical treatments can be used when needed to maintain satisfactory disease control

• If psoriasis cannot be controlled with topical therapy alone- specialist referral

2nd and 3rd Line Therapy

• Phototherapy

• Systemic therapy- methotrexate, ciclosporin etc

• Biologics- Infliximab etc

Summary

• Psoriasis is an immune mediated condition affecting skin, nails, joints

• Topical treatment is 1st line– Potent steroids and Vit D– Coal tar preparations

• Effective communication with patient to aid compliance with treatment

• Refer for Phototherapy/systemic therapy if not responding