Psoriasis

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Psoriasis

• By Anna Hodge
• 19.12.12

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Objectives

• Recognise psoriasis
• Know the first line treatments for psoriasis
• Use topical corticosteroids safely
• Know when to refer

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Psoriasis

• What is it?
• What does it look like?
• How do I treat it?
• When should I refer?

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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

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What does it look like?

• Red scaly patches
• Well defined
• Symmetrical

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• Plaque psoriasis
• Scalp psoriasis
• Guttate psoriasis

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NICE guidance

• Topical therapy is first line
• Offer referral for phototherapy or systemic
  therapy
• Extensive disease (lt10 of body affected)
• Where topical Rx is ineffective

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How to use topical steroids safely

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

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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

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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 14 (Betnovate RD)
• Clobetason Butyrate (Eumovate)
• Mild
• Hydrocortisone

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Management

• Step 1
• Potent steroid mane
• Vitamin D nocte
• For 4-8 weeks
• Step 2
• Vit D BD
• 8-12 weeks

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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

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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

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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

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2nd and 3rd Line Therapy

• Phototherapy
• Systemic therapy- methotrexate, ciclosporin etc
• Biologics- Infliximab etc

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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