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• British Association of Dermatologists & Primary
Care Dermatology Society •
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- Psoriasis affects 1-2% of the population of the United Kingdom;
there is often a positive family history. Most cases are mild
- The degree of psychological and social disability that accompanies
psoriasis is commonly underestimated by the medical profession
and this can result in suboptimal care
- There is no cure for psoriasis, although there are effective
suppressive treatments aimed at inducing a remission or making
the amount of psoriasis tolerable to the patient
- For the majority of patients, psoriasis follows a chronic course,
interspersed with periods of remission. Relapses are difficult
to predict
- The physician should make the patient aware of the possible
therapeutic options, including the simplest available therapies
and the option that treatment may not be necessary
- The patient's perception of his or her disability will often
dictate the need for treatment
- To be able to advise the patient on suitable therapies, the
physician needs to know the sites, extent and severity of the
psoriasis
- Treatment may depend on the patient's age, sex, occupation,
personality, general health, understanding and resources
- Most patients with mild or moderate plaque psoriasis can be
treated in primary care using topical therapies
- If the decision is made to refer (see Ôreferral') treatment
should usually be initiated while awaiting a clinic appointment
- Most patients with uncomplicated psoriasis will only require
referral in the instance of treatment failure
- The diagnosis of psoriasis is clinical, and laboratory investigations
are unhelpful
- There are several forms of psoriasis, and the type affecting
an individual may change over time. The sites and extent of involvement
can range from trivial to almost total coverage
- Psoriasis can change from stable plaques to an unstable form,
typified by eruptive inflammatory lesions that are easily irritated
by topical treatment
- Drugs thought to precipitate or worsen psoriasis include beta-adrenoceptor
blocking drugs and NSAIDs. Oral administration of lithium, chloroquine
or mepacrine may be associated with severe deterioration of psoriasis.
Alcohol may worsen psoriasis and may interfere with treatment
in various ways
- Assessment of severity should include the patient's own perception
of disability, the need for treatment, and an objective assessment
of the extent and severity of the disease
- the total area of involvement is a factor in assessing
severity, but is difficult to estimate accurately
- Management should take the patient's views into account. It
is helpful to record the patient's views of the most upsetting
aspect of his or her psoriasis. Management strategies can then
be directed appropriately within therapeutic limitations based
on the risk:benefit ratio
- Basic information about psoriasis and its management should
be provided
- To help patients come to terms with what is, for many, a lifelong
condition, great efforts should be made to improve communication
during consultations and to educate patients
- Patients should have a plan of management, including the therapeutic
options for the treatment of their psoriasis at each site involved,
and verbal and written information on the probable benefits, and
possible side-effects, of each therapy, enabling them to make
an informed decision about the treatment
- Ideally, practical demonstrations of the application of treatment
should be offered by appropriately trained members of a primary
healthcare team
- Points to discuss at initial presentation:
- explanation of psoriasis, including reassurance that it
is neither infectious nor malignant
- treatment options (including no active treatment)
- the probable benefit the patient can expect from treatment
- techniques of application of any topical treatment (especially
important with dithranol and scalp preparations)
- an introduction to patient support groups may be helpful,
e.g. the Psoriasis Association (7 Milton Street, Northampton
NN2 7JG Tel - 01604 711129) and the Psoriatic Arthropathy
Alliance (PO Box 111, St Albans, Herts AL2 3JQ Tel - 0870
770 3212)
| Treatment of chronic plaque psoriasis |
- Emollients should be used to soften scaling and reduce any
irritation
- For localised plaque psoriasis, e.g. on the elbows or knees,
one or more of the following topical preparations can be tried.
The sequence of choice will vary according to the extent and pattern
of psoriasis, and patient preference:
- a tar-based cream, or a tar/corticosteroid mixture (most
are relatively mild; stronger tar preparations tend to be
messy)
- a moderate potency topical corticosteroid (e.g. 0.05% clobetasone
butyrate); stronger agents can be used on palms and soles
or on the scalp
- use of topical steroids may lead to rebound exacerbation
when treatment is discontinued
- a vitamin D analogue (e.g. calcipotriol, calcitriol or
tacalcitol - the latter two tend to be less irritant and are
more suitable for face or flexures, but should still be used
with caution)
- calcipotriol with betamethasone dipropionate as a combination
product (note that long term data regarding relapse rates
is not yet established)
- a vitamin A analogue (tazarotene)
- a dithranol preparation, usually used as a short-contact
treatment (these are effective but more difficult to use,
especially if there are many small lesions)
- For more widespread plaque psoriasis, e.g. on the trunk or
the limbs, the same treatments may be appropriate. However, dithranol
is often impracticable to apply to multiple small lesions and
will irritate flexures. Topical corticosteroids may be inappropriate
for use in widespread psoriasis, particularly more potent agents
if used on a long-term basis. Application of treatment by appropriately
trained nurses may overcome these problems in some cases
- For scalp psoriasis a tar-based shampoo should be tried first;
this can be combined with the use of either a 2-5% salicylic acid
preparation, a coconut oil/tar/salicylic acid combination ointment,
a potent topical corticosteroid preparation (e.g. 0.1% betamethasone
valerate), calcipotriol scalp application, or more than one of
these
- it is important to use a keratolytic agent (e.g. 5% salicylic
acid in aqueous cream) first when there is significant scaling,
or other treatments will fail. Keratolytic creams should be
applied for a few hours or overnight. A different treatment
for day- and night-time is a useful approach
- In palm and sole psoriasis, as for the scalp, both hyperkeratosis
and inflammation are usually present and may require separate
treatments. Hyperkeratosis usually needs to be treated with a
keratolytic agent. Topical steroids (usually potent, due to the
thick skin at this site), tars and vitamin D analogues may all
be useful
- In general, milder agents are used for flexures. These include
low potency topical steroids, mild tar preparations, and tacalcitol
or calcitriol (not calcipotriol, this is usually irritant in flexures)
- In facial psoriasis, use mild agents: emollients, mild corticosteroids,
calcitriol, tacalcitol, mild tars
- Those patients with extensive disease who need secondary care
treatments such as systemic treatment or phototherapy will normally
be under the supervision of a consultant dermatologist because
of the potential adverse effects of these approaches
- The dermatologist will also be involved in the care of difficult
cases where the site or unresponsiveness of the rash are important
factors
- Indications for consultant referral:
- diagnostic uncertainty
- request for further counselling and/or education including
demonstration of topical treatment
- failure of appropriately used topical treatment for a reasonable
time (e.g. 2Ð3 months)
- extensive disease, if unresponsive to initial therapy or
difficult to self-manage
- need for increasing amounts or potencies of topical corticosteroids
- involvement of sites which are difficult to treat, e.g.
face, palms and soles, genitalia, if unresponsive to initial
therapy
- need for systemic therapy, phototherapy (e.g. guttate psoriasis),
day treatment or inpatient admission
- generalised erythrodermic or generalised pustular psoriasis
(emergency referral is indicated); acute unstable psoriasis
(urgent referral may be justified)
- adverse reactions to topical treatment
- occupational disability or excessive time off work or school
- Content of the referral letter:
- the reason for referral and what is hoped to be gained
from the consultation
- the consultant should try to address these issues in
reply
- the patient's present therapy, if any, its duration, and
quantity being used
- information on previous therapy, including responses or
side-effects
- a treatment could be mistakenly recorded as ineffective
when the real problem was under-treatment or incorrect
use of the prescribed treatment, or discontinued as unsuitable
when transient side-effects could have been overcome had
more advice been given
- any relevant background information, including the patient's
general health and current medication
- the patient's home circumstances; important because the
patients ability to apply topical therapies at affected sites
may be compromised, affecting treatment choice
full guideline available
from…
The British Association of Dermatologists, http://www.bad.org.uk
British Association of Dermatologists & Primary Care Dermatology
Society. Recommendations for the initial management of psoriasis.
2003
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