Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
DERMATOLOGY Management of psoriasis Guidelines adapted from Primary Care Dermatology Society Guidelines on Psoriasis Emollients ++ Ointments more effective but less well tolerated (e.g. Epaderm, white soft paraffin liquid paraffin 50:50) Ointments at night, lighter creams in day better tolerated (e.g. Cetraban, Diprobase). Encourage to try alternatives if not well tolerated Soap substitute, Dermol 500 or aqueous cream Active treatments should be used for flare ups for up to 6 weeks, continue emollients in treatment holidays Topical agents for plaques Dovobet o Dovobet gel, patients may prefer and can also be used on scalp psoriasis o Dovobet ointment, some patients may find more effective NB Use should be restricted in patients with extensive/unstable psoriasis and avoiding repeated applications/prescribing. Calcipotriol o Can also be used on scalp psoriasis Tar preparations e.g. Exorex lotion or Psoriderm Cream or Alphosyl HC (avoid latter in egg allergy) o Use on large thin plaques Other treatment options o Tazarotene 0.05% or 0.1% OD may cause irritation requiring topical steroids at the other end of the day o Dithrocream - short contact effective but limited by patient acceptability. The dermatology specialist nurse can advise on treatment. Hands and feet Consider skin scraping to exclude tinea Emollients and soap substitutes, also give advise about irritant contact dermatitis as likely to have some degree of this Calcipotriol or Coal Tar creams Can use treatments under occlusion (cotton gloves for hands, cling film for feet) Refer to dermatology for systemics or hand and foot PUVA if resistant to topicals Scalp Psoriasis Shampoos, Long term management –massage into scalp for 5mins then wash out (tar based polytar or capasal) Sebco or Cocois. For thick crust, apply for at least 2 hours or overnight under a shower cap (some patients cannot tolerate for more than a few hours, messy) Calcipotriol scalp application Flexures and Genitalia Moisturisers Mild topical steroids. Hydrocortisone 1% cream. Daktacort or Canestan HC for co-existent yeast. Stop steroid once controlled Curatoderm or Silkis alternative if concerns of too much steroid use. Elidel or Protopic, good alternatives but off licence treatment for psoriasis. Face Uncommon site for psoriasis Emollients Vitamin D analogues Silkis or Curatoderm 1% HC can be used although risk of atrophy, alternative is 0.1% tacrolimus, off label although can be very effective in this area (consider referral for specialist assessment) Guttate psoriasis Typically triggered 7 – 10 days after streptococcal URTI Mild cases emollients until spontaneous resolution in 2-3 months Tar preparations e.g. Exorex can be applied to large areas. (Vit D analogues can be used but time consuming to apply to individual lesions) Phototherapy, narrow band UVB in unresponsive/widespread cases Referral Criteria Moderate-severe psoriasis at onset Failure to respond adequately to topical treatments Generalised pustular psoriasis needs admission Second line treatments include light treatment (narrow band UVB (TL01) or PUVA) systemics (Ciclosporin, Methotrexate, Acitretin) Third line biologics Etanercept, Infliximab, Adalimumab Cryotron psoriasis or diagnostic uncertainty For patient information/leaflets – see PCDS (Advise patients that staining of clothes or cloth i.e. bed linen may occur with certain prescribed medications) For further advice patients can contact: The Psoriasis Association 7 Milton Street Northampton NN2 7JF N.B . For historical and educational reasons, medicines have been described using brand names. Wherever possible, prescribers should ensure appropriate consideration is given to generic preparations. REFERENCES: British Association of Dermatologists & Primary Care Dermatology Society Recommendations for the Initial Management of Psoriasis Guidelines 2009 39 Available online at: http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/BADPCDS%20Psoriasis%20reviewed%202010.pdf AUTHORS: Coastal West Sussex Dermatology Task & Finish Group, Dr A Karim and Dr Justine Hextall, Consultant Dermatologists WSHT. OTHERS INVOLVED: PUBLISHED: Western Sussex Hospitals NHS Trust LRMG Committee. 06/11 REVIEW DUE: 06/13