Download Management of chronic plaque psoriasis

DERMATOLOGY
Management of psoriasis
Guidelines adapted from Primary Care Dermatology Society Guidelines on Psoriasis
Emollients ++
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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
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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
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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
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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
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Moisturisers
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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
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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
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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
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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