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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