Psoriasis Psoriasis –Primary Care Treatment Pathway - PCDS

1 Psoriasis Psoriasis primary care Treatment Pathway What is Psoriasis ? Contributors Psoriasis is a chronic, relapsing, inflammatory condition affecting the skin, scalp, nails, flexures and joints, with cardiovascular and Dr Kash Bhatti Dr Vicky Jolliffe psychological co-morbidities1 Dr Timothy Cunliffe Dr Stephen Kownacki It is not contagious and there is often a family history Dr Angela Goyal Dr George Moncrieff Psoriasis typically manifests with sharply demarcated dull red plaques with silvery scales, which shed easily It can be well controlled and Treatment aims are to minimise skin manifestations.

2 Co-morbidities and improve quality of life Reviewed by the Psoriasis Association Triggers and Exacerbating Factors Assessment Management Stress An holistic approach is essential Explore expectations and discuss Treatment options initially Smoking, alcohol and obesity Examine the skin: using topical therapies Skin injury/surgery Body Emphasise benefits of lifestyle changes and provide support Arrange follow up and consider primary healthcare .. Infections Streptococci, HIV Special sites scalp and nail involvement and specifically ask about genital areas team's role in review of Psoriasis and management of Drugs (oral), such as lithium, beta-blockers,terbinafine and co-morbidities antimalarials such as hydroxychloroquine Joints be alert to signs of inflammatory arthritis including tendonitis and heel pain DLQI Cardio-metabolic risk ( modified Q-risk) quality-of-life-questionnaires/dermatolo gy-life-quality-index Cardiovascular risk assessment, smoking and alcohol Psoriasis Epidemiology Screening Tool (PEST).

3 Consumption Explore wellbeing ( how are you coping? ) Lifestyle Directed Advice Skin Directed Treatment Lifestyle change, reducing obesity, smoking and alcohol and managing psychological co-morbidities We strongly advocate the use of emollients both as soap substitutes and leave on preparations for have been shown to improve Psoriasis severity. Provide advice on managing stress, smoking and all patients, alongside active topical therapies. Emollients soften scale, relieve itch and reduce alcohol, diet and physical exercise. Utilise local resources where available. discomfort and should be prescribed in large quantities, (500g/week for an adult, 250-500g/week Natural sunlight can improve Psoriasis in some.)

4 However, sun-beds and exposing oneself to for a child). When choosing an emollient, patient preference is crucial for adherence excessive periods in the sun is not recommended, especially in patients with very fair complexions, Active topical treatments should be used daily during a flare. During remissions, improvement as this risks skin cancer and burning should be sustained by using less frequent active topical Treatment (apply twice weekly, on Monday and Friday, or Saturday and Sunday). Immediate referral if: Routine/urgent referral if: Secondary care Other Information Erythroderma (more than 90% skin Poor response to Treatment Treatments available in Secondary care .

5 Assessing psychological distress with DLQ I score coverage) Severe Psoriasis or widespread Psoriasis Phototherapy, especially for new guttate Assessing psoriatic arthritis with PEST score Severe worsening Psoriasis and (more than 10% body surface area) Psoriasis or hand and foot Psoriasis systemically unwell patient Reduce costs of multiple prescriptions by advising Psychological distress Systemic oral therapies methotrexate, a pre-payment certificate Generalised pustular Psoriasis ciclosporin, apremilast, Skilarence and Further information for patients can be found at actiretin and Injectable biologics Updated October 2019 by Dr Angelika Razzaque and Dr Kashif Bhatti, PCDS.

6 Psoriasis Psoriasis Clinical Features and Treatment Trunk & Limbs Clinical Features Treatment Face Clinical Features Treatment Well defined Calcipotriol/Betamethasone (Dovobet , Enstilar ) combination An uncommon and Eumovate Ointment many would use this initially, symmetrical small and product should be used first line, once daily until lesions distressing site for a week and follow on with any of large scaly plaques, flatten. This Treatment protocol differs from NICE guidance but sometimes with Protopic ointment once or twice a day and predominantly on is more patient-centred and clinically effective using once daily plaques but more reducing with response extensor surfaces but dosage often similar to that Silkis ointment can cause irritation so introduce can be generalised If the response is sub-optimal at 8-12 weeks: seen in seborrhoeic gradually (initially twice a week then build up 1.)

7 Review adherence dermatitis to daily). 2. Very thick scale can act as a barrier to topical therapies Daktocort cream once or twice a day for more and consider using a salicylic acid preparation to descale seborrhoeic types ( Diprosalic ointment once or twice daily) or occluding thick plaques with a greasy emollient or Sebco shampoo Guttate Psoriasis Clinical Features Treatment overnight under Clingfilm wrap Rapid onset of very small Refer to secondary care for light therapy. 3. Consider using a tar product such as Exorex lotion, or see raindrop like' plaques, In the interim, consider treating with tar lotion the PCDS website for using therapies such as Dithranol mostly on torso and (Exorex lotion ) 2-3 times a day, or using topical During remissions improvement should be sustained with limbs, usually following a steroids such as eumovate , Diprosalic ointment, emollients and by using less frequent active topical streptococcal infection Dovobet or Enstilar foam for itchy patches Treatment (twice weekly application)

8 May lack scale initially In cases of recurrent guttate Psoriasis with proven An important differential streptococcal infections, consider the early use of Scalp Psoriasis Clinical Features Treatment is secondary syphilis antibiotics and/or referral for tonsillectomy Much more common Treatments can be messy and this can be a difficult site to than appreciated and treat, so it is important to manage your patient's expectations Palmoplantar Pustular Clinical Features Treatment easier felt than seen and provide clear explanations Very resistant and This is more likely in smokers: strongly advise May be patchy 1.

9 Descale if necessary with coconut oil or if more severe, difficult to treat. Creamy stopping smoking Socially embarrassing Sebco Ointment massaged onto the scalp generously sterile pustules mature Dermovate Ointment at night under polythene and ideally left over night. Wash out with Capasal or into brown macules occlusion ( Clingfilm ). Typically extends just Alphosyl 2-in-1 shampoo. Continue to use until the scale A moisturiser of choice to be used through the day beyond the hairline, becomes much thinner best seen on nape of Early referral important for hand and foot PUVA/. neck 2.

10 Treat ongoing inflammation with potent topical steroids such Acitretin as Synalar Gel or Diprosalic scalp application applied at night. Dovobet Gel or Enstilar foam could be used Nails Clinical Features Treatment 3. Maintenance therapy: Once or twice weekly tar-based In about 50% of patients Practical tips keep nails short, use nail buffers shampoo such as Capasal or Alphosyl , with once or twice pitting, hyperkeratosis weekly potent topical steroids. If the scale thickens then Nail varnish and gel safe to use and onycholysis Trickle potent topical steroid scalp application or revert to Sebco ointment in short bursts NB.