Management of psoriasis

Psoriasis is characterised by scaly skin lesions which can be in the form of patches, papules, or plaques. Itch is often a feature.

Typical plaque psoriasis

See section 13.5.2 Preparations for psoriasis

Calcipotriol and betamethasone (Dovobet® gel and ointment)

  • Dovobet® should be applied once daily for 4 week bursts or until plaques are flat, repeating as required. Once under control it may be sufficient and cost effective to use an emollient and re-instate Dovobet® for subsequent flares. Avoid use on the face and skin flexures where skin atrophy is a risk. Usage should not exceed 100g per week.

Calcipotriol ointment

  • Calcipotriol should be used twice a day. Avoid use on the face or in the flexures as it can irritate. Maximum application rate 100g per week.

Calcitriol (Silkis®) ointment

  • May be less irritant and can be used on face and flexures. Apply twice daily, maximum of 30g daily and not more than 35% of body surface.

Dithranol (Dithrocream®) 0.1% - 2% (Short contact)

Dithranol (Micanol®) 1% and 3%

  • Dithranol cream should be applied sparingly to the psoriatic lesions and rubbed gently into the skin until it is absorbed. After 30 minutes any excess cream on the skin should be removed by bathing. Start at weakest dose and increase every 3 days if no burning.

Exorex® Lotion

  • Expect a slow response over 6-12 weeks. See also tar preparations under scalp psoriasis below.

Tazarotene Gel (Zorac®) 0.05% and 0.1%

  • Efficacy is limited by irritation. Use plenty of moisturisers prior to application of tazarotene gel and, if irritation occurs, possibly alternate with a weak topical corticosteroid.

Flexural, genital and facial psoriasis

See section 13.4 Topical corticosteroids

Eyelids

Hydrocortisone cream 1%

  • Apply twice daily

Face and flexures

Clobetasone butyrate 0.05% cream (Eumovate®)

  • Apply twice daily

Trimovate® cream (clobetasone/oxytetracycline/nystatin)

  • Apply twice daily
  • Best used in flexures where co-infection with mixed organisms in moist areas is likely to be contributing to inflammation.

Calcitriol (Silkis®) ointment

“Eczematous” plaque psoriasis

This is especially common in the elderly and represents psoriasis mixed with discoid eczema or eczema craquele.

Treat with moisturisers and topical corticosteroid ointments

See section 13.4 Topical corticosteroids

Hydrocortisone ointment 1%,

Clobetasone butyrate (Eumovate®) Ointment

Betamethasone 0.025% (Betnovate®) Ointment RD

Betamethasone 0.1% Ointment

Do not use:

  • Calcipotriol (Dovonex®) or Dithrocream or tazarotene (Zorac®) if the psoriasis is eczematous as it will be irritant.

Scalp psoriasis

Tar products

See section 13.5.2 Preparations for psoriasis

Scales need thinning before further treatment

Cocois®

  • can be left overnight with headscarf or old pillowcase as messy

Capasal® Shampoo

  • may be used to wash out

Steroid preparations

Once the plaques are thinned, use one of the following products (mild cases may respond to a tar-based shampoo)

See section 13.4 Topical corticosteroids

Betamethasone valerate scalp preparation

  • Scalp application
  • Lotion (Betnovate®) which should be used if the scalp stings with an alcohol based product
  • With salicylic acid (Diprosalic® scalp application) a combined steroid with descaler

Resistant cases

See section 13.5.2 Preparations for psoriasis

Calcipotriol plus betamethasone gel (Dovobet® Gel)

  • Use at night under occlusion with shower cap. Use for a maximum of 4 weeks. Repeat courses may be necessary, up to 4 weeks in duration.
  • Dovobet® gel is more effective long-term than calcipotriol, moderate steroids or potent steroids.

Calcipotriol scalp solution

  • Apply twice a day
  • Calcipotriol scalp solution is less effective than steroids or Dovobet® gel. It should be considered as a long-term twice daily alternative if repeat short courses of steroids do not provide general improvement of control.

Very potent for more severe cases

These are very potent steroids and should be used for the minimum length of time possible, maximum 4 weeks. Repeated short courses may be necessary.

See section 13.4 Topical corticosteroids

Dermovate® scalp application (clobetasol propionate 0.05%)

  • Use twice daily for a maximum of 4 weeks, repeated short courses may be necessary

Etrivex® shampoo (clobetasol propionate 0.05%)

  • Use once daily for a maximum of 4 weeks, repeated short courses may be necessary
  • Etrivex® shampoo may be considered in moderate scalp psoriasis where a patient is failing to comply with the administration regimen of Dermovate® scalp application, and who needs a very potent steroid. The short contact time reduces exposure to steroid.

Referral to secondary care

Suggested referral of psoriasis to secondary care:

  • If diagnosis uncertain
  • If too widespread to make treatment by patient at home practical
  • Failure of topical treatments

Treatments available in hospital:

  • UVB Phototherapy
  • Photochemotherapy (PUVA)
  • Retinoids e.g. Acitretin
  • Methotrexate and other cytotoxic drugs
  • Ciclosporin and mycophenolate
  • Biologic therapy

 

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