Psoriasis

Differential diagnosis

• Arthropathy
• Erythroderma – widespread fluid filled spots

Data gathering

• Red flags – joint pains, fluid filled spots on body, eye symptoms
• Others – nails, scalp, medications
• Examine – location, skin, scalp, nails, joints, eyes

Clinical management

• Explanation
  • Faster turnover of skin cells – leads to a buildup of cells on the top layer of skin causing plaques to form – not clear why this occurs
  • Not due to infection. Cannot be passed on
  • Triggers – stress, infections, medications, smoking
  • Sometimes people with psoriasis get nail and joint problems
  • Flare-ups happen

• Treatment
  • Lifestyle – avoid triggers, stop smoking, exercise, healthy diet
  • Emollients
  • Vitamin D based creams – reduces rate of cell division
  • Steroid creams – reduce inflammation
  • First line – Dovobet – vitamin D + steroid cream – use until improvement (max 4 weeks) then step down to just vitamin D (calcipotriol)

• Follow-up / Safety net
  • Refer
    • severe, extensive, poor response to treatment, social and psychological problems, arthropathy
  • Admit
    • if widespread pustules ?erythroderma
  • Annual CV review – BP, BMI, bloods

Specific treatments

• Chronic plaque
  • First line
    • Emollients/coal tar prep e.g. Evorex
  • Second line
    • Calcipotriol oinment (Dovonex – avoid face/flexures) for 8/52 + moderate steroid for 7 days
      • Calcitriol (Silkis) ointment less irriating than calcipotriol in long term treatment
  • Others
    • Diprosalic – for thick scale
    • Dithrocreme – for large plaques with gradual increase in concentration
• Palms and soles
  • very potent steroid e.g. Dermovate for 4 weeks
  • Diprosalic – thick scale
  • Emollients under occlusion
• Flexural/genital/breasts
  • Emollients/coal tar prep e.g. Evorex
  • Consider steroid/antifungal/antibacterial – Trimovate 2-4 weeks
  • Calcitriol for longer term use
• Guttae
  • Emollients
  • Consider early referral for phototherapy
• Face
  • Mild steroid OD or BD for up to 4 weeks
  • Coal tar prep e.g. Alphosyl HC sparingly for 2 weeks
  • nb: calcipotriol can only be used on hair margins/ears – may be better to use calcitriol
• Scalp
  • First line:
    • Tar based shampoo e.g. polytar liquid
    • Diprosalic scalp solution – if thick scale, leave overnight and wash off in the morning
  • Second line
    • Calcipotriol scalp application
  • Third line
    • Betamethasone valerate 0.1% scalp application up to 4 weeks
  • Fourth line
    • Steroid/calcitriol e.g. Xamiol
  • Fifth line
    • Etrivex shampoo – leave on for 15 minutes – max 4 weeks
• Nail
  • Nail varnish, avoid manicure
  • Treat co-exisitng fungal infections
  • Difficult to treat – consider referral to podiatry if severe