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Summary for primary care

Psoriasis Primary Care Treatment Pathway

Primary Care Dermatology Society

Overview

An easy-to-follow summary of the Primary Care Dermatology Society's treatment pathway for the assessment and management of psoriasis based on areas affected.
 

What is Psoriasis?

  • Psoriasis is a chronic, relapsing, inflammatory condition affecting the skin, scalp, nails, flexures and joints, with cardiovascular and psychological co-morbidities
  • It is not contagious and there is often a family history
  • 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, comorbidities and improve quality of life

Triggers and Exacerbating Factors

  • Stress
  • Smoking, alcohol and obesity
  • Skin injury/surgery
  • Infections—Streptococci, HIV
  • Drugs (oral), such as lithium, beta-blockers, terbinafine and antimalarials such as hydroxychloroquine

Assessment

  • An holistic approach is essential
  • Examine the skin:
    • body
    • special sites—scalp and nail involvement and specifically ask about genital areas
    • joints—be alert to signs of inflammatory arthritis including tendonitis and heel pain
    • cardio-metabolic risk (e.g. modified Q-risk)
    • cardiovascular risk assessment, smoking and alcohol consumption
    • explore wellbeing (e.g. ’how are you coping?’)

Management

Lifestyle Directed Advice

  • Lifestyle change, reducing obesity, smoking and alcohol and managing psychological co-morbidities have been shown to improve psoriasis severity. Provide advice on managing stress, smoking and alcohol, diet and physical exercise. Utilise local resources where available
  • Natural sunlight can improve psoriasis in some. However, sun-beds and exposing oneself to excessive periods in the sun is not recommended, especially in patients with very fair complexions, as this risks skin cancer and burning

Skin Directed Treatment

  • We strongly advocate the use of emollients both as soap substitutes and leave on preparations for all patients, alongside active topical therapies. Emollients soften scale, relieve itch and reduce discomfort and should be prescribed in large quantities (500 g/week for an adult, 250–500 g/week for a child). When choosing an emollient, patient preference is crucial for adherence
  • Active topical treatments should be used daily during a flare. During remissions, improvement should be sustained by using less frequent active topical treatment (apply twice weekly, on Monday and Friday, or Saturday and Sunday)

Table 1: Psoriasis—Clinical Features and Treatment 

Clinical FeaturesTreatment 
Trunk and Limbs   
  • Well defined symmetrical small and large scaly plaques, predominantly on extensor surfaces but can be generalised
  • Calcipotriol/Betamethasone (Dovobet®, Enstilar®) combination product should be used first line, once daily until lesions flatten. This treatment protocol differs from NICE guidance but is more patient-centred and clinically effective using once daily dosage
  • If the response is sub-optimal at 8-12 weeks:
    1. Review adherence
    2. Very thick scale can act as a barrier to topical therapies and consider using a salicylic acid preparation to descale (e.g. Diprosalic® ointment once or twice daily) or occluding thick plaques with a greasy emollient or Sebco® shampoo overnight under cling film wrap
    3. Consider using a tar product such as Exorex® lotion, or see the PCDS website for using therapies such as Dithranol®
  • During remissions improvement should be sustained with emollients and by using less frequent active topical treatment (twice weekly application)
Scalp Psoriasis
  • Much more common than appreciated and easier felt than seen
  • May be patchy
  • Socially embarrassing
  • Typically extends just beyond the hairline, best seen on nape of neck
  • Treatments can be messy and this can be a difficult site to treat, so it is important to manage your patient’s expectations and provide clear explanations
    1. Descale if necessary with coconut oil or if more severe, Sebco Ointment®—massaged onto the scalp generously and ideally left over night. Wash out with Capasal® or Alphosyl 2-in-1® shampoo. Continue to use until the scale becomes much thinner
    2. Treat ongoing inflammation with potent topical steroids such as Synalar Gel® or Diprosalic® scalp application applied at night. Dovobet Gel® or Enstilar foam® could be used
    3. Maintenance therapy: Once or twice weekly tar-based shampoo such as Capasal® or Alphosyl®, with once or twice weekly potent topical steroids. If the scale thickens then revert to Sebco® ointment in short bursts 
Flexures and Genitalia
  • Erythematous patches, shiny red, and lack scale. Commonly mistaken for candidiasis
  • Mild or moderate topical steroid, such as Daktacort®, 1% hydrocortisone, or eumovate® once daily. For thicker plaques consider a short course of Trimovate® for a week to gain control, then wean down to a moderate or mild topical steroid. Once the skin is under control, use the steroid twice weekly to keep under control
  • A topical vitamin D preparation such as Silkis® or Curatoderm® can be used opposite end of the day, to the topical steroid, and continued daily whilst using the steroid twice a week, to keep control. For flexures, topical calcineurin inhibitors can be used instead of topical steroid or vitamin D analogs, but we would advise avoid using these agents in uncirmcumised male patients unless directed by secondary care
Face
  • An uncommon and distressing site sometimes with plaques but more often similar to that seen in seborrhoeic dermatitis
  • Eumovate® ointment – many would use this initially, for a week and follow on with any of
    • Protopic 0.1% ointment – once or twice a day and reducing with response
    • Silkis ointment – can cause irritation so introduce gradually (initially twice a week then build up to daily)
    • Daktocort® cream once or twice a day for more seborrhoeic types 
Guttate Psoriasis
  • Rapid onset of very small ‘raindrop like’ plaques, mostly on torso and limbs, usually following a streptococcal infection
  • May lack scale initially
  • An important differential is secondary syphilis
  • Refer to secondary care for light therapy
  • In the interim, consider treating with tar lotion (Exorex® lotion) 2–3 times a day, or using topical steroids such as eumovate®, Diprosalic® ointment, Dovobet® or Enstilar® foam for itchy patches
  • In cases of recurrent guttate psoriasis with proven streptococcal infections, consider the early use of antibiotics and/or referral for tonsillectomy 
Palmoplantar Pustular
  • Very resistant and difficult to treat. Creamy sterile pustules mature into brown macules
  • This is more likely in smokers: strongly advise stopping smoking
  • Dermovate Ointment at night under polythene occlusion (e.g. cling film)
  • A moisturiser of choice to be used through the day
  • Early referral important for hand and foot PUVA/Acitretin 
Nails
  • In about 50% of patients pitting, hyperkeratosis and onycholysis
  • NB. Look for arthritis and co-existing fungal infection. Terbinafine may aggravate psoriasis
  • Practical tips—keep nails short, use nail buffers
  • Nail varnish and gel safe to use
  • Trickle potent topical steroid scalp application or apply Dovobet gel if nails are onycholytic 
Psoriatic Arthritis
  • Inflammatory polyarthritis, spondylarthritis, synovitis, dactylitis and tendonitis
  • Psoriatic arthritis is under-recognised and it is very important it is diagnosed and referred early to Rheumatology because of the risk of permanent joint destruction and functional damage
  • Refer to the PCDS website for more information www.pcds.org.uk/clinical-guidance/psoriatic-arthropathy

Referral

Immediate Referral if:

  • Erythroderma (more than 90% skin coverage)
  • Severe worsening psoriasis and systemically unwell patient
  • Generalised pustular psoriasis

Routine/Urgent Referral if:

  • Poor response to treatment
  • Severe psoriasis or widespread psoriasis (more than 10% body surface area)
  • Psychological distress

Other Information

  • Assessing psychological distress with Dermatology Life Quality Index (DLQI) score
  • Assessing psoriatic arthritis with Psoriasis Epidemiology Screening Tool (PEST) score
  • Reduce costs of multiple prescriptions by advising a pre-payment certificate
  • Further information for patients can be found at www.pcds.org.uk and www.psoriasis-association.org.uk.

References

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