Psoriasis

Question 1

Psoriasis is an inflammatory skin disease that usually follows a ___________ course and may have nail or joint involvement

Answer 1

relapsing and remitting

Question 2

Different forms of psoriasis exist; ______________ psoriasis is the most common, and is characterised by epidermal thickening and scaling, usually affecting extensor surfaces and the scalp

Answer 2

chronic plaque

Question 3

Different forms of psoriasis exist; chronic plaque psoriasis is the most common, and is characterised by _______________, usually affecting extensor surfaces and the scalp

Answer 3

epidermal thickening and scaling

Question 4

Different forms of psoriasis exist; chronic plaque psoriasis is the most common, and is characterised by epidermal thickening and scaling, usually affecting _______________ surfaces and the ______________

Answer 4

extensor

scalp

Question 5

Which drugs may provoke or exacerbate psoriasis? (5)

Answer 5

1. Lithium
2. Chloroquine and hydroxychloroquine
3. Beta blockers
4. NSAIDs
5. ACEi’s

• Psoriasis may not be seen until the drug has been taken for weeks or months

Question 6

Offer ____________ treatment first-line to all patients with psoriasis

Answer 6

topical; topical treatment options include emollients, topical corticosteroids, coal tar preparations, and topical vitamin D or vitamin D analogues

Question 7

What topical treatments are available for psoriasis? (4)

Answer 7

1. Emollients
2. Topical corticosteroids
3. Coal tar preparations
4. Topical vit D or vit D analogues

*When choosing topical treatment, consider patient preference, practical aspects of application, extent of psoriasis, and the variety of preparation forms available

Question 8

_______________ are widely used in psoriasis; they moisturise dry skin, reduce scaling, and relieve itching. They also soften cracked areas and help other topical treatments absorb through the skin to work more effectively.

Answer 8

Emollients

Some cases of mild psoriasis may settle with the use of emollients alone

Question 9

Continuous long-term use of ______________ may cause psoriasis to become unstable, and lead to irreversible skin atrophy and striae

Answer 9

potent or very potent topical corticosteroids

Question 10

Continuous long-term use of potent or very potent topical corticosteroids may cause psoriasis to become unstable, and lead to irreversible _____________ and ____________

Answer 10

skin atrophy

striae

Question 11

Widespread use of topical corticosteroids in the treatment of psoriasis (greater than 10% of body surface area affected) can also lead to _______________

Answer 11

systemic and local side-effects

Question 12

Widespread use of topical corticosteroids in the treatment of psoriasis (greater than ____% of body surface area affected) can also lead to systemic and local side-effects

Answer 12

10

Question 13

Patients with psoriasis who have been on intermittent or short courses of potent or very potent topical corticosteroids should be offered a review of treatment at least ___________

Answer 13

annually

Question 14

Consecutive use of potent topical corticosteroids should not be used for more than ____________ weeks at any one site; _______________ weeks for very potent topical corticosteroids

Answer 14

8

4

*Application may be restarted after a 4-week ‘treatment break’

Question 15

Consecutive use of potent topical corticosteroids should not be used for more than 8 weeks at any one site; 4 weeks for very potent topical corticosteroids. Application may be restarted after a _____-week ‘treatment break’

Answer 15

4

Question 16

____________ has anti-inflammatory, antipruritic, and anti-scaling properties and is often combined with other topical treatments for psoriasis. Several ___________ preparations are available including ointments, shampoos, and bath additives

Answer 16

Coal tar

coal tar

• Newer products are preferred to older products containing crude coal tar (coal tar BP), which is malodorous and usually messier to apply

Question 17

Vit D is available in which forms for the treatment of psoriasis? (4)

Answer 17

1. Ointments
2. Gels
3. Scalp solutions
4. Lotions

Question 18

What is the first line initial treatment of psoriasis of the trunk and limbs?

Answer 18

1. Potent topical CS
2. Topical Vit D or Vit D analogue

Applied once daily at different times of the day for up to 4 weeks

Question 19

If satisfactory control of psoriasis is not achieved after 8 weeks of initial therapy, what should be offered?

Answer 19

Offer a topical Vit D or Vit D analogue alone applied twice daily

*If satisfactory control is not achieved after 8–12 weeks of twice-daily topical vitamin D or vitamin D analogue, offer either a potent topical corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation

Question 20

If satisfactory control of psoriasis is not achieved after 8–12 weeks of twice-daily topical vitamin D or vitamin D analogue, offer either a _________________ applied twice daily for up to 4 weeks, or a ________________

Answer 20

potent topical corticosteroid

coal tar preparation

*A combination product containing calcipotriol with betamethasone for up to 4 weeks is an alternative in patients unable to use twice-daily potent topical corticosteroids, a coal tar preparation, or in patients where a once-daily application would improve adherence

Question 21

What can be offered to patients with psoriasis of the trunk and limbs when all other topical treatments have failed?

Answer 21

A very potent topical corticosteroid under specialist supervision for a maximum of 4 weeks

• In patients with treatment-resistant psoriasis of the trunk or limbs, consider treatment with short-contact dithranol

Question 22

What is the first-line initial management of scalp psoriasis?

Answer 22

Offer a potent topical corticosteroid applied once daily for up to 4 weeks

Question 23

If satisfactory control is not achieved after 4 weeks of initial treatment for scalp psoriasis, what treatment should be offered?

Answer 23

Consider a different formulation of the potent topical CS eg shampoo or mousse and/or topical agents to soften or remove adherent scales (eg agents containing salicylic acid, emollients, oils); these agents should be used prior to applying the potent CS to allow effective penetration

Question 24

If response of scalp psoriasis to potent topical corticosteroid treatment remains unsatisfactory after a further 4 weeks of treatment, offer a combination product containing __________________ for up to 4 weeks

Answer 24

calcipotriol with betamethasone

Question 25

In patients with mild to moderate scalp psoriasis who cannot use topical corticosteroids, offer treatment with a ______________ or _______________ only

Answer 25

topical vitamin D

vitamin D analogue

*If treatment with a vitamin D or vitamin D analogue for up to 8 weeks does not give a satisfactory response, either offer a coal tar preparation or refer the patient to a specialist.

Question 26

Can coal tar preparations be used alone for the treatment of scalp psoriasis?

Answer 26

Nope

Question 27

What is the first line treatment of facial, flexural, and genital psoriasis?

Answer 27

Mild to moderate potency topical corticosteroid

Question 28

The face, flexures, and genitals are particularly vulnerable to ______________ therefore topical corticosteroids should only be used short-term (e.g. 1–2 weeks per month)

Answer 28

steroid atrophy

Question 29

The face, flexures, and genitals are particularly vulnerable to steroid atrophy therefore topical corticosteroids should only be used short-term (e.g. _____________ per month)

Answer 29

1–2 weeks

*If response to a moderate potency topical corticosteroid is inadequate, or there is serious risk of side-effects from continuous use, offer a topical calcineurin inhibitor, such as pimecrolimus or tacrolimus [unlicensed indications], for up to 4 weeks (initiated under specialist supervision)

Question 30

Widespread unstable psoriasis of erythrodermic or generalised pustular types requires urgent same-day specialist assessment and should be managed as a _________________

Answer 30

medical emergency

Question 31

Widespread unstable psoriasis of erythrodermic or generalised pustular types requires _________________ and should be managed as a medical emergency

Answer 31

urgent same-day specialist assessment

Question 32

Widespread _____________ psoriasis of _____________ or generalised ____________ types requires urgent same-day specialist assessment and should be managed as a medical emergency

Answer 32

unstable

erythrodermic

pustular

Question 33

Narrowband _____________ phototherapy can be offered to patients with plaque or guttate psoriasis in whom topical treatment has failed to achieve control.

Answer 33

ultraviolet B (UVB)

Question 34

Narrowband ultraviolet B (UVB) phototherapy can be offered to patients with ____________ or ____________ psoriasis in whom topical treatment has failed to achieve control.

Answer 34

plaque

guttate

Question 35

Photochemotherapy combining ___________ with _____________ is available in specialist centres, given under the supervision of an appropriately trained healthcare professional in the treatment of psoriasis.

Answer 35

psoralen

ultraviolet A (PUVA)

• Psoralen enhances the effects of UVA and is administered either by mouth or topically

Question 36

PUVA irradiation can be considered for the treatment of ____________ and ___________-type psoriasis

Answer 36

localised palmoplantar pustulosis

plaque

Question 37

Cumulative doses of PUVA increase the risk of ______________ and ____________ skin lesions, especially ______________

Answer 37

dysplastic

neoplastic

squamous cell

Question 38

What systemic treatment is available for psoriasis? (5)

Answer 38

1. MTX
2. Ciclosporin
3. Acitretin
4. Apremilast
5. Biologics

Question 39

Under the supervision of a specialist, systemic non-biological treatment with _____________ or _____________ may be offered to some patients with psoriasis that cannot be controlled with topical treatment and if the psoriasis has a significant impact on physical, psychological or social well-being

Answer 39

methotrexate

ciclosporin

• In addition, the psoriasis would have to be extensive, or localised with significant distress or functional impairment, or have failed phototherapy treatment

Question 40

____________ can be considered first-line in patients who need rapid or short-term disease control, have palmoplantar pustulosis, or who are considering conception (both men and women).

Answer 40

Ciclosporin

Question 41

Only consider ____________ in patients where methotrexate and ciclosporin are not appropriate or have failed, or in patients with pustular forms of psoriasis

Answer 41

acitretin

Question 42

_____________ is licensed for the treatment of moderate to severe chronic plaque psoriasis in patients who failed to respond to other systemic treatments including ciclosporin, methotrexate, or PUVA, or in those who have contra-indications to or intolerance to these treatments

Answer 42

Apremilast

Question 43

What are the contraindications to using coal tar? (7)

Answer 43

1. Broken or inflamed skin
2. Avoid eye area
3. Avoid genital area
4. Avoid mucosal areas
5. Avoid rectal areas
6. Infection
7. Sore, acute, or pustular psoriasis

Question 44

Can coal tar be used to treat pustular psoriasis?

Answer 44

Nope

Question 45

In general, coal tar should be used with caution when applied to the ___________ and in ____________

Answer 45

Face

Children under 12 yo

Question 46

What are the side effects of coal tar? (2)

Answer 46

1. Photosensitivity

2. Skin reactions

Question 47

What advice should be given to patients and carers regarding coal tar?

Answer 47

May stain skin, hair, and fabric

Question 48

What are the contraindications to using combined calcipotriol/betamethasone preparations in the treatment of psoriasis? (2)

Answer 48

1. Erythrodermic psoriasis

2. Pustular psoriasis