Psoriasis

Question 1

Background

Answer 1

Psoriasis is a systemic, immune-mediated, inflammatory skin disease has a chronic relapsing-remitting course.
Affects people of all ages.

Not contagious or due to allergy.

Chronic plaque is most common 80-90%. localised pustular psoriasis next. Can have Family Hx with psoriasis

Question 2

Types

Answer 2

Chronic plaque psoriasis- large flat patches (plaques) covered in scales, most often on the elbows, knees and lower back.

Flexural psoriasis: smooth well-defined patches in body folds.

Scalp psoriasis: one or + scaly plaques in the scalp.

Acute guttate psoriasis: numerous and often widespread small patches.

Sebopsoriasis: overlap of seborrhoeic dermatitis and psoriasis, affecting scalp, face, ears and chest.

Nail psoriasis: pitting, onycholysis, yellowing and ridging.

Intraoral psoriasis: desquamation (condition where the outer layer of the skin starts to replace itself) inside the mouth, most often associated with the more severe forms of cutaneous psoriasis.

Koebnerised psoriasis: psoriasis arising in healing wounds or scars.

Photosensitive psoriasis: psoriasis affecting sun-exposed skin.

Pustular psoriasis: generalised or localised to palms and soles.

Palmoplantar psoriasis: several patterns of psoriasis on the palms and soles.

Erythrodermic psoriasis: severe psoriasis affecting the entire skin surface.

Psoriatic arthritis: joint disease related to psoriasis. (Can be as severe damage as RA). . Joint deformity and changes on X-rays may be found.

Question 3

Signs and Symptoms/ Factors

Answer 3

Can be itchy. Salmon-pink lesions with slivery-white scales
Rash, irritation, burning, pain, bleeding. Some types can cause systemic illness - Fever, malaise, and weight loss

Factors that can lead to/ Exacerbate psoriasis
Stress
Infection
Injury
Hormones - Post puberty and menopause peak times for psoriasis
Meds - lithium, beta blockers, ACEi, chloroquine and hydroxychloroquine, NSAIDs. Ceasing oral corticosteroids or strong topical corticosteroids
UV light - can be beneficial unless photosensitive psoriasis
Obesity
Alcohol and smoking

Question 4

Diagnosis

Answer 4

Ask on clinical features, triggers, meds etc.
Examine person look for:
- Distribution of psoriasis (determine the type)
- Size and shape of lesions
- Colour
- Other areas involved eg joints, Nail

Question 5

Treatment

Answer 5

Non pharmacological
Lifestyle advises weight loss etc
Managing stress, anxiety etc
Sun exposure, Baths (soften and lift scales), occlusive dressings, rest, UV treatment (V effective in chronic plaque and guttate psoriasis)

Pharmacological
1st line topical treatment Options;
emollients, topical corticosteroids, coal tar, and topical Vit D or Vit D analogues - depends of patient pref, psoriasis extent, preparation forms.

Corticosteroid - long term Potent/V potent topical use.
MAX 8 weeks on 1 site - potent
MAX 4 weeks 1 site - V potent
- Can restart application after 4 weeks treatment breaks during break can continue non steroids ie VIT d.

Coal tar - often + other topical options. ointments, shampoos, bath additives
Vit D - ointments, gels, scalp solutions, and lotions. (Tacalcitol, calcitriol less irritating than calcipotriol)

Phototherapy UVB, PUVA. 2nd line + topical. UVB>PUVA. Quicker response 3/week use

Systemic drugs is 3rd line + Topical
Systemic choice:
Methotrexate, ciclosporin.
ALT Acitretin
- Ciclosporin 1st line in emergency short term/rapid control for palmoplantar pustulosis.

Question 6

Treatment CKS/BNF more detailed (Pre reg) >18 yrs

Answer 6

LIFESTYLE APPLIES FOR ALL
Pustular or erythrodermic psoriasis:
- Medical emergency - Same day referral

Trunk and limbs/ Guttate psoriasis:
- Emollient reduce scale & relieve itch
- Potent topical steroid + topical vit D OD (at different times of day) for up to 4 weeks - initial treatment.
FAIL THEN
- continue for another 4 weeks OR
- stop steroid and use topical Vit D BD for up to 12 weeks. If continue option fails then try VIT D BD option 4weeks.
FAIL with VIT D BD THEN:
- Potent topical corticosteroid BD for 4 weeks OR
- Coal tar prep OD/BD (Exorex® lotion, Psoriderm® cream)
STILL FAIL:
- Consider combos Potent steroid + VIT D OD 4 weeks - can be use as ALT if coal tar unable or BD unable.

Scalp psoriasis:
Potent topical steroid OD for up to 4 weeks - initial treatment. Fail after 4 weeks try different formulation (shampoo) and/or topical agents to remove or soften adherent scale - use agents b4 steroid. Another 4 weeks FAIL try COMBO calcipotriol + betamethasone for 4 weeks. STILL FAIL = V potent topical steroid BD 2 weeks or Coal tar (not alone for severe)
ALT VIT D alone OD if Steroid not tolerated - 8 weeks. FAIL - coal tar or refer.

Facial/flexural/genital psoriasis:
Mild/moderate topical corticosteroid OD/BD 2 weeks (treatment break 4 week) - initial treatment, emollient to reduce scale and relieve itch. FAIL/side effect risk: topical calcineurin inhibitor, pimecrolimus or tacrolimus 4 weeks (specialist)

Nail psoriasis:
- Nail hygiene - keep short, avoid fake nails.

ALL:
UVB- plaque or guttate psoriasis when topical FAIL.
PUVA +Psoralen (enhances effects)
- localised palmoplantar pustulosis and plaque-type psoriasis
SHOULD USE topical adjunctive

Systemic:
3rd line + topical. Methotrexate or ciclosporin if fail - acitretin
Ciclosporin 1st line in emergency short term/rapid control for palmoplantar pustulosis. or ppl. considering conception (both men and women).

Question 7

Treatment BNF kids

Answer 7

Psoriasis of the trunk and limbs:
Topical calcipotriol (>6yrs) or OD Potent topical corticosteroid (>1yrs)
Resistant - Dithranol (short contact)

Scalp psoriasis:
same as adults

Facial, flexural, and genital psoriasis:
same as adults BUT NO Topical calcineurin inhibitor

Pustular or erythrodermic psoriasis:
- Medical emergency - Same day referral SAME AS ADULTS

Phototherapy and systemic same as adults

Question 8

Drug info’s

Answer 8

Coal tar:
DONT GIVE - pregnant 1st trimester others take with caution, broken/ inflamed skin, skin infection, pustular/genital/rectal psoriasis. AE- Photosensitivity (minimise sunlight exposure), stains, skin irritation

Topical Corticosteroid:
Long term Potent/V potent topical use can cause irreversible skin atrophy and stretch marks. Widespread use = systemic and local side effects. Patients in intermittent or short term use need annual review.
Continuous - review every 4 weeks/2 weeks in kids.
MAX 8 weeks on 1 site - potent
MAX 4 weeks 1 site - V potent
Treatment can be restarted after 4 weeks break.
AVOID in skin lesions, acne etc.
- usage can be stopped once skin is clear or nearly clear reduces risks

Systemic drugs:
Acitretin - exclude P and use contraception. Avoid in P, BF
Methotrexate - effective contraception during & 6 months post. Men shouldn’t have kids. Avoid in P and stop in BF
Ciclosporin - Avoid in BF, P (unless potential outweighs)

Salicylic acid (topical agent to remove scale) - Contraindicated - broken/ inflamed skin, local infection, pustular psoriasis.
AE- irritation, excessive dryness, dont apply to >20%BSA = toxicity risk.

VIT D- contraindicated - severe liver/kidney disease, calcium metabolism issues. AE- local effects (itching, burning etc), photosensitivity (avoid excess sun), Hypercalcaemia, PTH suppression

Dithranol - contraindicated - Acute, pustular, or inflamed psoriasis.
Facial psoriasis.
Sensitive areas of skin.
AE- skin irritation, burning, staining of skin/hair (temp) fabrics (permeant)