Psoriasis

Guideline

·   http://www.gpnotebook.co.uk/simplepage.cfm?ID=1577451541

·   Precipitating factors – [Stress] [Trauma] [BBlockers] [Lithium] [Antimalarials]

Chronic plaque

·         Emollients

·         Aqueous cream – Use at least 4 times a day until rash settles – once rash improves, use every day to prevent flare ups.  Remember to start using at the slightest sign of rash coming back. Also use as soap substitute to wash with.

·         Polytar [Bath & shower] – Use as directed for bathing or showring with.Do NOT use soap as it can worsen psoriasis.

·         Hydrous ointment [for moderate dryness] Emulsifying Ointment [server dryness] – Use at least 2-4 times a day until rash settles – once rash improves, use the lighter emollients (e.g. aqueous cream) every day to prevent flare ups.

·         Vitamin D analogue – [Curatoderm (better than calcipotriol as OD & can use on face & if used with steroid.  Max 30gm/week.) – Apply thinly to affected areas once at night. CAREFULLY FOLLOW INSTRUCTIONS ON PRODUCT INFORMATION SHEET. Rash will improve only after 2 weeks can take 8 weeks to resolve – See doctor for review at 4 weeks.]

·         Corticosteroid only if skin inflamed or very itchy [Eumovate (moderate) Betnovate (potent) – Use thinly once in the morning on affected areas – stop using as soon as itchiness/inflammation settles – DO NOT USE ON FACE.  Do NOT USE DAILY FOR MORE THAN 4 WEEKS as unsafe for skin.] 

·         r/v 6-8w – [Calcipotriol  Max 30gm/week. – apply thinly twice a day to affected areas.  DO NOT USE ON FACE.   CAREFULLY FOLLOW INSTRUCTIONS ON PRODUCT INFORMATION SHEET. Rash will improve only after 2 weeks and can take 8 weeks to resolve  – See doctor for review at 4 weeks.]

·         r/v @ 8 – 12w [Betnovate (potent) – Use thinly once in the morning on affected areas – stop using as soon as the rash settles – DO NOT USE ON FACE.  DO NOT USE DAILY FOR MORE THAN 4 WEEKS as unsafe for skin. Come for review at 4 weeks even if rash settles]or [Coal Tar Paste – Apply twice a day – Always read medication information sheet – Come for review at 4 weeks, even if rash better] or [Dovobet – Apply thinly to affected areas once a day. CAREFULLY FOLLOW INSTRUCTIONS ON PRODUCT INFORMATION SHEET. Rash will improve only after 2 weeks can take 4 weeks to resolve – See doctor for review at 4 weeks even if rash gone]

·         r/v 4w – Refer [Dithranol] [very potent steroid] [Methotrexate] [Cyclophosphamide] [Phototherapy]

·         Maintain with – [Curatoderm – Use when psoriasis flares up – use once a day.  Stop using when satisfactory control.  If not improved in 6-8 weeks, see doctor.  Maximum dose 30gm/week.  ALWAYS USE WITH EMOLLIENTS] [Do not use potent or very potent steroid within 4 weeks]

Scalp psoriasis

·   Everyone – [Polytar shampoo – Use as directed until psoriasis settles and at the first sign of psoriasis on scalp (to prevent it worsening)]

·   1st line – [Betnovate Scalp ointment (Potent) – Use once daily.  Stop using when your condition settles –  Maximum use for 4 weeks.  If psoriasis persists after 4 weeks, review with doctor. NOT SAFE FOR CONTINOUS USE]

·   Thick adherent scales Or not better @ 4 weeks – [Cocois scalp ointment – Once weekly as necessary (if severe use daily for first 3–7 days) – Shampoo off after 1 hour – then apply Betnovate scalp ointment – Review in 4 weeks if not better]

·   r/v @ 4 weeks – [xamiol scalp gel (VitD analogue & steroid) – Use as directed once daily – Maximum 4 weeks.  Review after 4 weeks if not better.]

·   Then … If not better @ 4 weeks – [Dermovate scalp application (adults only) – Apply twice daily for 2 weeks.  DO NOT USE AGAIN FOR 4 WEEKS as it is unsafe to do so.  Come for review with a doctor in 2 weeks] Or [Coal Tar Paste – Apply twice a day – Come for review in 2 weeks time] Or [Refer]

Face, flexures & genitals

·         Emollients

·   Aqueous cream – Use at least 4 times a day until rash settles – once rash improves, use every day to prevent flare ups.  Remember to start using at the slightest sign of rash coming back. Also use as soap substitute to wash with.

·   Hydrous ointment [for moderate dryness] Emulsifying Ointment [server dryness] – Use at least 2-4 times a day until rash settles – once rash improves, use the lighter emollients (e.g. aqueous cream) every day to prevent flare ups.

·   Hydrocortisone 1% (Mild) or Eumovate (Moderate) – Apply twice a day for maximum of 2 weeks.  Stop using sooner if satisfactory control of rash.  DO NOT USE ON EYE LIDS.  Do not use for more than 2 weeks per month in total as can damage skin. Always use with emollients.]

·   Refer if not better

Guttate [DD Pytriasis rosea – scaling confined to edges]

·   Antibiotics if active infection of throat – Refer tonsillectomy if recurrent

·   Nothing – Resolves in 2 – 3m [erupting disease is intolerant to treatment]

·         Emollients [dryness or itch present]

·   Aqueous cream – Use at least 4 times a day until rash settles – once rash improves, use every day to prevent flare ups.  Remember to start using at the slightest sign of rash coming back. Also use as soap substitute to wash with.

·   Hydrous ointment [for moderate dryness] Emulsifying Ointment [server dryness] – Use at least 2-4 times a day until rash settles – once rash improves, use the lighter emollients (e.g. aqueous cream) every day to prevent flare ups.

·   Polytar [Bath & shower] – Use as directed for bathing or showring with.Do NOT use soap as it can worsen psoriasis.

·   Non erupting disease – [Curatoderm (better than calcipotriol as OD & can use on face & if used with steroid.  Max 30gm/week.) – Apply thinly to WORST affected areas once at night. CAREFULLY FOLLOW INSTRUCTIONS ON PRODUCT INFORMATION SHEET – See doctor for review of your psoriasis if rash has not gone away significantly in 3 moths of it starting or 4 weeks after starting this treatment.] Or [Eumovate (moderate) Betnovate (potent) – Use thinly once in the morning on worst affected areas – stop using sooner if possible – DO NOT USE ON FACE.  Do NOT USE DAILY FOR MORE THAN 4 WEEKS as unsafe. doctor for review of your psoriasis if rash has not gone away significantly in 3 moths of it starting or 4 weeks after starting this treatment.] 

PIL on plaque psoriasis [http://www.patient.co.uk/health/psoriasis]