Psoriasis

Psoriasis is a chronic relapsing condition that can usually be managed by self-care or in primary care.

Chronic plaque psoriasis

• Localised stable plaques on extensor aspects with characteristic scale

Guttate psoriasis

• Acute onset of numerous small scaly lesions often after a throat infection
• Usually self-limiting within three to six months

Scalp psoriasis

• Scaly localised or diffuse plaques extending to scalp margin
• May be associated with temporary thinning of scalp hair

Flexural psoriasis

• Smooth, shiny well demarcated areas in body folds
• May occur without psoriasis elsewhere

Nail psoriasis

• Mild disease is a cosmetic problem requiring no treatment

Assess lifestyle factors which may precipitate or aggravate psoriasis i.e. smoking, alcohol, certain medications and infections.

Severe psoriasis is associated with increased risk of metabolic syndrome. Advise healthy lifestyle and consider annual BMI, lipids and diabetic screening.

Review patient at 3 months to encourage compliance and assess treatment  response.

(SIGN guideline 121 http://sign.ac.uk/pdf/qrg121.pdf)

Chronic plaque psoriasis

• Emollient and soap substitute
• Vitamin D analogue +/- moderate potency topical steroid
• Coal tar preparations
• Dithranol cream as short contact therapy
• Topical retinoid (tazarotene)

Guttate psoriasis

• Emollient and soap substitute
• Vitamin D analogue
• moderate potency ( eg clobetasone buytrate) topical steroid for symptomatic patients
• Coal tar
• Consider referral for phototherapy

Scalp psoriasis

Step 1: soften and remove scale using

• Oil or keratolytic e.g. coconut, tar and salicylic ointment (eg sebco/cocois)
• Tar based shampoo

Step 2: Active treatment (once scale removed)

• Vitamin D analogue + / – potent topical steroid (mousse, gel and solutions available)

Flexural psoriasis

• Mild to moderate potency steroids combined with antibiotic/antifungals
• Vitamin D analogue (calcitriol /tacalcitol possibly less irritant)

Facial psoriasis

• Mild/moderate potency topical steroid +/- antifungal

Dermatology Referral Criteria

• Emergency referral is indicated for generalised erythrodermic or pustular psoriasis
• Extensive / severe / recalcitrant disease requiring phototherapy or systemic therapy
• Diagnostic uncertainty
• Involvement of sites which are difficult to treat, e.g. the face, palms and genitalia
• Failure of appropriate topical treatment after 2 or 3 months’ use
• Request for further counselling and/or education including demonstration of topical treatment
• Rheumatology referral if any possibility of psoriatic arthropathy