Psoriasis

Question 1

What conditions is psoriasis associated with?

Answer 1

• Cardiovascular disease
• Metabolic syndrome and diabetes
• Depression

Question 2

What tool can you use to assess for impact of skin diseases?

Answer 2

Dermatology Quality of Life Index

Question 3

How do you manage psoriasis on the Trunks and Limbs?

Answer 3

1. Potent TCS (Topical corticosteroid) once daily plus VDA (Vitamin D Analogue) (calcipotriol, calcitriol & tacalcitol) once daily for 4 weeks. Apply one in the am and the other in the evening. Only use combined product if it is likely to improve adherence and use for up to 4 weeks. (Dovobet)
2. If not satisfactory control after 4 to 8 weeks, offer VDA twice daily.
3. If not satisfactory after another 4 to 8 weeks, offer either a potent TCS bd for up to 4 weeks or a coal tar preparation applied once or twice daily.
4. Dithranol is considered a specialist option for treatment-resistant psoriasis.

Question 4

How do you manage psoriasis on the face, flexures and genitals?

Answer 4

1. Mild or moderate TCS OD or BD for a maximum of 2 weeks
2. If unsatisfactory response, or long-term treatment needed for adequate control, then refer to dermatologist or GPSI for TCI (Topical Calcineurin Inhibitor) (e.g. tacrolimus, pimecrolimus)

Question 5

How do you manage psoriasis on the scalp?

Answer 5

1. Step 1 - Beclometasone 0.1%(Potent TCS OD) for 4 weeks + Emollient.
2. Step 2 - Try a different formulation of the TCS (e.g. shampoo or mousse) and/or topical agents to remove adherent scale (containing salicicylic acid, emollients and oils e.g. cocois, sebco etc) for 4 weeks.
3. Step 3 - Offer Dovobet (combined TCS & VDA) product for up to 4 weeks
4. Step 4 - If still inadequate response, consider
   
   • Dermovate- very potent TCS bd for up to 2 weeks
   • A coal tar preparation once or twice daily

Question 6

What factors may exacerbate psoriasis?

Answer 6

• Trauma
• Alcohol
• Drugs:
  
  • Beta blockers
  • Lithium
  • Antimalarials (chloroquine and hydroxychloroquine)
  • NSAIDs
  • ACE inhibitors
  • Infliximab
• Withdrawal of systemic steroids (Psoriatic Erythroderma)

Question 7

What % of psoriasis cases will require referral to secondary care

Answer 7

60%

Question 8

What are NICE’s guidance for when to refer cases of psoriasis to secondary care?

Answer 8

• If there is diagnostic uncertainty
• If any type of psoriasis is severe or extensive, for example more than 10% of the body surface area is affected
• Cannot be controlled with topical therapy
• Acute guttate psoriasis requires phototherapy
• Nail disease has a major functional or cosmetic impact
• Any type of psoriasis is having a major impact on a person’s physical, psychological or social wellbeing
• All children and young people should be referred.

Question 9

Who should be referred immediately

Answer 9

• Erythroderma
• Generalized pustular psoriasis

Question 10

What can exacerbate psoriasis?

Answer 10

• Trauma
• Alcohol
• Drugs:
  
  • Beta blockers
  • Lithium
  • Antimalarials (chloroquine and hydroxychloroquine)
  • NSAIDs
  • ACE inhibitors
  • Infliximab
• Withdrawal of systemic steroids