Psoriasis Primary Care Treatment Pathway

Latest Guidance Updates

April 2022: updates to Table 1 on the clinical treatment of psoriasis on the trunk and limbs, scalp, and nails.

• Well-defined symmetrical small and large scaly plaques, predominantly on extensor surfaces, but can be generalised

• A calcipotriol/betamethasone combination product should be used first line, once daily until lesions flatten. This treatment protocol differs from NICE guidance but is more patient-centred and clinically effective using once daily dosage
• If the response is suboptimal at 8 weeks:
  1. Review adherence
  2. Very thick scale can act as a barrier to topical therapies and consider using a salicylic acid preparation to descale (e.g. Diprosalic^® ointment once or twice daily) or occluding thick plaques with a greasy emollient or Sebco^® shampoo overnight under cling film wrap
  3. Consider using a tar product such as Exorex^® lotion
  4. During remissions improvement should be sustained with emollients and by using less frequent active topical treatment (twice weekly application)

• Much more common than appreciated and easier felt than seen
• May be patchy
• Socially embarrassing
• Typically extends just beyond the hairline, best seen on nape of neck

• Treatments can be messy and this can be a difficult site to treat, so it is important to manage your patient’s expectations and provide clear explanations
  1. Descale if necessary with coconut oil or if more severe, Sebco Ointment^®—massaged onto the scalp generously and ideally left over night. Wash out with Capasal^® or Alphosyl 2-in-1^® shampoo. Continue to use until the scale becomes much thinner
  2. Ongoing inflammation should be treated with a calcipitriol/
     betamethesaone combination product daily. Review at
     4 weeks and once controlled, consider twice weekly
     application for maintenance. Alternatives are Synalar Gel^®
     if not particularly scaly, or Diprosalic^® scalp application if
     scale remains problematic
  3. Maintenance therapy: Once or twice weekly tar-based shampoo such as Capasal^® or Alphosyl^®, with once or twice weekly potent topical steroids. If the scale thickens then revert to Sebco^® ointment in short bursts 

• Erythematous patches, shiny red, and lack scale. Commonly mistaken for candidiasis

• Mild or moderate topical steroid, such as Daktacort^®, 1% hydrocortisone, or eumovate^® once daily. For thicker plaques consider a short course of Trimovate^® for a week to gain control, then wean down to a moderate or mild topical steroid. Once the skin is under control, use the steroid twice weekly to keep under control
• A topical vitamin D preparation such as Silkis^® or Curatoderm^® can be used opposite end of the day, to the topical steroid, and continued daily while using the steroid twice a week, to keep control. For flexures, topical calcineurin inhibitors can be used instead of topical steroid or vitamin D analogs, but we would advise avoid using these agents in uncirmcumised male patients unless directed by secondary care

• An uncommon and distressing site sometimes with plaques but more often similar to that seen in seborrhoeic dermatitis

• Eumovate^® ointment—many would use this initially, for a week and follow on with any of
  • Protopic 0.1% ointment—once or twice a day and reducing with response
  • Silkis ointment—can cause irritation so introduce gradually (initially twice a week then build up to daily)
  • Daktocort^® cream once or twice a day for more seborrhoeic types 

• Rapid onset of very small ‘raindrop like’ plaques, mostly on torso and limbs, usually following a streptococcal infection
• May lack scale initially
• An important differential is secondary syphilis

• Refer to secondary care for light therapy
• In the interim, consider treating with tar lotion (Exorex^® lotion) 2–3 times a day, or using topical steroids such as eumovate^®, Diprosalic^® ointment, a calcipotriol/betamethasone combination product foam for itchy patches
• In cases of recurrent guttate psoriasis with proven streptococcal infections, consider the early use of antibiotics and/or referral for tonsillectomy 

• Very resistant and difficult to treat. Creamy sterile pustules mature into brown macules

• This is more likely in smokers: strongly advise stopping smoking
• Dermovate Ointment at night under polythene occlusion (e.g. clingfilm)
• A moisturiser of choice to be used through the day
• Early referral important for hand and foot PUVA/acitretin 

• In about 50% of patients pitting, hyperkeratosis and onycholysis
• NB. Look for arthritis and coexisting fungal infection. Terbinafine may aggravate psoriasis

• Practical tips—keep nails short, use nail buffers
• Nail varnish and gel safe to use
• Trickle potent topical steroid scalp application or apply Enstilar^® foam. Enstilar^® foam is sprayed on to the palm, and fingertips rubbed in the mousse to get under onycholytic nails, or mousse rubbed around the tips of toenails

• Inflammatory polyarthritis, spondylarthritis, synovitis, dactylitis and tendonitis

• Psoriatic arthritis is under-recognised and it is very important it is diagnosed and referred early to Rheumatology because of the risk of permanent joint destruction and functional damage
• Refer to the PCDS website for more information www.pcds.org.uk/clinical-guidance/psoriatic-arthropathy