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Psoriasis—primary care treatment pathway

What is psoriasis?

  • Psoriasis is a chronic, relapsing, inflammatory condition affecting the skin, scalp, nails and joints, with cardiovascular and psychological co-morbidities
  • It is not contagious and there is often a family history
  • Psoriasis typically manifests with sharply demarcated dull red plaques with silvery scales, which shed easily
  • It can be well controlled and treatment aims are to minimise skin manifestations, co‑morbidities and improve quality of life

Triggers and exacerbating factors

  • Stress
  • Smoking, alcohol, and obesity
  • Skin injury/surgery
  • Infections—streptococci, HIV
  • Drugs; including lithium and antimalarials (such as hydroxychloroquine)

Assessment

  • A holistic approach is essential
  • Examine the skin:
    • body
    • special sites—scalp and nail involvement and specifically ask about genital areas
    • joints—be alert to signs of inflammatory arthritis including tendonitis and heel pain
    • cardio-metabolic risk (e.g. modified Q-risk) 
    • explore wellbeing (e.g. ‘how are you coping?’)

Management

  • Explore expectations and discuss treatment options initially using topical therapies
  • Emphasise benefits of lifestyle changes and provide support
  • Arrange follow up and consider primary healthcare team’s role in review of psoriasis and management of co-morbidities

Lifestyle directed advice

  • Provide advice on managing stress, smoking, alcohol, and obesity (in accordance with local resources), physical activity, and diet (consider recommending a Mediterranean diet)
  • Safe natural sunlight exposure depending on individual risks and benefits. Patients are especially vulnerable to suboptimal lifestyles due to the cardiovascular and metabolic risk and a negative impact on psoriasis itself. A dietary plan and physical exercise has been shown to reduce psoriasis severity
  • Obesity, excess alcohol, smoking also are associated with worsening psoriasis

Skin directed treatment

  • We strongly advocate the use of emollients both as soap substitutes and leave on preparations for all patients, alongside active topical therapies. Emollients soften scale, relieve itch and reduce discomfort and should be prescribed in large quantities, (e.g. a 70 kg adult is likely to need at least 500 g/month). When choosing an emollient, patient preference is crucial for adherence
  • Active topical treatments should be used daily during a flare, during remissions improvement should be sustained by using less frequent active topical treatment, for example, weekend therapy

Clinical features and treatment according to site of psoriasis

Please note this guidance is the views of the contributors and does not consider costs of treatments.
Clinical features Treatment
TRUNK AND LIMBS
  • Well defined symmetrical small and large scaly plaques, predominantly on extensor surfaces but can be generalised
  • 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 sub-optimal at 8–12 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. 0.065% w/w betamethasone dipropionate with 3.00% w/w salicylic acid ointment once daily)
    3. consider other therapies such as tar products (e.g. 5% v/w coal tar solution), tazarotene, or dithranol. See www.pcds.org.uk for more details
  • During remissions improvement should be sustained with emollients and by using less frequent active topical treatment, for example, weekend therapy
SCALP PSORIASIS
  • 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 coal tar solution/salicylic acid/sulphur ointment—massaged onto the scalp generously and ideally left over night. Wash out with tar-based shampoo. Continue to use until the scale becomes much thinner
  2. Treat ongoing inflammation with:
    • potent topical steroids such as topical fluocinolone, or 0.064% w/w betamethasone dipropionate with 2.00% w/w salicylic acid scalp application applied at night
    • betamethasone dipropionate/calcipotriol monohydrate gel could be used
  3. Maintenance therapy:
    • once or twice weekly tar based shampoo
    • once to twice weekly potent topical steroids as above or more frequently if needed
    • if the scale thickens then revert to coal tar solution/salicylic acid/sulphur ointment
FLEXURES AND GENITALIA
  • Erythematous patches, shiny red, and lack scale. Commonly mistaken for candidiasis
  • 0.05% w/w clobetasone butyrate cream or ointment
  • Hydrocortisone/miconazole nitrate
  • Calcitriol
FACE
  • An uncommon and distressing site sometimes with plaques but more often similar to that seen in seborrhoeic dermatitis
  • 0.05% w/w clobetasone butyrate cream or ointment—many would use this initially and follow on with any of these therapies:
    • 0.1% tacrolimus monohydrate ointment—twice a day (off-licence) and reducing with response
    • calcitriol ointment—can cause irritation so introduce gradually (initially twice a week)
    • hydrocortisone/miconazole nitrate cream twice a day for more seborrhoeic types
GUTTATE PSORIASIS
  • 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 diagnosis is secondary syphilis
  • Refer to secondary care for light therapy and in the interim consider treating with tar lotion 2–3 times a day
  • There is insufficient evidence for the routine use of antibiotics however, in cases of recurrent guttate psoriasis with proven streptococcal infections, consider the early use of antibiotics and/or referral for tonsillectomy
PALMOPLANTAR PUSTULAR
  • Very resistant and difficult to treat. Creamy sterile pustules mature into brown macules
  • Stop smoking
  • Clobetasol propionate ointment at night under polythene occlusion (e.g. cling film)
  • A moisturiser of choice to be used through the day
  • Early referral is important for hand and foot psoralen with ultraviolet A light therapy/acitretin
NAILS
  • In about 50% of patients pitting, hyperkeratosis and onycholysis
  • NB. Look for arthritis and co-existing 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 betamethasone dipropionate/calcipotriol monohydrate gel under the onycholytic nail
PSORIATIC ARTHRITIS
  • 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 and radiological damage
  • Refer to the PCDS website for more information:
    www.pcds.org.uk/clinical-guidance/psoriatic-arthropathy

Referral

Immediate referral if:

  • Erythroderma
  • Unstable or pustular

Routine/urgent referral if:

  • Poor response to treatment
  • Severe
  • Psychological distress

Secondary care

  • Treatments available in secondary care:
    • phototherapy
    • systemic therapy e.g. methotrexate, cyclosporin
    • apremilast
    • biologics (TNF and interleukin blockers)

Other information

 

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Read the Guidelines in Practice article Psoriasis: PCDS treatment pathway provides practical advice for GPs for more information on implementing the PCDS Psoriasis—primary care treatment pathway.

full guideline available from…
Primary Care Dermatology Society, PO Box 789, Rickmansworth, WD3 0NU (Tele—0333 939 0126)
www.pcds.org.uk

Primary Care Dermatology Society. Psoriasis—primary care treatment pathway. September 2017.

First included: October 2017.