Psoriasis - Leeds Pathway

1.  Background Information / Scope of Pathway

Quick info:
Important Principles:

  • Psoriasis is a chronic relapsing condition and successful management may require trial of various different treatments.
  • NICE guidance suggests patients with psoriasis should have a cardiovascular risk assessment and be assessed for psoriatic arthritis. - see NICE Guidance :- Offer adults with severe psoriasis[18] of any type a cardiovascular risk assessment at presentation using a validated risk estimation tool. Offer further assessment of cardiovascular risk every 5 years, or more frequently if indicated following assessment.
  • Psoriasis is helped by soap substitutes and emollients as this helps signs and symptoms.
  • Emollients should be prescribed in all cases.
  • Used directly on the skin during and after bathing or showering
  • Greasier preparations are better at hydrating the skin
  • Some patients have a preference and you may have to supply several until the patient finds something they like and will therefore use. Please advise patients as to the frequent need for reapplication.
  • A history of excess alcohol consumption should be sought as this can be associated with psoriasis.
  • Smokers are more likely to have palmar plantar pustular psoriasis and smoking cessation advice should be given.
  • Family history of psoriasis and evidence of nail changes (especially pitting) can support if diagnosis is uncertain.
  • Certain drugs may exacerbate flares (e.g. beta blockers and anti-malarials)
  • Sun beds are not to be recommended.

Topical Steroids: Suggested First Line Choices
Emollients: Suggested First Line Choices
Fingertip Unit for topical steroids Guidance
General Notes on Prescribing Dermatology Products

Back to top

2. Information Resource for Patients and Carers

Quick info:
Patient Support Group:
Psoriasis Association
Milton House
7 Milton Street
Northampton
NN2 7JG
Tel: 01604 711129
Fax: 01604 792894

 

Patient Information Leaflets:
British Association of Dermatology Patient Information Leaflets:
Psoriasis - an overview
Psoriasis - topical treatment
Psoriasis - treatment for moderate or severe psoriasis

Back to top

3. Development and Updates to this Pathway

Quick info:
Developed July 2014
Updated June 2019

Back to top

4. Training and Further Resources

Quick info:
Additional Resources:
Derm Net NZ: The Dermatology Resource: https://www.dermnetnz.org/topics/psoriasis
British Association of Dermatologists
Primary Care Dermatology Society

Topical Steroids: Suggested First Line Choices
Emollients: Suggested First Line Choices
Fingertip Unit for topical steroids Guidance
General Notes on Prescribing Dermatology Products

Back to top

6. Chronic Plaque Psoriasis

Quick info:
Clinical Features:
Classic silver scale plaques in extensive distribution but can be more widespread.

Back to top

7. Guttate Psoriasis

Quick info:
Clinical Features:
Numerous and small lesions, mostly on trunk, generally affecting children / young adults acutely. Often follows Streptococcal tonsillitis and is self-limiting over 3-6 months

Back to top

8.  Scalp Psoriasis

Quick info:
Clinical Features:
Well demarcated, scaly, red plaques within the scalp or around the hairline.

Back to top

9.  Flexural Psoriasis

Quick info:
Clinical Features:
Smooth well demarcated areas in axillae, groins, inframammary folds and natal cleft. May occur alone or with chronic plaques elsewhere

Back to top

10. Facial Psoriasis

Quick info:
Clinical Features:
Can have typical appearance but often less well defined scaly patches.
If seborrheic distribution (e.g. eyebrows, ears, nasolabial folds) consider sebopsoriasis, in which case treatment is more as per seborrheic dermatitis.

Back to top

11. Nail Psoriasis

Quick info:
Clinical Features:
Changes include pitting, onycholysis, subungual hyperkeratosis. Secondary fungal infections can complicate the clinical picture.
Please perform mycology.

Back to top

12. Treatment

Quick info:
First line therapy: Emollients should be prescribed in all cases

Vitamin D Analogues such as:

  • Calcitriol ointment (Silkis) - Apply twice daily (up to 210g weekly) Or
  • Calcipotriol oint (Dovonex) - Apply generously twice daily (up to 100g weekly) Or
  • Tacalcitol oint (Curatoderm) - Apply generously once daily or
  • Calcipotriol & potent topical steroid (Dovobet ointment or gel as per patient preference) - for use in stable plaque psoriasis. Apply accurately to plaques and review at 4 weeks
  • Enstilar foam (50 mcg/gm calcipotriol and 0.5 mg/gm betamethasone) - for use in stable plaque psoriasis. Apply accurately to plaques and review at 4 weeks

Expect improvements to be gradual, achieving maximum effect over 12 week’s treatment. If useful can be continued intermittently long term. If used correctly many patients will achieve at least flattening and partial clearance of plaques.

Alternative therapies:
Tar Preparations between 5-10% are available (e.g. Exorex lotion)
Apply away from flexures twice daily
Refined tar products are less smelly or messy than old unrefined preparations. Expect slow response over 6-12 weeks.

Dithranol Preparations are an option but rarely used in primary care. If prescribed prescribing guidance should be closely followed as they can be problematic if prescriber is not familiar with treatment..

Topical Retinoid

  • Tazarotene (Zorac)
  • Apply daily. Start with 0.05% increasing to 0.1% preparation. If effective can be continued long term.
  • Irritancy can be reduced with the use of a potent topical steroid at the opposite end of the day or intermittently.

Back to top

13. Treatment

Quick info:
Emollients should be prescribed in all cases
Combination vitamin D analogue and topical steroid would be recommended first line. Other options may be tried in motivated patients or for individuals not keen on other options (e.g. phototherapy)
If treatment is required the following can be tried:
Vitamin D analogues, moderate potency steroid (e.g. Clobetasone Butyrate 0.05%. (Eumovate) or combination vitamin D analogue and topical steroid (eg. Dovobet or Enstilar foam); 5-10% coal tar preparations (e.g. Exorex lotion),
If showing no signs of resolution after 6-8 weeks consider referral to secondary care.
If severe, early referral for phototherapy may be the best option.
Note: Streptococcal infection can be a trigger. Consider a throat swab / treatment.

Back to top

14. Treatment

Quick info:
Generally requires combination of agents.
Consider the following always with a tar based shampoo:
Calcipotriol  scalp application or Calcipotriol & potent topical steroid gel (Dovobet gel)
If very itchy a topical steroid or steroid based shampoo (e.g. Clobetasol Propionate (Etrivex)) could be substituted. If very scaly use Betamethasone 0.5% + Salycilic Acid 3% (Diprosalic)
If very thick scaly plaques use keratolytic e.g. Cocois or Sebco ointment massaged in and left overnight, washed out in the morning before applying a topical potent steroid in gel or lotion form e.g. Betamethasone 0.1%,

Back to top

15. Treatment

Quick info:
Use mild to moderate potency steroids or the combination products if required e.g.

  • Daktocort cream
  • Trimovate cream

Apply once to twice daily
Calcitriol (Silkis) and Tacalcitol (Curatoderm) can be effective and well tolerated in flexural / sensitive areas
Intermittent use is recommended.

Back to top

16. Treatment

Quick info:
Can be treated with:

  • Tacalcitol (Curatoderm) or
  • Calcitriol (Silkis)
  • 1% hydrocortisone.  Avoid potent steroids to the face and eyes

Consider topical steroid antifungal combination creams if Sebopsoriasis

Back to top

17. Treatment and Referral Criteria

Quick info:
Treat fungus if present.
Keeping the nails tidy may be all that is possible as topical treatments are poorly effective.
Cosmetic nail treatments are not contraindicated but may make some cases worse.
If functional impairment consider referral to secondary care as systemic treatment is required. Please counsel patients on the implications of such treatments.

Back to top

18. Referral Criteria

Quick info:
Criteria for referral to Community Dermatology Clinic:

  • To optimise topical treatment plan

Criteria for referral to Secondary Care Clinic:

  • Moderate to severe disease, at any site, that has failed to respond to appropriately used topical treatments for greater than 3 months
  • Severe guttate or extensive chronic plaque psoriasis
  • Acute unstable psoriasis or generalised erythrodermic or pustular psoriasis refer acutely to hospital via PCAL to on call dermatology registrar
  • Only refer nails for consideration of systemic treatment if functional impairment is present.

Back to top

19. Refer Community Dermatology Clinic

Quick info:
Criteria for referral to Community Dermatology Clinic:

  • To optimise topical treatment plan

Back to top

20. Refer Secondary Care

Quick info:
Criteria for referral to Secondary Care Clinic:

  • Moderate to severe disease, at any site, that has failed to respond to appropriately used topical treatments for greater than 3 months
  • Severe guttate or extensive chronic plaque psoriasis
  • Acute unstable psoriasis or generalised erythrodermic or pustular psoriasis refer acutely to hospital via PCAL to on call dermatology registrar
  • Only refer nails for consideration of systemic treatment if functional impairment is present.

 

Back to top