Psoriasis - Leeds Pathway

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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 all patients with psoriasis should have a cardiovascular risk assessment and be assessed for psoriatic arthritis. - see NICE Guidance
  • 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.

Steroid Ladder
Emollient Ladder
Fingertip Unit Guidance
General Notes on Prescribing Dermatology Products

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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
www.psoriasis-association.org.uk

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

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3. Development and Updates to this Pathway

Quick info:
Developed July 2014

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4. Training and Further Resources

Quick info:

Additional Resources:
NICE - Psoriasis: assessment and management
Derm Net NZ: The Dermatology Resource
British Association of Dermatologists
Primary Care Dermatology Society

Steroid Ladder
Emollient Ladder
Fingertip Unit Guidance
General Notes on Prescribing Dermatology Products
Monitoring information for GPs Following first referral with psoriasis

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6. Chronic Plaque Psoriasis

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

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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

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8.  Scalp Psoriasis

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

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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

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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.

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11. Nail Psoriasis

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

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12. Treatment

Quick info:
First line therapy:
Vitamin D Analogues such as:

  • Calcitriol (Silkis) - Apply twice daily (up to 210g weekly) Or
  • Calcipotriol (Dovonex) - Apply generously twice daily (up to 100g weekly) Or
  • Tacalcitol (Curatoderm) - Apply generously once daily or
  • Calcipotriol  & potent topical steroid (Dovobet) - 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 weeks treatment. If useful can be continued intermittently long term. If used correctly many patients will achieve at least flattening and partial clearance of plaques.

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 can be used but ensure prescribing guidance is followed. Topical Retinoid

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

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13. Treatment

Quick info:
If treatment is required the following can be tried:
Treat with 5-10% coal tar preparations (e.g. Exorex lotion), Vitamin D analogues (e.g. Dovonex) or moderate potency steroid (e.g. Clobetasone Butyrate 0.05%. (Eumovate)
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.

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14. Treatment

Quick info:
Generally requires combination of agents.
Consider the following always with a tar based shampoo:
Calcipotriol (Dovonex) 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%,

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15. Treatment

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

  • Timodine cream
  • 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.

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16. Treatment

Quick info:
Can be treated with:

  • Tacalcitol (Curatoderm)
  • Calcitriol (Silkis)
  • 1% hydrocortisone or clobetasol 0.5%

Consider topical steroid antifungal combination creams if Sebopsoriasis (Daktacort) Avoid potent steroids to the face and eyes.

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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.

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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.

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19. Refer Community Dermatology Clinic

Quick info:
Criteria for referral to Community Dermatology Clinic:

  • To optimise topical treatment plan

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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.

Key Dates

Published: 18-Dec-2014, by Leeds
Valid until: 01-Jun-2016

References

This is a list of all the references that have passed critical appraisal for use in the care map Dermatology - Psoriasis

Reference

  1. American Academy of Dermatology (AAD). Psoriasis and psoriatic arthritis. Schaemburg, IL,US: AAD; 2008. http://www.aad.org/education-and-quality-care/clinical-guidelines/current-and-upcoming-guidelines/current- guidelines-and-guidelines-in-development
  2. British Association of Dermatologists (BAD), Primary Care Dermatology Society. Recommendations for the initial management of psoriasis. London: BAD; 2009.
  3. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults. National clinical guideline 121. Edinburgh: SIGN; 2010. http://www.sign.ac.uk/pdf/sign121.pdf
  4. Practice-informed recommendation. 2013.
  5. National Institute for Health and Clinical Excellence (NICE). Psoriasis: the assessment and management of psoriasis. Clinical guideline 153. London: NICE; 2012. http://www.nice.org.uk/nicemedia/live/13938/61190/61190.pdf
  6. British National Formulary (BNF). BNF April 2013. London: BMJ Group and RPS Publishing; 2013. http://bnf.org/bnf/bnf/current/
  7. Health Protection Agency (HPA). Fish pedicures: Information for the Public. London: HPA; 2011. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Zoonoses/FishPedicures/zooFishpedic uresinformationforpublic/
  8. British Association of Dermatologists (BAD). British Association of Dermatologists' guidelines for biologic interventions for psoriasis. London: BAD; 2009.
  9. Reich K, Burden AD, Eaton JN et al. Efficacy of biologics in the treatment of moderate to severe psoriasis: a network meta-analysis of randomized controlled trials. Br J Dermatol 2012; 166: 179-188. http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?ID=12012002139

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