ACNE VULGARIS

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Psoriasis Definition A chronic,
non-infectious, inflammatory skin disorder, with
well defined, erythematous plaques large
adherent silvery scales May develop at any age,
though rarely first presents after 60
yrs Earlier onset (Type 1 -under 40 yrs) is
more likely to be associated with a positive
family history (HLA Cw6)
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• PSORIASIS
• Common
• Diagnosis not always straightforward
• Incurable and naturally relapses and remits
• Visible
• Potentially serious effect on quality of life
• Treatments sometimes messy / unpleasant

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Psoriasis Common _at_2 population (40 have
FH) Average GP with 2000 patients has about
40 patients -Majority have relatively mild
disease -Estimated gt50 never consult
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• Psoriasis
• Impact on quality of life
• Disfiguring -relationships / employment /
  depression
• Itch -often more than textbooks suggest
• Arthritis -up to 14
• Treatments -side effects / lotions potions
  etc
• www.psoriasis-association.org.uk
• www.changingfaces.org.uk - charity

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The Patients Perspective

• Explore patients concerns, e.g. is it due to
  diet /stress etc
• Ask about impact on life -DLQI
• Provide information on
• -Diagnosis / extent / outcome
• -Treatments (ideally to enable self-management)
• -Resources available (local / national /
  internet etc)
• -Lifestyle advice
• Arrange follow-up

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Psoriasis Impact on QALY Comparable to DM /
IHD Increase risk of IHD Chronic
inflammatory process Quershi et al. A
prospective study of US nurses. Arch Dermatol
2009 145(4) 379-82 Peter Lapsley APPGS 2008
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• Patterns of Psoriasis
• Chronic stable plaque psoriasis
• Guttate
• Flexural / genital (hidden areas)
• Nails
• Scalp
• Palmar plantar pustular psoriasis
• Otitis externa
• Arthritis
• Erythrodermic / pustular (unstable)

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• Psoriasis -examination
• Well-defined plaques with large adherent silvery
  scales
• -beware though, flexures and palms / soles look
  different
• Look for clues
• - Family history (40)
• - Scalp (80)
• - Nails (50)
• - Hidden areas
• Auspitz sign
• Koebner phenomenon
• Heinrich Auspitz 1835-1886 Vienna (also occurs
  with Darriers / AKs etc)

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Treatment options in Primary Care Nothing /
avoid exacerbating factors / drugs (esp steroids)
Emollients Salicylic acid Tars Vitamin D
analogues (/- steroid) Topical retinoids
(Zorac) Dithranols Steroids ? Natural
sunlight therapy Advice re prescription
pre-payment! Quantities (FTU)
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Vitamin D analogues (/- steroid) Calcipotrio
l Dovonex / Dovobet / Xamiol gel Tacalcitol Cu
rataderm Calcitriol Silkis
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Difficult Psoriasis Superficial
psoriasis Guttate psoriasis Flexural
psoriasis Palmo-plantar pustular
psoriasis Scalp Arthritis Nail
psoriasis Facial psoriasis Severe / pustular /
erythrodermic psoriasis
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Guttate Psoriasis Recent streptococcal
infection (not necessarily in throat) ASOT titre
is an antibody so not raised immediately Can
occur more than once Often the first marker of
the tendency to psoriasis Typically
self-limiting (6-12 weeks) ? CSPP
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• Guttate psoriasis treatment options
• Nothing / emollients
• Natural sunlight therapy
• Tar lotions
• Antibiotics
• UV light

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Scalp psoriasis 50-80 patients with
psoriasis Examine - Modern day leper -
Hidden surprises - Patient appreciates you
understand
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SCALP PSORIASIS Differential diagnosis
Seborrhoeic dermatitis (sebo-psoriasis) Fungal
infection Contact dermatitis Lupus / Lichen
planus Cicatricial Bowens disease etc
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SCALP PSORIASIS Particular characteristics of
this skin area
1. Terminal hair 2. Thick epidermis 3.
Adjacent to the delicate thin epidermal skin on
face
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SCALP PSORIASIS
50-80 patients with psoriasis Examine! -
Modern day leper - Hidden surprises -
Patient appreciates you understand
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SCALP PSORIASIS
Mild Dry, flaking skin, hairline unaffected No
hair loss Moderate Changes extend to
hairline Minimal hair loss Severe The entire
scalp is affected Thick lumpy scales extend
beyond scalp margins Significant hair loss
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Scalp psoriasis Treatment plan - Reduce scale
severe dandruff - Relieve
irritation - Prevent scarring - Patient
education
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SCALP PSORIASIS
De-scale (keratolytics) Salicylic
acid e.g. Diprosalic scalp application
2 Sebco (coal tar 12, S.A. 2, sulphur,
coconut oil) -same as Cocois (8.52 vs
11.23)
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SCALP PSORIASIS Shampoos
Tar Alphosyl 2 in 1 (Coal tar 5,
conditioner) Capasal (Coal tar 1, SA 0.5,
coconut oil 1) Anti-septic / anti-yeast Dermax
(Benzalkonium chloride 0.5) Ketoconazole Ot
her Meted (SA 3, sulphur 5)
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SCALP PSORIASIS Treatment plan
Topical steroids -Need to be potent (scalp
epidermal thickness) Diprosalic scalp
application Betnovate / Dermovate scalp
applications Bettamousse Etrivex shampoo
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SCALP PSORIASIS Treatment plan
Vitamin D analogues Dovonex scalp
solution Xamiol gel (equivalent to
Dovobet) -How to use washout
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SCALP PSORIASIS
Dithranol Dithrocream 0.1 / 0.25 / 0.5 / 1
/ 2 Miconal cream 1 or 3 Psorin scalp gel
0.25 SA 1.6
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Arthritis Estimated to effect about 14
patients with psoriasis -thats 1 in 7 or _at_ 6/
average GP Often associated with enthesitis
(e.g. Achilles) May even precede onset of skin
manifestations Destructive, so early diagnosis
important
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When to refer

• Not coping / treatment failure
• Very severe (?needs oral treatment / PUVA etc)
• Arthritis
• Patient request
• Needing specialist nursing care e.g. removal of
  scale from scalp with oil and comb

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Changes in my practice Statins as per
diabetes if psoriasis more other than
mild Smoking / lipids / hypertension
etc ?Long-term ABi Natural sunlight
therapy PASI score Caution with
steroids Methotrexate
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• Useful psoriasis web sites for patients
• www.psoriasis-association.org.uk
• www.changingfaces.org.uk
• www.psoriasisthenakedtruth.com
• Useful dermatology web sites
• www.dermnet.org.nz
• www.pcds.org.uk
• www.bad.org.uk