PSORIASIS

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PSORIASIS

• Nicki Ball
• Dermatology Nurse Specialist
• Bristol PCT

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Aims Objectives

• To describe the condition of psoriasis
• To discuss different presentations of psoriasis
• To describe and discuss different treatments for
  psoriasis
• Explain how to refer to primary care dermatology
  service

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INTRODUCTION

• Psoriasis is a chronic, inflammatory and
  non-infectious skin condition
• Can occur anywhere in the body
• Underestimated source of physical suffering and
  psychological distress (comparable to diabetes
  and asthma)?

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EPIDEMIOLOGY

• Psoriasis affects 2 of the UK population
• Incidence on Black and Asians lower than
  Caucasians
• Less common in children
• Males and females equally affected
• Onset generally in early adulthood and earlier in
  females
• Prevalence has 2 peaks
• 23-34 years
• 55-74 years

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AETIOLOGY

• Autoimmune multifactorial condition
• Genetic component
• TRIGGER FACTORS
• Skin trauma ( Koebner phenomenon)?
• Infection ( Streptococcal URTI on guttate)?
• Stress
• Climatic factors
• Alcohol
• Smoking ( palmo-plantar psoriasis)?
• UV trigger in 10 of patients

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PATHOGENESIS

• 1. Epidermal keratinocyte proliferation
• Turnover increased from 28 to 4-5 days
• Immature surface cells
• Silvery scale
• 2. Vascular proliferation
• Dermal level
• Erythema
• 3. Inflammation
• T lymphocyte mediators

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CHRONIC PLAQUE PSORIASIS

• Well demarcated erythematous plaques with silvery
  scale
• SITES elbows, knees, lower back
• Nail involvement common
• AUSPITZ SIGN Punctate bleeding from dermal
  capillaries when lifting scale
• DIFFERENTIAL DIAGNOSIS
• Discoid eczema
• Bowens disease
• Fungal

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CHRONIC PLAQUE PSORIASIS
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GUTTATE PSORIASIS

• Small, multiple, erythematous scaly plaques
• SITES trunk
• Most common presentation in children and
  teenagers
• Can be preceded by a Streptococcal throat
  infection
• Can clear in 3-6 months, recur or develop into
  chronic plaque psoriasis
• DIFFERENTIAL DIAGNOSIS
• Pityriasis Rosea
• Pityriasis versicolor
• Seborrhoeic dermatitis
• Secondary syphilis

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GUTTATE PSORIASIS
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FLEXURAL PSORIASIS

• Well demarcated beefy red plaques with no scale
• SITES sub mammary folds, axillae, groins,
  anogenital region, periumbilical
• More common in obese, elderly and women
• Often over infected by bacteria, fungus and
  candida
• DIFFERENTIAL DIAGNOSIS
• Seborrhoeic dermatitis
• Intertrigo
• Tinea
• Candida ( satellite lesions)?

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FLEXURAL PSORIASIS
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SCALP PSORIASIS

• Can range from dry and flaky scalp to well
  demarcated very scaly plaques
• SITES Occipital, retroauricular, hairline
• 50 of patients with chronic plaque psoriasis
• Can give TEMPORARY hair thinning or loss
• DIFFERENTIAL DIAGNOSIS
• Seborrhoeic dermatitis
• Tinea capitis

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SCALP PSORIASIS
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LOCALISED PUSTULAR PSORIASIS

• Erythematous plaques with sterile yellow pustules
• Progress to brown scaly macules
• SITES Palms and soles
• More frequent in smokers and middle aged females
• DIFFERENTIAL DIAGNOSIS
• Infected eczema
• Tinea

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LOCALISED PUSTULAR PSORIASIS
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FACIAL PSORIASIS

• Usually small scaly patches
• SITES Forehead, hairline, external ear, upper
  eyelids
• DIFFERENTIAL DIAGNOSIS
• Eczema
• Seborrhoeic dermatitis
• Fungal

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FACIAL PSORIASIS
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GENITAL PSORIASIS

• Minimal scale
• SITES penis, perivulval skin

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GENITAL PSORIASIS
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NAIL PSORIASIS

• Affects 25-50 of all psoriatics
• Commoner in elderly
• Affects finger and toe nails
• PSORIATIC NAIL CHANGES
• Pitting
• Salmon patches
• Onycholysis
• Subungual hyperkeratosis
• DIFFERENTIAL DIAGNOSIS
• Onychomycosis ( send clippings and subungueal
  debri for mycology)?

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NAIL PSORIASIS
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GENERALISED PUSTULAR PSORIASIS

• Acute ( dermatological emergency)?
• Erythrodermic patient ( gt 85 skin surface
  involvement)?
• Confluent sterile pustules on a background of
  generalised erythema
• Develops rapidly
• Can occur after withdrawal of systemic or potent
  topical steroids
• Requires admission and intensive nursing care

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GENERALISED PUSTULAR PSORIASIS ( 1 )?
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GENERALISED PUSTULAR PSORIASIS ( 2 )?
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PSORIATIC ARTHROPATHY

• Affects between 5-7 of psoriatics
• Asymmetrical oligoarthropathy
• Affects PIP and DIP joints
• NSAIDs
• Some require systemic drugs like methotrexate and
  rheumatology input

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PSORIATIC ARTHROPATHY
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REMEMBER!

• IF YOU SUSPECT PSORIASIS
• EXAMINE THE WHOLE PATIENT

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MANAGEMENT PRIMARY CARE

• TOPICAL TREATMENT
• Emollients
• Coal tar
• Topical steroids and combinations
• Vitamin D analogues /- steroids
• Dithranol
• Topical Retinoids
• Scalp treatments

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MANAGEMENT SECONDARY CARE

• PHOTOTHERAPY
• UVB/ narrow band UVB ( TL-01 )?
• PUVA ( systemic or bath)?
• SYSTEMIC
• Methotrexate
• Acitretin
• Cyclosporin
• Azathioprine
• Biologics i.e. alefacept,efalizumab,etanercept
  and infliximab
• Fumaric acid esters

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EMOLLIENTS

• Help to reduce scale
• Softens and hydrates skin
• More receptive to next treatment
• Relieves itching and discomfort

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Role of an Emollient

• Main stay treatment of most chronic inflammatory
  skin diseases
• Reduce the clinical signs of dryness including
  roughness and scaling
• Reduce sensations such as itching and tightness
• Be cosmetically acceptable fit in with the
  individuals lifestyle as well as being one they
  will use regularly

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Emollients

• Achieve this by trapping moisture in the skin or
  by actively drawing moisture into the stratum
  corneum from the dermis
• substance whose main action is to occlude the
  skin surface and encourage build up of water in
  the stratum corneum (Marks 2001)?

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Complete Emollient Regime

• 3 pronged approach
• Bath emollient / additive
• Soap substitute
• Leave-on emollient

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COAL TAR

• Used since 19th century
• Anti mitotic effect
• Messy, smelly, stains clothes
• Used in baths, lotions ,creams, scalp
  preparations and shampoos
• Prepared coal tar products available over the
  counter ( Exorex lotion 1 prepared coal tar)?
• Maximum benefit achieved with 5 coal tar
• Can irritate skin
• GOECKERMAN REGIME coal tar UVB ( hospital day
  care treatment)?

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TOPICAL STEROIDS

• Easy to use, clean, non-staining
• Moderate to potent steroid
• No more than 100g over 4 weeks only
• Useful for special body sites like face and
  genitalia ( mild/moderate potency)?
• There may be rebound of psoriasis on withdrawal
• Can precipitate generalised pustular psoriasis
• Beware of local side effects ( atrophie,
  telangiectasia, striae)?

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DIPROSALIC OINTMENT

• 3 salicylic acid 0.05 betamethasone
• Good for descaling thick plaques
• Can be applied overnight under occlusion
• Use up to 4 weeks

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VITAMIN D ANALOGUES ( 1 )

• Clean, non-staining
• Antiproliferative and immunological action
• Promotes differentiation of keratinocytes
• Start to improve psoriasis after 2 weeks
• Clearance can be achieved within 12 weeks
• Plaques clear from the centre leaving peripheral
  ring
• DOVONEX ( CALCIPOTRIOL)?
• Cream, ointment and scalp application
• Only one licensed in children gt 6 years
• Apply thickly twice a day
• Maximum 100g/ week
• Can be irritant

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VITAMIN D ANALOGUES ( 2 )?

• SILKIS ( CALCITRIOL )?
• Ointment
• Apply twice a day, max 30g /day
• Less irritant
• Suitable for face and flexures
• CURATODERM ( TACALCITOL )?
• Ointment
• Apply once a day, maximum 5g/day
• Suitable for face and flexures

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VITAMIN D ANALOGUES WITH CORTICOSTEROIDS

• DOVOBET ( CALCIPOTRIL 50MCG/G BETAMETHASONE
  DIPROPIONATE 0.5MG/G )?
• Chronic plaque psoriasis
• Synergistic effect
• Apply once daily
• Maximum 15g /day or 100g/ week
• Use for up to 4 weeks
• Change to calcipotriol as maintenance when
  controlled
• Beware of risk of generalised pustular psoriasis

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DITHRANOL ( 1 )

• Used in psoriasis since 19th century
• Anti mitotic and anti proliferative
• INGRAM REGIME Dithranol tar baths UVB(
  hospital day care treatment)?
• DITHRANOL IN LASSARS PASTE
• 0.05-1
• Short contact therapy ( 20 main-12h)?
• Mostly used in hospital treatment
• Patients needs training
• Stains hair, skin and clothes

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DITHRANOL ( 2 )?

• DITHROCREAM
• Short contact therapy ( 20 min -2h)?
• Patient needs training
• Staining
• Gradual increase of strength at weekly intervals
  if tolerated
• Strengths 0.1, 0.25, 0.5, 1 and 2
• If prescribed together in brackets on FP10
  patient pays just 1 prescription fee
• Can cause erythema and burning
• Surrounding skin and plaque becomes flatter and
  stained purple/brown
• MICANOL
• Applied once a day
• No patient training
• Clean
• Irritant

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TOPICAL RETINOIDS

• TAZAROTENE GEL
• Vitamin A derivative
• Mild to moderate psoriasis
• Antiproliferative and promotes keratinocyte
  differentiation
• Clean
• Not suitable for face and flexures
• Apply once a day for up to 12 weeks
• Can produce irritation
• Contraindicated in pregnancy and lactation

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SCALP TREATMENTS ( 1 )

• Usually messy and staining
• Thick plaques needs descaling first
• COCOIS OINTMENT
• Coal tar 12 salicylic acid 2 sulphur 4
  coconut oil
• Apply to scalp and leave overnight
• Stains bedding
• Wear shower cap or cling film
• MESSY
• BRI POMADE
• Cheaper than cocois
• Similar composition
• Will be made up by BRI pharmacy
• Prescribable on FP 10 as Pomade UBHT 69

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SCALP TREATMENTS ( 2 )?

• SHAMPOOS
• Polytar, Nizoral, Capasal, etc
• Use twice a week as maintenance and after Cocois
  or Pomade
• Alternate with mild shampoo or conditioner
• OTHER TREATMENTS
• Betnovate scalp application irritant as contains
  alcohol
• Prescribe betnovate lotion for scalp
• Diprosalic scalp application
• Dovonex scalp application
• Elocon lotion

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NAIL TREATMENTS

• Not effective
• Podiatrist and manicure
• Dovonex applied twice a day to nail bed and plate
• PUVA ( systemic)?
• Acitretin
• Consider pros and cons of treatment if psoriasis
  only limited to nails

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PHOTOTHERAPY

• NARROW BAND UVB ( TL-01)?
• 311 nm
• Good for chronic plaque and guttate psoriasis
• Treatments are 3 times a week for 6-8 weeks
• PUVA
• Psoralen UVA
• Systemic oral psoralen taken 2h before Rx
• Bath immediately prior to treatment
• Psoralen makes patient light sensitive for up to
  24h
• Systemic side effects of headaches and G-I
  symptoms are possible
• Eye protection is required for 24h after
  treatment
• Treatments are twice a week for up to 8 weeks

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PHOTOTHERAPY
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REFERRAL

• Generalised pustular or erythrodermic psoriasis
• Widespread guttate psoriasis ( phototherapy)?
• Sufficiently extensive to make self-management
  impractical
• Education support required from dermatology
  nursing team
• Psoriasis unresponsive to conventional treatments
• Assessment for management with systemic therapies
• Diagnosis uncertain

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Contact Details Primary Care Dermatology Team

• Clinics held at Cossham hospital, Southmead
  hospital (soon), Lawrence Hill Health Centre,
  William Budd and Greenway Community practice
  (soon)
• All referrals via C B or address below
• Dermatology Nurse Specialists or GPSI (please
  state which)?
• Primary Care Dermatology Team
• William Budd Health Centre
• Downton Road
• Knowle
• 0117 9449786
• nicolaball_at_nhs.net