Psoriasis

Dermatology
Written By Maladywise
 

Fact Sheet

Background

Chronic inflammatory skin disease with multiple body system involvement. Occurs in people with a genetic susceptibility and is due to dysregulation of the immune system. 

Risks

Psoriasis increases your risk of metabolic syndrome, diabetes, hypertension, atherosclerosis, cancer, lung disorders, liver disorders and mental health (particularly anxiety and depression). 

Associated with psoriatic arthritis. Pain, swelling and stiffness in joints. Can involve spine, tendons and eyes.

Triggers

  • Medications (commonly lithium, beta-blockers, antimalarials, anti-inflammatories)

  • Skin Trauma

  • Alcohol

  • Cigarette smoking

  • Stress

  • Infections (both viral and bacterial, streptococcal and HIV are known triggers) 

  • Low Vitamin D Levels

Treatment

Psoriasis is treatable but often has a relapsing and remitting course. Options include lifestyle changes, different creams, phototherapy and systemic tablet therapy.

  • Treat any obvious infective triggers such as a strep sore throat

  • Stopping any medications that may be a trigger if it is safe to do so

  • Stop smoking

  • Reduce Stress

  • Increase Exercise

  • Improve diet (Low Calorie Diet, Mediterranean diet, consider Fasting, strict gluten-free if Coeliac Disease)

  • Appropriate UV exposure can improve some psoriasis

  • Avoid direct pressure and injury to skin

  • Weight loss if appropriate improves psoriasis

Skin care routine

Take short warm showers and limit it to 5 minutes

Keep skin well moisturised. Ideally applied soon after bathing or showering.

Avoid soap, liquid soap, bubble bath, and any fragranced products.

Emollients / Moisturisers can be used to help soften and soothe skin, reducing cracking and dryness.

Apply 2 to 3 times a day, or as frequently as necessary.

  • Light, non greasy (Hamilton Skin Therapy Lotion, Alpha-Keri)

  • Slightly greasy (Aveeno pump lotion, Sorbolene, QV Cream, Cetaphil)

  • Moderately greasy (Silic 15, Hydraderm, Dermeze treatment cream)

  • Very Greasy (Dermeze ointment, QV Intensive, Eucerin)

Use bath oils or soap-free washes and shampoo substitutes.

Bath oils: AlphaKeri™ bath oil, Oilatum™ emollient, QV™ bath oil, Dermaveen™ shower and bath oil, Hamilton™ oil, oatmeal, or dissolve a teaspoon of emulsifying ointment under the hot tap. 

Soap-free wash: aqueous cream, soap-free washes that contain no fragrance or perfume e.g., Cetaphil™ lotion and cleansing bar, Dermaveen™ cleansing bar, Eulactol™ body wash, Hamilton™ gentle wash, QV™ wash, QV™ bar.

Shampoo substitutes: aqueous cream, Cetaphil™ lotion, DermaVeen Oatmeal Shampoo™, Hairscience Daily Care Shampoo™, QV™ wash. 

Specific treatment is based on the psoriasis type.

Common types include chronic plaque, guttate, pustular, erythrodermic, nail and flexural.

Plaque psoriasis

Thickened sharply demarcated red or salmon-pink coloured plaques with silvery scale. Often itchy. Usually symmetrical. Usually chronic. Prefers extensor surfaces of limb, scalp, ears, trunk, or anogenital area.

For localised or mild to moderate plaque psoriasis (< 5% of total body area), treat with topical therapy alone.

Psoriasis usually responds better to ointments rather than creams. Ointments are more moisturising, and will not sting if there are cracks. However, ointment bases are messier so may reduce treatment compliance.

Monotherapy can be successful, but commonly a combination is used e.g., a tar preparation at night and a topical corticosteroid / calcipotriol combination in the morning, especially if monotherapy fails.

If there is extensive or moderate to severe psoriasis, refer to a dermatologist early.

 
 

Topical steroids:

  • Can be used as monotherapy or in combination. Often helpful when lesions are itchy or irritated. 

  • Intermittent pulses of a topical regimen that includes steroid can be the mainstay of treatment, although rotational use of these topical therapies can also be helpful in the setting of psoriasis. 

  • Tailor strength of preparation to the severity of the psoriasis, body site, amount of use, and risk of side effects. 

  • Use an appropriate potency steroid for the body location and apply to the rash only, and not on normal skin. 

  • Advise intermittent exposure, e.g. at least 1 to 2 weeks off between bursts of treatment usually lasting 1 to 4 weeks.

Strength of preparation

  • Very potent

    • betamethasone dipropionate 0.05% in optimised vehicle (e.g. Diprosone OV™)

  • Potent

    • betasmethasone dipropronate 0.05% (e.g. Diprosone™, Eleuphrat™)

    • betamethasone valerate 0.1% (e.g. Betnovate™)

    • mometasone furoate 0.1% (e.g. Elocon™, Novasone™)

    • methylprednisolone aceponate 0.1% (e.g. Advantan™)

  • Moderate

    • betamethasone valerate 0.02%, 0.05% (e.g. Antroquoril™, Betnovate ½™, Betnovate 1/5™, Celestone M™, Cortival™)

    • clobetasone butyrate 0.05% (e.g. Eumovate™)

    • desonide 0.05% lotion

    • triamcinolone acetonide 0.02% (e.g. Aristocort™, Tricortone™)

  • Mild

    • hydrocortisone 0.5% or 1.0% (multiple brands)

    • hydrocortisone acetate 1.0% (e.g. Cortic-DS™, Sigmacort™)

Calcipotriol with betamethasone (e.g. Daivobet gel or ointment / Enstilar (spray-on foam)

  • Apply to the affected area once daily.

  • The maximum dose is 100 g ointment or 100 mL of foam or gel per week (equivalent to calcipotriol 5 mg per week) for up to 4 weeks. 

  • Do not apply to > 30% of body surface. 

  • Review progress in 4 weeks. Advise the patient to stop treatment if it clears before then, and restart if it recurs.

Tar preparations (e.g. LPC)

  • Can be compounded with keratolytics (e.g. salicylic acid) by a compounding pharmacy.

  • Advise the patient about the possible strong odour of the preparation.

  • May cause mild stinging and avoid use on broken or infected skin.

  • May cause photosensitivity or staining of skin and clothing.

  • Use liquor picis carbonis (LPC) 3 to 6% + salicylic acid 3% +/- sulphur 3% initially- Apply twice daily.

 
 

Guttate psoriasis

  • Most commonly seen in young adults 2 to 3 weeks after they have had streptococcal pharyngotonsillitis or viral infection. Develops over weeks, may improve over months. Widespread, small, thin lesions on the trunk and limbs.

  • Some cases self resolve and you can use general skin care and observation alone. 

  • Topical agents can be used, but due to a large number of small lesions, applying creams can be tedious.

  • Phototherapy is often successful with minimal risk.

Facial and flexural psoriasis

  • Tends to involve seborrheic areas of the face. Flexural psoriasis affects body folds and genital areas. Presents with minimal or absent scale, but often well demarcated, beefy erythema.

  • Facial and flexural areas are more prone to side effects from steroid creams. 

  • Stronger steroids are usually contraindicated.

  • A mild topical steroid (e.g. 1% Hydrocortisone) is often adequate.

  • If insufficient then you can increase to methylprednisolone aceponate 0.1% in short pulses.

Scalp Psoriasis

Use topical bases that penetrate hair easily without leaving a greasy residue. Use a soft comb to avoid trauma to skin and worsening of psoriasis. Phototherapy is generally ineffective for scalp disease.

  • Mild Symptoms

    • Shampoos may be enough. Leaving in for 10 minutes before washing out, 2 to 3 times per week. 

    • Options include tar shampoos, steroid shampoos (Clobex) and selenium-based shampoos (Selsun)

  • Moderate Symptoms

    • Try therapeutic shampoos as above. 

    • Can combine with mometasone scalp lotions applied as a leave-in product. 

    • Use once or twice daily until skin is clear (typically 2 to 6 weeks)

  • Severe Symptoms

    • Either add in Daivobet OR alternatively- 

    • You could add in tar cream (LPC), applied at night under a shower cap with a pillowslip protector

    • Wash out in the morning with a therapeutic shampoo.

    • Followed up with the application of mometasone lotion or Daivobet gel.

Palmoplantar psoriasis and pustulosis

  • Palms and soles. More common in smokers and middle-aged females. Presents with multiple sterile yellow deep-seated pustules and red macules on the palms of hands and soles of feet.

  • Use potent steroids e.g. betamethasone dipropionate or clobetasol 0.05%

  • Applied once or twice daily for up to 4 weeks, stop if the eruption clears

Nail psoriasis

  • Looks like a fungal nail infection with discolouration, pitting, ridging, and nail thickening. Often triggered or worsened by trauma. 50 to 80% of patients with psoriatic nail changes will have concurrent psoriatic arthritis. Treatment is purely for cosmetic reasons. The response is slow and takes months for the normal nail to grow out. 

  • If at the nail tips, try a steroid lotion under the end of the nail. 

  • For pitting or ridging use a steroid ointment or Daivobet ointment to the cuticle or nail fold.

 
 
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