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13.5.2 Psoriasis 

See SIGN 121 Diagnosis and management of psoriasis and psoriatic arthritis in adults.

Topical Coal Tar preparations

Capasal^® shampoo (coal tar and salicylic acid)

Exorex^® lotion
Dose: Apply 2-3 times daily

Psoriderm^® cream
Dose: Apply 1-2 times daily

Sebco^® scalp ointment (coal tar, sulphur and salicylic acid)
Dose: Apply to scalp, shampoo after one hour. Use daily for three to seven days until control is obtained. With mild scaliness use intermittently as necessary.  Not recommended for children under 6 years.

T-gel^® shampoo 

If a topical steroid is required to be used in conjunction with a coal tar preparation, they should be used in an alternating regimen, e.g. coal tar in the morning and steroid in the evening.   

Other topical preparations

Calcipotriol ointment, scalp solution
Dose: Apply once or twice daily avoiding the face, wash hands after application.  Max adult dose: 100g weekly of ointment or 60g ointment plus 30ml scalp solution or 30g ointment plus 60ml scalp solution. Max dose: aged 6-12: 50g weekly, aged >12: 75g weekly.

Calcitriol ointment
Dose: Apply to the affected area(s) twice daily, once in the morning and once in the evening after washing. Maximum 30g daily on not more than 35 per cent of the body surface.

Calcitriol (Silkis^®) ointment may be considered if calcipotriol causes unacceptable irritation.  Unlike calcipotriol, calcitriol is licensed for use on the face.

Diprosalic^® ointment, scalp application (betamethasone and salicylic acid)
Dose: Ointment, apply 1-2 times daily, max 60g per week.  Scalp application, apply a few drops 1-2 times daily

Betamethasone scalp application 0.1%
Dose: Apply 1-2 times daily (for short-term use if itchy scalp)

Refer to guidance “Management of psoriasis” and see SIGN 121 Diagnosis and management of psoriasis and psoriatic arthritis in adults.

Management of Psoriasis 

R  Management of psoriasis with emollients only may be adequate in mild or asymptomatic cases, as well as for maintenance between exacerbations.  

·       Localised plaque 

An emollient is important to lubricate skin at all times

-  An emollient is important to lubricate skin at all times.

- The addition of a tar preparation may be appropriate in mild cases.

-  Alternatively, calcipotriol ointment should be used to a maximum of 100g per week in adults, due to risk of hypercalcaemia.  20% of patients experience irritation, and for this reason the face and flexures should be avoided.  Calcitriol ointment and tacalcitol ointment are less likely to cause irritation.

-   A moderately potent or potent steroid ointment may be added for patients intolerant of or unresponsive to calcipotriol alone. These should be used in an alternating regimen, e.g. calcipotriol in the morning and steroid in the evening.

-  Dovobet^® ointment (betamethasone dipropionate 0.05% plus calcipotriol 50mcg/g) may be considered for patients with localised (<10% body surface) stable plaque psoriasis who are unresponsive to, or unable to comply with, an alternating regimen of calcipotriol and steroid. Clinical review should be performed after a maximum of 4 weeks treatment, and further treatment considered with calcipotriol, calcitriol or tar. Recurrent disease may require intermittent Dovobet^® up to a maximum of 4 weeks for each course, but Dovobet^® should not be prescribed on a repeat basis as it is a potent steroid. 

R Potent topical steroids carry the risk of destabilising psoriasis and side-effects from prolonged use – regular review is required by prescribers.

- Short contact dithranol may be useful if there are just a few large plaques.

 - Clearance is deemed to have occurred when the skin is flat to the touch.

·      Itchy plaques - consider alternating tar or calcipotriol with moderately potent topical steroid  

·       Hyperkeratotic - salicylic acid preparation, which is sometimes appropriate to combine with a topical corticosteroid e.g. Diprosalic^®, in combination with tar or calcipotriol  

·       Flexural - moderately potent topical steroid, often used in combination with anti-yeast and antibacterial preparations, e.g. Trimovate^®.

·       Guttate - emollient plus coal tar preparation.  Consider referral for phototherapy if not settling after 6 weeks.

·       Scalp

o     Application of olive or coconut oil to scalp, leave overnight to remove scale and wash out with tar-based shampoo T-gel^® or Capasal^® 

o     If not itchy, use a descaling ointment such as Sebco^® 

o     If itchy, use short-term (up to 1 week) intermittent steroid lotion or scalp application e.g. Calcipotriol (Dovonex^® scalp solution). Xamiol^®  (calcipotriol and betamethasone dipropionate scalp gel) is a newer combination preparation, which may for some people be more effective than monotherapy.

o     If hairline affected, use moderately potent topical steroid   

·       Refer to secondary care if:

o      fails to respond adequately to above

o     diagnostic uncertainty

o      >20% skin involved (to consider phototherapy or systemic therapy)

o      stubborn guttate (to consider phototherapy)

o      unstable (pustular or fiery) psoriasis - emergency referral indicated  

Phototherapy

Phototherapy is now the treatment of choice for moderate to severe psoriasis.  Ultraviolet B (UVB) helps in the majority of cases of psoriasis but treatment has to be carefully monitored.  Sunbeds should not be used for treatment as they cannot be carefully monitored and importantly, are not an effective treatment whereas phototherapy (narrow-band UVB and PUVA) is highly effective.

Photochemotherapy combining long-wave ultraviolet A radiation with a psoralen (PUVA) is also effective in most forms of psoriasis, and can be effective when UVB phototherapy has been inadequate. The psoralen interacts with ultraviolet A (UVA) and is administered either by mouth or topically. Refer to the BAD Phototherapy PIL, the Photonet topical PUVA PIL and the Photonet oral PUVA PIL.

 8-Methoxypsoralen 10mg tablets [unlicensed],  5-Methoxypsoralen 20mg tablets [unlicensed],  8-Methoxypsoralen 0.005% gel [unlicensed], and  8-Methoxypsoralen 1.2% Bath Lotion [unlicensed] may be used in PUVA light therapy for various inflammatory skin disorders.

Systemic therapies

Patients with severe or refractory psoriasis should be considered for systemic therapy with  oral methotrexate or  parenteral methotrexate,  ciclosporin (see section 13.5.3) or  acitretin, following discussion of benefits and risks.  Acitretin is a retinoid and like other systemic retinoids, should only be prescribed by a consultant dermatologist or the Dermatology clinic. It is teratogenic and must not be given to women of child bearing potential unless they practise effective contraception 4 weeks before, during treatment and for at least 3 years after stopping treatment.  There must be continual assessment and explanation by the prescribing physician. See BNF for dose and monitoring requirements. Monitoring is undertaken by the Dermatology clinic.  

 Hydroxycarbamide (hydroxyurea) [unlicensed use ‘off-label’] or  fumaric acid esters [unlicensed] (dose gradually increased from 1 tablet daily to a maximum of 2 tablets 3 times daily) can be considered as an alternative maintenance therapy for patients who are not suitable for other systemic therapies or who have not responded to other therapies for psoriasis. See section 13.5.3 for biologic therapies in severe psoriasis.

 Acitretin may also be prescribed by specialists for severe congenital ichthyosis [licensed], severe Darier’s disease (keratosis follicularis) [licensed], or hidradenitis suppurativa [unlicensed use ‘off-label’]. See BNF for licensed doses, typical dose range for unlicensed ‘off-label’ indications is 20-60mg daily.

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