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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 am/pm or am/am regimen.

-  Dovobet^® ointment (betamethasone 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 contains a potent steroid. 

RPotent 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, eg Trimovate^®.

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

·       Scalp

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

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

• 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.

• If hairline affected, use moderately potent topical steroid   

·       Refer to secondary care if:

•  fails to respond adequately to above

• diagnostic uncertainty

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

•  stubborn guttate (to consider phototherapy)

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

Phototherapy is now the treatment of choice for moderate to severe psoriasis.  Ultraviolet light does not help all cases of psoriasis and 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.

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