SAME DAY ADMISSION:
Erythrodermic psoriasis and generalised pustular psoriasis are medical emergencies and require same-day specialist assessment and treatment. See Skin crises page
- Advise patient to stop smoking
- Exclude and manage stress as a factor in flares
- Check medications: Lithium, NSAIDs, ACEi, Beta-blockers,
- Assess for arthropathy (if psoriatic arthritis suspected see link: Rheumatology RMS)
- Assess for cardiovascular disease (severe psoriasis is an independent risk factor)
MAIN TREATMENT (between flares):
Emollients – reduce scale with copious emollients.
- Ointments are less well tolerated but better. Prescribe a trial of different emollients so patient can choose.
- Warn patients they make sting for a couple of days
- FIRE RISK! - Please advise ALL patients of fire risk with topical emollients: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/904956/Emollients_A5_leaflet_290720.pdf
- Vitamin D Analogues– calcipotriol (e.g. Dovonex)
** Nail disease – only if concerned re appearance/associated arthropathy.
- Most important aspect of managing paediatric psoriasis is to put time limits on duration. Consider referring those over 6 years for UV treatment
- Use vitamin D analogue and steroid separately to enable lower doses of steroid.
TYPICAL REGIME (6yrs+):
- Moderate/severe: 2/52 Calcipotriol AND Eumovate/Betnovate
- Stepping down/mild: Then Calcipotriol alone
SCALP PSORIASIS: Cocois/sebco useful for thick scale
- Plus capasal shampoo
- Use steroid-based rx only after above have been tried
- FLEXURES: Canesten HC
- FACIAL: Elidel/Protopic 0.03% (over 2 years).
Dermatology happy to answer questions via A&G if needed).
- PROTOPIC OINTMENT (0.03% for 2-15 yrs, 0.1% 16+yrs) – Tends to work quickly but sometimes stings a little
- ELIDEL – (2yrs+) – Cream, no stinging,
- BAD leaflet: https://www.bad.org.uk/shared/get-file.ashx?id=155&itemtype=document
- Typical regime: Use protopic/Elidel Mon-Fri then steroid cream at weekend, review after 3/12 and if improving drop Elidel to twice weekly and steroid cream at weekend, then stop Elidel etc
IMPORTANT PRESCRIBING POINTS:
- Do not use continuously for more than 6/52. Have 2/52 application-free period between
- Avoid in: immunocompromised, patients with neoplasia, those with skin disorders liable to lead to increased systemic absorption e.g. ichthyosis, patients with recurrent skin infections including viral e.g. HSV, molluscum, also bacterially infected eczema (can make it worse)
- Patients should also be encouraged to use a broad-spectrum sunscreen daily on all sunlight-exposed skin4.
- We also advise night time use only during summer months and on sunny days
BAD leaflet Psoriasis overview: https://www.bad.org.uk/shared/get-file.ashx?id=178&itemtype=document
BAD leaflet Psoriasis topical treatments: https://www.bad.org.uk/shared/get-file.ashx?id=123&itemtype=document
Psoriasis: assessment and management. Clinical guideline [CG153] Published: 24 October 2012 Last updated: 01 September 2017
Review date May 2022
Next review due May 2023
Reviewing GP Dr Madeleine Attridge