Psoriasis

Contributed by Dr Anthony Bewley, consultant dermatologist at Whipps Cross University Hospital and The Royal London Hospitals NHS Trust.

Section 1: Impact on patients
Patients with mild-to-moderate cutaneous psoriasis are mostly (and rightly) managed in primary care, either by GPs and practice nurses, or by GPSIs in dermatology.

A patient's first port of call is to their GP. The diagnosis is usually straightforward.

The initial management of patients with psoriasis is often safely delivered in primary care (see box).

What is clear from research is that the initial consultations are pivotal and simply listening to the patient's story and asking respectfully about the psychosocial aspects of their disease is hugely beneficial.1,2

Psoriasis can occur anywhere but most commonly affects the extensor surfaces, such as knees and elbows

Comorbidities of psoriasis
Psoriasis can be physically disabling; 10 per cent of patients may develop psoriatic arthropathy, an erosive seronegative joint disease which, in its severe form, may render the patient wheelchair bound and immobile. But other comorbidities are increasingly recognised.

Patients with chronic active disease are now known to have a significantly greater risk of atheromatous disease, in particular ischaemic heart and cerebrovascular disease.3

Patients with chronic active psoriasis may have low-grade inflammatory hepatopathy and a greater risk of diabetes and hypertension.3

Psychosocial effects
The psychosocial comorbidities of psoriasis are of immediate importance to patients and their relatives.2,4

Developing a condition that elicits a visible (and/or hidden) difference carries enormous implications for psychosocial wellbeing. It is these comorbidities that patients say are most often dismissed by healthcare professionals. While this may be understandable, given the time and other resource pressures in contemporary clinical practice, time invested in listening to patients can elicit enormous benefits. Psoriasis is very much more than skin deep.

Psoriasis is disfiguring.5 One of its most common implications is impaired self-esteem, to the extent that some patients may consider suicide.6

Many seek help from support groups, especially the Psoriasis Association (www.psoriasis-association.org.uk), or from cognitive behavioural therapy (CBT).4,5

Another source of support is Changing Faces (www.changingfaces.org.uk), a charity challenging reaction to disfigurement.

Chronic Plaque Psoriasis

FIRST-LINE TREATMENT

Emollients Bath additives and emollients used on the skin.

Combination vitamin D analogues/topical betamethasone

Calcipotriol with betamethasone may be preferred because it is unfragranced, less oily and easy to apply.

Vitamin D analogues Calcipotriol, calcitriol. Also unfragranced and less oily. Calcitriol may be used on the face. Care should be exercised with flexures because this can be slightly irritating.

Topical steroids Usually for flexures (careful, intermittent use).

Topical tar additives Bath additions or emulsion, or mixed with other topical agents.

OTHER TOPICAL AGENTS

Topical retinoids Usually for very scaly areas.

Dithranol Can be useful, if time-consuming, in motivated patients; proprietary and non-proprietary preparations available.

Other topical agents Salicylic acid may be added to topical steroids or white soft paraffin as a keratolytic.

 

Section 2: Diagnosis
If there is any doubt about the diagnosis, the patient can be referred to an interface service, such as that provided by GPSIs.

In many areas of the UK (including my own), there are excellent GPSIs who are eminently able to diagnose and deliver appropriate care to this group of patients.

If there are no GPSIs in your area, or if patients have more severe, recalcitrant, poorly responsive, extensive and acute inflammatory psoriasis, referral to secondary care is important. GPSIs in dermatology also need access to secondary or tertiary care for patients with severe, acute or recalcitrant psoriasis.

Clinical features
The most common form of psoriasis is chronic plaque psoriasis. This is characterised by large, red plaques, usually with a clearly demarcated border and a thickly adherent silvery scale.

Plaques can affect any part of the skin, but most commonly, the extensor surfaces, such as those overlying the elbows and knees.

The individual extent of psoriasis is highly variable and, importantly, does not correlate with psychological morbidity. Patients with limited disease may be extremely disabled by their condition and patients with extensive disease may cope relatively easily.

In addition to the disfiguring appearance of their skin, patients are often troubled with the persistent itching (despite what it says in some of the standard medical textbooks), soreness, flakiness and discomfort of cutaneous disease. It is often the itch, scaling and disfigurement that are most disabling.

Psoriasis can affect all skin areas, so it is important to ask specifically about genital skin because patients may be too embarrassed to be explicit about penile or vulval psoriasis. Some patients even assume their genital psoriasis is an STI.

Section 3: First-line treatments
First-line treatments are relatively inexpensive, easily applied, rapidly beneficial and acceptable to the patient. Second-line treatments are generally systemic, with a potentially greater risk of side-effects. Third-line agents are newer, more costly, or have more immediate, severe possible side effects.

For all patients, treatment is tailored to needs and lifestyle. Easy to apply, unscented, stain-free and less oily preparations are preferred by patients.

Many with mild-to-moderate psoriasis prefer to use once-daily combination topical vitamin D/betamethasone products. There is evidence that these are safe and well tolerated in the longer term (up to one year) with careful medical supervision.7

Emollients are important, especially in scaly conditions. Relatively thin, frequent applications of not-too-oily emollients are likely to encourage the patient.

Other first-line treatments include topical retinoids (usually used on very scaly psoriasis), which may be irritant on flexural skin. Careful application of moderately potent topical steroid is the treatment of choice for most flexural and genital psoriasis.

Many dermatology units use topical dithranol. This was used extensively previously, when inpatient beds were much more plentiful in the UK. Short-contact dithranol is still a useful technique, but requires time and care to apply.

First-line treatments for scalp and face
Scalp disease can be devastating because the condition causes severe itch, scaling and hair loss. Persistently untreated and infected (bacterial superinfection) scalp psoriasis can lead to permanent hair loss.

Treatment in primary care (see box) is often with a calcipotriol/betamethasone combination product. This is neither odorous nor staining and is usually applied at night then washed out the following morning. Shampoo should be applied to dry hair the following morning, before washing out the product.

Other newer agents for psoriatic scalp disease include clobetasol shampoo, which is a short-contact superpotent topical steroid shampoo. This is also non-odorous and non-staining. Patients apply the shampoo to dry hair for 15 minutes before washing it out.

Older and well recognised treatments for scalp psoriasis include coconut compound ointment, which although effective, will potentially stain dyed hair and has a tarry smell. It is usually applied at night, then washed out the following morning with an antipsoriasis shampoo (tar and/or salicylic acid based).

Many patients then use a topical steroid lotion or gel. This cycle can be repeated on a nightly basis until the psoriasis is cleared or improved (provided there is medical supervision).

Facial psoriasis can be treated successfully (off-licence) with topical calcineurin inhibitors (TCIs), tacrolimus and pimecrolimus. TCIs are usually used for atopic eczema, but can be invaluable in the management of mild-to-moderate facial psoriasis.

Patients should be warned about the erythema and burning sensation that some (about 10 per cent) experience on first using these agents. It is best to counsel that the erythema and burning settle after a couple of days, and that after the psoriasis has settled with initial treatment, use of TCIs a few times a week may prevent recurrence.

Topical agents for scalp psoriasis
Combination products Betamethasone and vitamin D analogue combinations are quick, effective and well tolerated by patients.

Steroid shampoo Short-contact superpotent topical steroid shampoo is a newer treatment for scalp psoriasis.

Coconut compound ointment Although messy, staining and odorous, it can be very effective in particularly scaly and more difficult scalp psoriasis.

Tar shampoo Useful as an adjunct to other treatments or to control milder disease.

Steroid lotion and gel Also used as an adjunct to tar shampoos, to help manage inflammation and itch, or for milder disease.

Section 4: Second- and third-line treatments
Second- and third-line treatments (see box) may be necessary but most dermatologists will attempt to find the safest, most effective treatment that is acceptable to patients.

Second- and third-line treatments
SECOND-LINE
Phototherapy and photochemotherapy
  • UVB (TLO1 or narrow band)
  • PUVA (topical to hand and/or feet, and systemic)/Re-PUVA (retinoids plus PUVA)
Systemics
  • Methotrexate
  • Ciclosporin
  • Retinoids
  • Hydroxyurea
  • Azathioprine
  • Mycophenolate mofetil
  • Fumarates

THIRD-LINE
Biological agents:
TNF-alpha blockers
  • Infliximab
  • Etanercept
  • Adalimumab
Interleukin 12/23 'blocker'
  • Ustekinumab

Second- and, especially, third-line agents need to be carefully monitored and are used under the supervision of dermatologists.

Many GPSIs in dermatology are trained to share the care of patients using second-line agents with their dermatology unit.

Biological agents
The newer biological agents have been widely publicised.

British Association of Dermatologists (www.bad.org.uk) and NICE (www.nice.org.uk) recommendations limit the use of biologics to patients with severe, recalcitrant psoriasis that is unresponsive to second-line agents, or patients who have very active disease and for whom there is no alternative.

The biologics are either TNF-alpha blockers (etanercept, infliximab or adalimumab) or the newer agent, ustekinumab, which targets receptors on interleukin 12 and 23 cytokine molecules.

Efalizumab (which targeted the CD11a receptor) was withdrawn from use in the UK after a few patients developed progressive multifocal leukoencephalopathy.

Patients who have anxiety and/or depression or feel suicidal should be referred to secondary care or a psychodermatology clinic.

Treating cutaneous disease does not always lead to improvements in affective disease, and medication and/or CBT may be useful.

Resources

References
1. Ghaffar S, Clements S, Griffiths C. Modern management of psoriasis. Clin Med 2005; 5: 564-8.

2. Koblenzer C. The emotional impact of chronic and disabling skin disease: a psychoanalytic perspective. Dermatol Clin 2005; 23: 619-27.

3. Qureshi A, Choi H, Setty A et al. Psoriasis and the risk of diabetes and hypertension, a prospective study of US female nurses. Arch Dermatol 2009; 145(4): 379-82.

4. Krueger G, Koo J, Lebwohl M et al. The impact of psoriasis on quality of life. Arch Dermatol 2001: 137; 280-4.

5. Ramsay B, O'Reagan M. A survey of the social and psychological effects of psoriasis. Br J Dermatol 1998; 118: 195-201.

6. Gupta M, Gupta A. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol 1998; 139: 846-50.

7. Kragballe K, Austad J, Barnes L et al. A 52-week randomized safety study of a calcipotriol/betamethasone dipropionate two-compound product (Dovobet/Daivobet/Taclonex) in the treatment of psoriasis vulgaris. Br J Dermatol 2006; 154(6): 1,155-60.

For an archive of all GP clinical reviews visit www.healthcarerepublic.com/clinical/GP.

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