Diagnosis and Management of

Psoriasis and Psoriatic Arthritis

SIGN November 2010

Objectives
 According to this new guideline:
 Be able to diagnose psoriasis
 Know the recommended treatment in primary
care
 Have an understanding of psoriasis
management in secondary care.
What are the characteristics of
psoriasis?
What risks are associated with
psoriasis or psoriatic arthritis?
Co Morbidities associated with
psoriasis

 Diabetes  Obesity
 Hypertension  MI – young pt with
 Hyperlipidaemia severe disease.
 Metabolic syndrome  Low mood
Treatment - Topical
 Short term potent steriod or potent steriod
plus calcipotriol gain improvement in
plaque psoriasis.
 Long term treatment is a Vit D Analogue.
 If unsuccessful then consider dithranol,
coal tar solution or tazaotene gel.
Vitamin D analogues
 Calcipotriol and talcalcitol.
 Dovonex, silkis, curatoderm.
 Dovobet (with betamethasone)

 Analogues of vit D and affect cell division

and differentiation
 Do not smell or stain
Coal Tar
 Anti-inflammatory properties and anti-
scaling properties.
 Crude coal tar most effective, but not
tolerated due to smell and mess.
 Contact allergy or folliculits may occur.
 Polytar, alphosyl HC, Cocois
Tazarotene
 For plaque psoriasis.
 A retinoid.
 Less effective and more irritation than
calcipotriol.
 Use sparingly on plaques only.
 Clean and odourless.
Dithranol
 Effective treatment for plaque psoriasis.
 Irritation and staining of the skin.
 Only on plaques.
 Not in flexures or on the face.
 Wear gloves to apply and wash afterwards.
 Best used by specialist nursing staff.
Topical therapy
Therapy Efficacy Remission Maintanence Patient
acceptability
Coal tar X X - -
Steriods XXXX XXX X XX
Dithranol XX XX - -
Tazarotene XX XX XX XX
Vit D XXX XXX XXX XX
analogues
Special Sites
 Scalp – scalp preparations – salicylic acid
/ tar preparations. Vit D analogues and
steriods
 Face and Flexures – more easily irritated.
 Moderate steriods short term
 Vit D Analogues or tacrolimus ointment.
Assessing Psoriasis

 PASI  DLQI
 - calculated based on  Simple 10 questions,
severity, intensity, assess effect on life.
and surface area
 Requires experience
at calculating the
score.
Dermatology Life Quality Index
0-1 = no effect at all on patient's life
2-5 = small effect on patient's life

6-10 = moderate effect on patient's life

11-20 = very large effect on patient's life
21-30 = extremely large effect on patient's
life
Referral to dermatology
 Diagnostic problem
 Extensive disease
 Occupational disability / time lost
 Difficult places
 Failure of topical therapy
 Adverse reaction to topical
 DLQI above 6
Generalised Pustular Psoriasis
 Life threatening
complications.
 May have
erythroderma.
 Requires
hospitalisation.
Secondary Care
 Erythroderma or generalised pustular
psoriasis need emergency referral to
dermatology.
 These patients should have inpatient care.
Secondary Care - Phototherapy
 Narrow band UVB phototherapy should
be offered if failure to topical therapy.
 Three times weekly where practical
Systemic
 In general poor studies to go on and of
short duration. However,
 Severe or refractory psoriasis pt should be
offered tx with ciclosporin, methrotrexate,
acitretin.
 If respond – shared care with primary
care.
Biological
 Strong evidence base for infliximab (NNT
2) adalimumab, and etanercept (NNT 4).
 Should be offered to pt who do not
respond to systemic therapies.