When to Refer?

1. If the diagnosis is uncertain.

2. Extensive disease.

3. Failure of first or second line topical treatment.

Treatment of Psoriasis in General Practice

Typical Plaque Psoriasis

First Choice: -

Vitamin D analogues (Dovonex, Silkis or Curatoderm Ointment or Cream) should be used twice/once a day. However, care must be taken when applying to the flexures or face as they can irritate (Silkis less so). These preparations must be used for at least 6-8 weeks before efficacy is achieved.

Dovobet ointment is a combination of Dovonex and Diprosone but seems to work faster than these agents in isolation. It can be prescibed as a once a day topical application and should only be used for short bursts of 4 to 6 weeks or once psoriasis plaques are flat. It should not be prescribed on an ongoing basis due to the potent steroid.

Second Choice: -

Tar preparations eg Eumovate ointment with 5% LPC (available in hospital pharmacy), Exorex, Alphosyl HC, Polytar baths.

Short contact Dithrocream (see Patient Information pages). Alternative product Micanol 1% and 3%. Beware of irritation and staining.

“Eczematous” Plaque Psoriasis/Psoriatic dermatitis

Especially common in the elderly and represents psoriasis mixed with discoid eczema or eczema craquele. Treat with moisturisers and topical corticosteroid ointments, eg: - Hydrocortisone Ointment 1%, Eumovate Ointment or Betnovate Ointment RD. Do not use Dovonex, or Dithrocream or Tazarotene if the psoriasis is eczematous as it will only irritate.

Scalp

If the plaques are thick, it may be necessary to thin them down prior to other treatments. Recommendations include keratinolysis overnight with a salicylic acid preparation eg. Cocois, Oil of Cade, 2-5% salicylic acid ointment. Use a medicated shampoo to wash off in the morning eg. Capasal, T gel, Polytar, Nizoral shampoo.

Once the plaques are thinned use one of the following: -

Dovonex scalp Solution bd
Diprosalic scalp application
Bettamousse
Betnovate scalp application
Elocon lotion (alcohol base may sting).

Flexures

Use a mild or moderately potent topical corticosteroid such as Hydrocortisone 1% or Eumovate cream or Silkis ointment.

Face

Silkis can be used with care. Alternatively use a mild or moderately potent topical corticosteroid, eg. 1% Hydrocortisone or Eumovate, Cream or Ointment, whichever the patient prefers. A mild tar preparation such as Alphosyl HC can be used also.

Nails

There is no effective topical treatment. Dovonex scalp preparation can be applied.

What Treatments Can We Offer?

Refer patients with severe disease.

1. Ingram Treatment – Dithranol and UVB Phototherapy. Only available to inpatients. 2-3 weeks.

2. Broad or narrow band phototherapy (TL-01) or PUVA.

3. Retinoids- Acitretin

4. Systemic immunosuppressive eg Methotrexate, Cyclosporin, Hydroxyurea, Thioguanine

Please suggest that your patients see the CD Rom Patient Information Programme on psoriasis in the Health Information Unit at

Psoriasis Association
Milton House
7 Milton Street
Northampton
NN2 7JG
Telephone: 01604 711129