OVERVIEW

Management of psoriasis is related not only to the severity of the disease but also to patient expectation.
The treatment ladder starts with topical therapy, then phototherapy and finally systemic medication.
New biological agents are transforming the management of patients with severe disease who have failed on conventional therapies.
Encouraging patients to stop smoking, lose weight and reduce alcohol consumption are important to reduce their risk of cardiovascular disease associated with psoriasis.

An essential aspect of managing psoriasis is managing the patient’s expectation of the disease and the outcome of any treatment offered. It is also important that medical practitioners understand on an individual level the impact the disease is having on a patient’s life. Indeed, managing psoriasis is as much a challenge for patients as it is for medical practitioners. The appearance of the scaly plaques may cause social embarrassment; time needs to be set aside for the application of creams, and even if the skin is cleared recurrence is the rule. Assessing the impact of any skin disease on a patients’ quality of life can be undertaken using the validated dermatology life quality index (DLQI) score based on a questionnaire. A more specific survey for psoriasis patients is the psoriasis disability index (PDI) which can also be used to assess the impact of the disease on the patients’ life. The questionnaires embrace all aspects of life including work, personal relationships, domestic situation and recreational activities.

Patients often wish to know what has caused their psoriasis and are keen for a cure. However, our current understanding of psoriasis is that it is an inherited autoimmune disease that can be suppressed by current therapies rather than cured. Management comprises avoidance of known exacerbating factors (smoking, alcohol), using topical preparations, undertaking phototherapy or photochemotherapy and taking systemic therapy (tablet, S/C, IV). Selection of the most appropriate treatment for each patient should be tailored to the type of psoriasis, their age, comorbidities, social and occupational factors, their level of motivation, quality of life and patient acceptability. As a general rule, there is a treatment ladder that patients may climb as the disease becomes more severe or recalcitrant to treatments. Patients may start initially using simple topical therapy and/or ultraviolet treatment before switching to the stronger systemic agents if their disease is poorly controlled.

Management of psoriasis
Type of psoriasis	Standard therapy	Alternatives
Localised stable plaques	Tar preparations Vitamin D analogues Salicylic acid preparations Topical steroids	Dithranol/ichthammol TL01 (UVB)
Extensive stable plaques	TL01 (UVB) PUVA Acitretin PUVA + Acitretin	Methotrexate Ciclosporin A Hydroxyurea Biological agents
Widespread small plaque	TL01 (UVB)	Steroid with LPC
Guttate psoriasis	Moderate-potency topical steroids TL01 (UVB)	Steroid with LPC
Facial psoriasis	Mild-moderate potency topical steroid	Steroid with LPC
Flexural psoriasis	Mild-moderate potency topical steroid + antifungal	Methotrexate
Pustular psoriasis of hands and feet	Moderate-potency topical steroids Potent topical steroid + propylene glycol +/− occlusion	Acitretin Methotrexate Hand and foot PUVA
Acute erythrodermic, unstable/ generalised pustular psoriasis	In-patient management Short-term mild topical steroids	Methotrexate Ciclosporin Biological therapy

Key: PUVA, psoralen with ultraviolet A; TL01, narrow band ultraviolet B; UVB broad band ultraviolet B; LPC, Liquor Picis Carbis.

Dermatology Day Treatment Units

Dermatology day treatment units (DDTUs) facilitate the management of psoriasis, particularly in relation to topical therapy, phototherapy and administration of intravenous or subcutaneous injections. Benefits of the DDTU include compliance, monitoring, education, counselling/support and an overall reduction in the patients’ stress levels. Treatments not possible at home including short-contact dithranol and crude coal tar that can be applied to psoriatic plaques by specialist nurses, phototherapy can be delivered in custom-built cabinets and regular administration of biological therapy can be given by specialist dermatology nurses. These units have helped reduce the number and frequency of in-patient admissions of patients with severe psoriasis.

Rationalisation of skincare services and a shift in the emphasis away from specialist units to primary care settings however mean DDTUs may become less commonly available and therefore less local and accessible for patients.

Topical treatment

Topical treatments are those applied directly to the skin surface, including ointments, creams, gels, tars, lotions, pastes and shampoo. The topical approach to therapy results in changes at and just below the skin surface (epidermis and dermis). Conventionally, topical medicaments are applied directly to the diseased skin only, in contrast to moisturisers (emollients), which are usually applied more freely. In general, combination therapy is more effective than monotherapy, and change of therapy is superior to continuous usage. The following are the advantages of topical treatments:

local effects only
self-application
safe for long-term use
relatively cheap.

The following are the disadvantages of topical treatments:

time consuming in extensive disease
poor compliance (insufficient amounts and frequency)
messy and may affect clothing/bedding/hair
no benefit for associated joint disease
tachyphylaxis (become less effective with continuous use).

The majority of psoriasis patients with mild to moderate disease can be managed in the community by their general practitioner, with guidance from local GPwSIs (General Practitioners with a Special Interest) in dermatology. Patients with very extensive, recalcitrant or unstable psoriasis and associated severe arthritis are usually managed in specialist dermatology centres.

Emollients act as a barrier to cutaneous fluid loss, relieve itching and help replace water and lipids and therefore restore the barrier function of dry skin. Patients are able to purchase these over the counter, and personal preference and acceptability usually guide their choice. Regular application of emollients should be encouraged in all patients with dry/flaky skin.

Coal tar obtained by distillation of bituminous coal. Many coal tar preparations are available for purchase over the counter and include ointments, pastes, paints, soaps, solutions and shampoo. Coal tar is keratoplastic (normalises keratinocyte growth patterns), antipruritic (reduces itch) and antimicrobial. It can be used on stable chronic plaque psoriasis but will irritate acute, inflamed skin. Coal tar in combination with salicylic acid may be more effective for very thick plaques.

Ichthammol (ammonium bituminosulfonate) is a distillation of sulfur-rich oil shale. It has anti-inflammatory properties and is therefore suitable to be used on ‘unstable’ or inflamed psoriasis. Various preparations can be purchased over the counter including ichthammol ointment.

Dithranol (anthralin, Goa powder), originally derived from araroba trees, is now produced synthetically. Irritation and burning can occur if it comes into contact with normal skin; therefore, careful application to psoriatic plaques is needed (Figure 3.1). Normal skin can be protected with petroleum. Dithranol temporarily stains the skin/hair a purple-brown colour. Short/long contact dithranol can be applied by dermatology nurses to chronic stable plaques in specialist units. Dithranol creams can be applied by the patients themselves, left on for 30 min and then washed off. The strength is gradually increased from 0.1% to 3% as necessary. Strengths up to 1% can be purchased over the counter, whereas higher concentrations are available by prescription only.

c03f001 — **Figure 3.1** Psoriasis suitable for topical dithranol treatment.

Calcipotriol and tacalcitol, vitamin D analogues, are calmodulin inhibitors used topically for mild or moderate plaque psoriasis. Mild irritation can be experienced and after continuous use, a plateau effect may be encountered with the treatment becoming less effective after an initial response. These preparations are therefore best used in combination with other topical agents. It is important not to exceed the maximum recommended dose as there is a risk of altering calcium metabolism.

Corticosteroids in topical formulations are an important adjuvant to the management of patients with psoriasis; these are prescription-only preparations (except very mild steroids) and can be supervised by the general medical practitioner. Corticosteroids help reduce the superficial inflammation within the plaques. However, relapse usually occurs on cessation and tachyphylaxis is observed. Tachyphylaxis is thought to result from tolerance to the vasoconstrictive action of corticosteroids on cutaneous capillaries. Topical steroids should be applied to the affected areas of skin only once or twice daily. Manufacturers suggest topical steroids should be applied sparingly but this is difficult for patients to quantify; therefore, practitioners advise the use of finger tip units (FTUs) as a guide. When the steroid ointment/cream is squeezed out from a tube, it comes out in a line, and the quantity between the finger tip and the first skin crease is 1 FTU (approximately 500 mg) enough to cover a hand-sized area of skin (back and front of the hand).

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