Psoriasis – Management and complications
Management
The non-infectious nature of psoriasis, its relapsing nature and the likely need for long-term therapy should be explained. A sympathetic approach is helpful, and patients often obtain support from the self-help group The Psoriasis Association (see p. 132). Treatment is tailored to the patient’s particular requirements, taking into account the type and extent of the disease, and the age and social background (Table 1).
Table 1 A guide to psoriasis therapy
| Type of psoriasis | Treatment options |
|---|---|
| Stable plaque | Vitamin D analogue with topical steroid Dithranol (short contact), coal tar, tazarotene Narrow-band ultraviolet B |
| Extensive plaque | Narrow-band ultraviolet B (plus topicals) Methotrexate, ciclosporin, PUVA or Re-PUVA Biologics |
| Guttate | Topical steroids (mild/moderate), coal tar Narrow-band ultraviolet B |
| Facial/flexural | Topical steroids (mild/moderate); tacalcitol |
| Palmoplantar | Topical steroids (potent) Acitretin, PUVA or Re-PUVA |
| Generalized pustular; erythrodermic | Acitretin, methotrexate, ciclosporin Biologics |
Topical therapy
It is usual to prescribe topical agents as the first-line treatment.
Topical corticosteroids
Topical steroids have the advantage of being clean, non-irritant and easy to use. However, against this must be balanced the risk of side-effects (p. 23) and of precipitating an unstable form of psoriasis, especially on their withdrawal. Topical steroids are the treatment of choice for face, genitalia and flexures, and are useful for stubborn plaques on hands, feet and scalp. Potent steroids should not be applied to the face, although they may be used judiciously on palms and soles. Elsewhere, moderately potent steroids normally suffice. Their use must be monitored carefully. Creams are often preferred to ointments. Lotions and gels are available for the scalp.
