Clinical Topic A-Z Clinical Speciality

Psoriasis

Psoriasis
D011565Psoriasis
Skin and nail
2012-12-01Last revised in December 2012

Psoriasis - Summary

Psoriasis is characterized by scaly skin lesions, which can be in the form of patches, papules, or plaques. Itch is often a feature.

The skin lesions of psoriasis are characterized by:

Hyperproliferation of the epidermis.

Dilatation and proliferation of blood vessels in the dermis.

Accumulation of inflammatory cells, particularly neutrophils and T-lymphocytes.

Chronic plaque psoriasis (including scalp psoriasis, flexural psoriasis, and facial psoriasis) is the most common form, affecting 80–90% of people with psoriasis. The second most common form is localized pustular psoriasis of the palms and soles.

Other forms of psoriasis include:

Nail psoriasis.

Guttate psoriasis.

Erythrodermic psoriasis.

Generalized pustular psoriasis.

Psoriasis is common. Around 1–3% of the world's population has psoriasis, with the prevalence varying among ethnic groups.

Several factors are believed to affect the onset or exacerbation of psoriasis, including:

Streptococcal infection — strongly associated with guttate psoriasis.

Sunlight — usually beneficial, but may sometimes exacerbate psoriasis.

Trauma — various types of trauma to previously uninvolved skin can be followed 7–14 days later by the development of psoriasis. This phenomenon is known as the 'Koebner reaction'.

Psychological stress.

Excessive alcohol intake.

Smoking.

Psoriasis is associated with several other conditions including psoriatic arthritis and inflammatory bowel disease (particularly Crohn's disease).

Psychosocial effects of psoriasis are common, can be profound, and are not necessarily related to the severity of skin involvement.

The diagnosis of psoriasis is usually based on clinical findings. Features suggesting psoriasis include:

Distribution — psoriasis can occur on extensor surfaces (elbows and knees), the trunk, and flexor surfaces (including genital areas).

Size and shape of lesions. There is usually a clear delineation between normal and abnormal (affected) skin.

Colour — may be pink or red, but in people with darker skin this may not be obvious. Scale is typically silvery in colour.

Involvement of other areas — such as the joints or nails.

Topical preparations such as emollients, topical corticosteroids, and vitamin D preparations are the mainstay of treatment in primay care.

Additional treatments in secondary care with systemic drugs, such as methotrexate or light treatment, may be necessary.

Refer for same-day specialist assessment and treatment anyone with erythrodermic psoriasis and generalised pustular psoriasis, these are medical emergencies and require same-day specialist assessment and treatment.

Refer the person for dermatology specialist advice if:

Diagnostic uncertainty exists.

Psoriasis is extensive, for example more than 10% of the body surface area is affected.

Psoriasis is severe as measured by the Physician's Global Assessment.

Topical treatments have failed.

The person cannot tolerate the treatment options available in primary care.

There is a significant impact on physical, psychological or social well being.

Further information or education is needed (for example about application of topical treatments).

Refer to a rheumatologist if the person requires assessment for the management of associated arthropathy.

Assess the severity and impact of psoriasis before referral.

Have I got the right topic?

216months3060monthsBoth

This CKS topic covers the management of psoriasis in adults. The topic covers the diagnosis and management of chronic plaque psoriasis (including that of the scalp and flexures), guttate psoriasis, pustular psoriasis, and erythrodermic psoriasis, and briefly covers psoriasis of the nails.

This CKS topic does not cover psoriasis in children, or the management of psoriatic arthritis.

There are separate CKS topics on Candida - skin, Eczema - atopic, Fungal nail infection, Fungal skin infection - body and groin, Fungal skin infection - scalp, Scabies, Seborrhoeic dermatitis, and Venous eczema and lipodermatosclerosis.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in December 2012

May 2013 — minor update to the text to reflect advice issued by the MHRA regarding aqueous cream [MHRA, 2013].

December 2012— reviewed. A literature search was conducted in November 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. There are several changes to the recommendations, following the publication of guidance from the National Institute for Health and Clinical Excellence; Assessment and management of psoriasis [National Clinical Guideline Centre, 2012].

Previous changes

March 2011 — update to the text to reflect recommendations from a guideline published by the Scottish Intercollegiate Guidelines Network on Diagnosis and management of psoriasis and psoriatic arthritis in adults [SIGN, 2010]. Issued in June 2011.

August 2010 — minor update. The usage instructions for calcipotriol combined with betamethasone products have been clarified. Issued in September 2010.

February to May 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines published since 1 November 2012.

A consensus report has been published since the last revision of this topic:

Mrowietz, U., de Jong, E.M., Kraqballe, K., et al. (2014) A consensus report on appropriate treatment optimization and transitioning in the management of moderate-to-severe plaque psoriasis. Journal of the European Academy of Dermatology and Venereology 28(4), 438-453. [Abstract] [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 November 2012.

Economic appraisals

No new economic appraisals relevant to England since 1 November 2012.

Systematic reviews and meta-analyses

Systematic reviews published since the last revision of this topic:

Armstrong, A.W., Brezinski, E.A., Follansbee, M.R., et al. (2014) Effects of biologic agents and other disease-modifying antirheumatic drugs on cardivascular outcomes in psoriasis and psoriatic arthritis: a systematic review. Current Pharmaceutical Design 20(4), 500-512. [Abstract]

Armstrong, A.W., Harskamp, C.T. and Armstrong, E.J. (2013) Psoriasis and metabolic syndrome: a systematic review and meta-analysis of observational studies. Journal of the American Academy of Dermatology 68(4), 654-662. [Abstract]

Armstrong, A.W., Harskamp, C.T., and Armstrong, E.J. (2013) Psoriasis and the risk of diabetes mellitus: a systematic review and meta-analysis. JAMA Dermatology 149(1), 84-91. [Abstract]

Armstrong, A.W., Harskamp, C.T., and Armstrong, E.J. (2013) Psoriasis and major adverse cardiovascular events: a systematic review and meta-analysis of observational studies. Journal of the American Heart Association 2(2), e000062. [Abstract] [Free Full-text]

Armstrong, A.W., Harskamp, C.T., Dhillon, J.S. and Armstrong, E.J. (2014) Psoriasis and smoking: a systematic review and meta-analysis. British Journal of Dermatology 170(2), 304-314. [Abstract]

Deng, S., May, D.H., Zhang, A.L., et al. (2013) Topical herbal medicine combined with pharmacotherapy for psoriasis: a systematic review and meta-analysis. Archives of Dermatological Research 305(3), 179-180. [Abstract]

Deng, S., May, D.H., Zhang, A.L., et al. (2013) Topical herbal formulae in the management of psoriasis: systematic review with meta-analysis of clinical studies and investigation of the pharmacological actions of the main herbs. Phytotherapy Research epub ahead of print. [Abstract]

Deng, S., May, B.H., Xhang, A.L., et al. (2013) Plant extracts for the topical management of psoriasis: a systematic review and meta-analysis. British Journal of Dermatology 169(4), 769-782. [Abstract]

de Vries, A.C.Q., Bogaards, N.A., Velema, M., et al. (2013) Interventions for nail psoriasis (Cochrane Review). The Cochrane Library. Issue 1. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

Glavan-Banqueri, M., Marin Gil, R., Santos Ramos, B. And Bautista Paloma, F.J. (2013) Biological treatments for moderate-to-severe psoriasis: indirect comparison. Journal of Clinical Pharmacy and Therapeutics 305(3), 179-89.[Abstract]

Mason, A.R., Mason, J.M., Cork. M.J., et al. (2013) Topical treatments for chronic plaque psoriasis of the scalp: a systematic review. British Journal of Dermatology 169(3), 519-527. [Abstract]

Puig, L., Lopez, A., Vilarrasa, E., and Garcia, I. (2013) Efficacy of biologics in the treatment of moderate-to-severe plaque psoriasis: a systematic review and meta-analysis of randomized controlled trials with different time points. Journal of the European Academy of Dermatology and Venereology epub ahead of print. [Abstract]

Samarasekera, E.J., Neilson, J.M., Warren, R.B., et al. (2013) Incidence of cardiovascular disease in people with psoriasis: a systematic review and meta-analysis. Journal of Investigative Dermatology 133(10), 2340-2346. [Abstract]

Samarasekera, E.J., Sawyer, L., Wonderling, D., et al. (2013) Topical therapies for the treatment of plaque psoriasis: systematic review and network meta-analysis. British Journal of Dermatology 168(5), 954-967. [Abstract]

Schmitt, J., Rosumeck, S., Thomaschewski, G., et al. (2014) Efficacy and safety of systemic treatments for moderate-to-severe psoriasis: meta-analysis of randomized controlled trials. British Journal of Dermatology 170(2), 274-303. [Abstract]

Primary evidence

No new randomized controlled trials published in the major journals since 1 November 2012.

New policies

No new national policies or guidelines since 1 November 2012.

New safety alerts

No new safety alerts since 1 November 2012.

Changes in product availability

No changes in product availability since 1 November 2012.

Goals and outcome measures

Goals

To diagnose psoriasis and exclude other dermatological conditions which present similarly

To treat appropriately depending on the areas affected

To refer appropriately

To address the physical, psychological and social impact of psoriasis

Background information

Definition

What is it?

Psoriasis is defined as 'a chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations'. It is characterized by scaly skin lesions, which can be in the form of patches, papules, or plaques. Itch is often a feature [Menter et al, 2008].

The skin lesions of psoriasis are characterized by [Griffiths et al, 2004; Menter et al, 2008]:

Hyperproliferation of the epidermis.

Dilatation and proliferation of blood vessels in the dermis.

Accumulation of inflammatory cells, particularly neutrophils and T-lymphocytes. When the number of neutrophils in the stratum corneum (present in all forms of psoriasis) is sufficient to be clinically obvious, the condition is termed 'pustular psoriasis'.

Chronic plaque psoriasis (including scalp psoriasis, flexural psoriasis, and facial psoriasis) is the most common form, affecting 80–90% of people with psoriasis. The second most common form is localized pustular psoriasis of the palms and soles [Menter et al, 2008; Meier and Sheth, 2009].

Other forms of psoriasis include:

Nail psoriasis .

Guttate psoriasis .

Erythrodermic psoriasis .

Generalized pustular psoriasis .

Prevalence

How common is it?

Psoriasis is common.

Around 1–3% of the world's population has psoriasis, with the prevalence varying among ethnic groups [Myers et al, 2006].

In the UK around 1.3–2.2% of the population is thought to have psoriasis [Parisi et al, 2013].

Psoriasis is most common in white people (the prevalence is estimated to be 2.5%) [Griffiths and Barker, 2007; Meier and Sheth, 2009].

Only 0.3% of China's population are affected [Griffiths and Barker, 2007].

A US population-based study found a prevalence of 1.3% in African–Americans [Meier and Sheth, 2009].

Presentation can be at any age, but psoriasis is likely to first present between 15 years and 30 years of age, or after 40 years of age [Meier and Sheth, 2009]. Psoriasis is thought to be uncommon in children; one population based European study found a prevalence of 0.71% [Parisi et al, 2013].

Men and women are equally affected [Meier and Sheth, 2009].

Triggering factors

What factors may trigger episodes of psoriasis?

Several factors are believed to affect the onset or exacerbation of psoriasis, including:

Streptococcal infection — strongly associated with guttate psoriasis, especially if the throat is infected. This association may also apply to chronic plaque psoriasis.

Drugs — anecdotal evidence suggests that certain drugs may be associated with the onset or exacerbation of psoriasis (for example lithium; antimalarials; beta-blockers; nonsteroidal anti-inflammatory drugs; angiotensin-converting enzyme inhibitors; trazodone; terfenadine; gemfibrozil; and antibacterials, such as tetracycline and penicillin).

Sunlight — usually beneficial, but may exacerbate psoriasis in a small number of people.

Trauma — various types of trauma to previously uninvolved skin can be followed 7–14 days later by the development of psoriasis. This phenomenon is known as the 'Koebner reaction'.

Post-partum hormonal changes.

Psychological stress.

Excessive alcohol intake.

Smoking.

HIV infection and AIDS.

Environment (for example change in climate).

[Yosipovitch and Tang, 2002; Griffiths et al, 2004; Meier and Sheth, 2009]

Associated conditions

What conditions are associated with psoriasis?

Psoriasis is associated with several other conditions:

Psoriatic arthritis — a seronegative inflammatory arthritis that occurs in the presence of psoriasis. Epidemiological studies suggest that 7–40% of people with psoriasis are affected.

Traditional cardiovascular risk factors, such as hyperlipidaemia, hypertension, diabetes, and history of myocardial infarction.

There is growing evidence of a link between moderate-to-severe psoriasis and atherosclerosis.

Inflammatory bowel disease (particularly Crohn's disease).

Obesity.

Depression.

Venous thromboembolism in adults (especially if psoriasis is severe).

Non–melanoma skin cancer.

[Griffiths and Barker, 2007; Gulliver, 2008; Alexandroff et al, 2009; Meier and Sheth, 2009; Boehncke et al, 2010; National Clinical Guideline Centre, 2012]

Complications

What are the complications?

Psychological and social effects

Psychological and social effects of psoriasis are common, can be profound, and are not necessarily related to the severity of skin involvement [Pathirana et al, 2009]. These include [Barankin and DeKoven, 2002; de Korte et al, 2004; Meier and Sheth, 2009]:

Anxiety and depression.

Negative body image and self image.

Shame, guilt, embarrassment, and fear of being considered dirty or infectious.

Limitation of activities, including those requiring skin exposure (such as swimming) and work.

Negative effect on social, professional, and personal relationships.

Physical effects

Erythrodermic psoriasis substantially affects the body's ability to regulate temperature and also affects haemodynamics, intestinal absorption, and protein and water metabolism. The effects of erythroderma can be life-threatening and include [Griffiths et al, 2004; Griffiths and Barker, 2007]:

Heart failure — due to increased skin blood flow, blood volume, and cardiac output.

Malabsorption — enteropathy causes changes in intestinal absorption.

Hypothermia — due to increased heat loss from the body surface.

Dehydration — from increased transepidermal water loss due to the reduction in the barrier function of the skin.

Mild anaemia — iron loss due to skin loss from excess scaling and impaired absorption and utilization of iron. Vitamin B12 and folate levels may also be low.

Generalized pustular psoriasis can cause fever, malaise, tachycardia, weight loss, and hypothermia, and has a significant mortality rate [Ashton and Leppard, 2005; Myers et al, 2006].

Less severe psoriasis can also cause physical discomfort, including itch (which is common, especially in elderly people; they are more likely to experience itch because of coexisting dry skin) [Yosipovitch and Tang, 2002; Griffiths and Barker, 2007].

Prognosis

What is the prognosis?

Knowledge about the natural history of psoriasis is lacking. Studies suggest that spontaneous remission may occur in about a third of people [Griffiths and Barker, 2007]. Without treatment:

Psoriasis (particularly the plaque type) is usually chronic, but the person may experience remissions which can sometimes last for years.

Guttate psoriasis is self limiting and typically resolves within 3–4 months of onset. Long-term prognosis is unknown, but it is thought that about a third of people with guttate psoriasis develop classic plaque disease [Griffiths and Barker, 2007]. Recurrent 'guttate' type psoriasis may occur either spontaneously or in response to strep infection.

The prognosis of flexural psoriasis is likely to be similar to that of chronic plaque psoriasis [van de Kerkhof et al, 2007].

Localized palmoplantar pustular psoriasis can be chronic [Meier and Sheth, 2009].

Age of onset may also affect the severity of the disease. A Spanish study found that in people in whom psoriasis developed before 30 years of age, there was an association with more severe disease, a higher incidence of guttate psoriasis and nail involvement, and more psychological impact [Ferrándiz et al, 2002]. In people older than 30 years of age, palmoplantar pustular psoriasis was more common.

Diagnosis and assessment

Diagnosis and assessment of psoriasis

Diagnosis

How do I know my patient has it?

The diagnosis of psoriasis is usually based on clinical findings.

Ask about, and look for, features suggesting psoriasis [Ashton and Leppard, 2005; Myers et al, 2006; Douglas et al, 2009].

Distribution — psoriasis can occur on extensor surfaces (elbows and knees), the trunk, and flexor surfaces (including genital areas). Also check the superior gluteal cleft (buttock crease), scalp, and umbilicus for lesions.

Size and shape of lesions — plaque psoriasis generally presents as large plaques, whereas guttate psoriasis presents as smaller lesions. There is usually a clear delineation between normal and abnormal (affected) skin.

Number of lesions — some people will have only a few lesions (for example chronic plaque psoriasis affecting only the extensor surfaces), but others will have many (for example the numerous small lesions of guttate psoriasis).

Surface features — whether smooth, scaly, or pustular.

Colour — may be pink or red, but in people with darker skin this may not be obvious. Scale is typically silvery in colour.

Involvement of other areas — such as the joints or nails.

Determine whether there is any relationship of lesions to areas of trauma — in around 20% of people with psoriasis, the Koebner phenomenon (development of psoriatic lesions after nonspecific irritation or trauma at that site) is present.

Images of different types of psoriasis can be found at www.dermnet.com.

If in doubt about whether the person has psoriasis or a similar condition, consider referral to a dermatologist. In rare cases, a skin biopsy may be needed to confirm the diagnosis [Meier and Sheth, 2009].

Chronic plaque psoriasis

How do I know my patient has chronic plaque psoriasis?

Plaques often occur on the scalp, trunk, buttocks, and extensor surfaces (such as elbows and knees). There can be a single lesion, a few, or a large number of lesions. When greater numbers of lesions are present, they are typically distributed symmetrically and can coalesce to form larger lesions.

On white skin, the plaques are pink, but on darker skin this characteristic colour is not apparent.

Most lesions are 1 cm to several centimetres in diameter, with an oval or irregular shape.

There is usually a clear delineation between normal and affected skin.

Scale is present.

It is usually silver–white in colour, but less commonly can be a waxy yellow or orange–brown.

The thickness of the scale varies, but occasionally it can be very thick.

If the scale is gently removed, a glossy red membrane with small bleeding points (Auspitz's sign) is revealed.

Fissures may form if the plaque is over a joint line or on the palm or sole.

Occasionally, a halo-like effect is seen around the plaque, because of vasoconstriction (Woronoff's ring).

Images of chronic plaque psoriasis can be found at www.dermnet.com.

[Griffiths et al, 2004; Myers et al, 2006; Menter et al, 2008; Meier and Sheth, 2009]

Scalp psoriasis

How do I know my patient has scalp psoriasis?

Scalp psoriasis is usually of the chronic plaque type.

The whole scalp can be affected, or individual plaques may be visible. Plaques may be very thick, particularly in the occipital region.

Scalp psoriasis can cause hair loss for some people, particularly if there is:

Thick adherent scale extending up the hair shaft (pityriasis amiantacea)

Psoriatic erythroderma. This can cause severe hair loss.

Repeated scratching of the scalp. This is usually reversible.

Images of scalp psoriasis can be found at www.dermnet.com.

[Griffiths et al, 2004]

Facial psoriasis

How do I know my patient has facial psoriasis?

People with facial psoriasis are more likely to have longstanding psoriasis which started early in life.

Facial psoriasis classically presents with well-demarcated plaques on the face, similar to those of chronic plaque psoriasis.

If facial psoriasis presents with mild scaling around the eyebrows and nasolabial fold (sebo-psoriasis), it can be difficult to differentiate from seborrhoeic dermatitis.

If lesions affect the hairline, they should be considered as scalp psoriasis.

Images of facial psoriasis can be found at www.dermnet.com.

[van de Kerkhof et al, 2007]

Flexural psoriasis

How do I know my patient has flexural psoriasis?

Flexural psoriasis is also known as 'inverse psoriasis' and involves the groins; genitals; vulva; axillae; submammary folds (under the breasts); abdominal folds; gluteal cleft (buttock crease); and other body folds, such as the antecubital fossa (elbow crease) [Griffiths et al, 2004; Menter et al, 2008; Meier and Sheth, 2009].

Flexural psoriasis is a type of chronic plaque psoriasis and thus is not a separate disease entity. It looks different to chronic plaque psoriasis because of the site of the lesions [van de Kerkhof et al, 2007].

Lesions are well defined, but in contrast to chronic plaque psoriasis, there may be little or no scaling. The lesion appears red and glazed, and there is often a fissure at the depth of the flexure [Griffiths et al, 2004]. Itch is a feature in more than half of people with flexural psoriasis [Wang et al, 2005].

Adults are more commonly affected than children, particularly older adults, those confined to bed, and overweight people [Yosipovitch and Tang, 2002; Menter et al, 2008].

If a rash initially presumed to be infective or seborrhoeic intertrigo does not respond to antibacterial or antifungal preparations, consider a diagnosis of flexural psoriasis [Griffiths et al, 2004].

Images of flexural psoriasis can be found at www.dermnet.com.

Guttate psoriasis

How do I know my patient has guttate psoriasis?

Guttate psoriasis usually presents in children and adults younger than 30 years of age. It can occur as the first presentation of psoriasis or as an acute exacerbation of plaque psoriasis, particularly after acute streptococcal infection (usually of the throat) or viral infection.

Lesions are small, round or oval (2 mm to 1 cm in diameter) scaly papules. They may be pink or red, but this can vary depending on the person's skin colour. Lesions occur all over the body, usually in large numbers and particularly on the trunk and proximal limbs (although the distal limbs can also be involved). Guttate psoriasis can occur on the face, ears, and scalp, but is rarely seen on the soles of the feet.

Images of guttate psoriasis can be found at www.dermnet.com.

[Griffiths et al, 2004; Griffiths and Barker, 2007; Menter et al, 2008]

Pustular psoriasis

How do I know my patient has pustular psoriasis?

Pustular psoriasis can be generalized or localized.

Localized pustular psoriasis (palmoplantar pustular psoriasis).

This is much more common in women than in men (ratio of 9:1), and usually occurs in the fourth or fifth decade of life.

The palms and soles are involved, with development of yellow-brown pustules within established plaques, or redness, scaling, and pustules at the tips of the fingers and toes.

Systemic symptoms are not usually present.

Generalized pustular psoriasis

This is much less common than the localized type and is a medical emergency that requires same–day hospital referral.

It presents with rapidly developing widespread redness, followed by the eruption of small pustules.

Symptoms and signs of systemic illness often occur, including fever, malaise, tachycardia, weight loss, and arthralgia.

Occasionally, generalized pustular psoriasis can be precipitated by infection, change in drugs, withdrawal of steroids, or exposure to ultraviolet light.

Images of pustular psoriasis can be found at www.dermnet.com.

[Myers et al, 2006; Griffiths and Barker, 2007; Menter et al, 2008; Meier and Sheth, 2009]

Erythrodermic psoriasis

How do I know my patient has erythrodermic psoriasis?

Erythroderma occurs when psoriasis is so diffuse that more than 90% of the body surface is involved [Meier and Sheth, 2009]. Acute erythroderma is a medical emergency that requires same–day hospital referral.

It can develop gradually from chronic plaque psoriasis or appear acutely, even in people with mild psoriasis [Menter et al, 2008].

It can be precipitated by various factors, including systemic infection; irritants, such as tar, drugs, phototherapy, or withdrawal of corticosteroids; and ciclosporin [Myers et al, 2006].

The skin is red, with varying degrees of scaling (scale is finer and flakier than the silvery, coarse, thick scale of plaque psoriasis), and the defined plaques of psoriasis are lost. The person may be febrile and ill, they may report itching, and the skin may be warm to the touch [Griffiths et al, 2004; Menter et al, 2008; Meier and Sheth, 2009].

The person may have associated features, such as lymphadenopathy, fever or hypothermia, tachycardia, and peripheral oedema [Meier and Sheth, 2009].

Images of erythrodermic psoriasis can be found at www.dermnet.com.

Nail psoriasis

How do I know my patient has nail psoriasis?

Nail psoriasis can occur with all types of psoriasis and is particularly common in people with psoriatic arthritis, up to 90% of whom may have nail changes [Myers et al, 2006; Menter et al, 2008].

Of people with psoriasis, 50% have fingernail involvement and 35% have toenail involvement [Menter et al, 2008].

Psoriatic nail changes include:

Pitting of the nails (depressions in the nail plate).

Discolouration (for example the oil drop sign — orange-yellow discolouration of the nail bed).

Subungual hyperkeratosis — hyperproliferation of the nail bed, with accumulation of keratinocytes under the nail.

Onycholysis (detachment of the nail from the nail bed, which may allow bacteria and fungi to enter and cause infection).

Images of nail psoriasis can be found at www.dermnet.com.

[Griffiths et al, 2004; Griffiths and Barker, 2007]

Differential diagnosis

What else might it be?

Yeast and fungal infections

Seborrhoeic dermatitis — due to an overgrowth of pityrosporum yeast in the skin [Ashton and Leppard, 2005]. It is usually limited to characteristic areas and has greasy scales, which are usually more diffuse and less well defined than those in psoriasis. There is no joint or nail involvement. Scalp psoriasis can be very difficult to differentiate from severe seborrhoeic dermatitis [Meier and Sheth, 2009]. Psoriasis and seborrhoeic dermatitis can occur together. For more information, see the CKS topic on Seborrhoeic dermatitis.

Fungal skin infection — may be scaly, but not the characteristic silvery scale of psoriasis. Lesions in fungal infection are more typically either solitary or unilateral and asymmetrical (compared with psoriasis, which is typically symmetrical) and have central clearing with peripheral scaling. There may be fungal infection elsewhere [Yosipovitch and Tang, 2002; Meier and Sheth, 2009]. For more information, see the CKS topics on Fungal skin infection - body and groin, Fungal skin infection - foot, and Fungal skin infection - scalp.

Fungal nail infection — can look similar to nail psoriasis, but tends to affect only a few nails. For more information, see the CKS topic on Fungal nail infection.

Candidal intertrigo — can appear similar to flexural psoriasis, but may have bright red papules, pustules, and superficial erosions with satellite lesions [Myers et al, 2006; Meier and Sheth, 2009].

Infections and infestations

Norwegian scabies — there may be significant hyperkeratosis similar to that of psoriasis. The genitals and axillary folds can be involved. Often there is a contact history. Irritation predominates [Yosipovitch and Tang, 2002]. For more information, see the CKS topic on Scabies.

Secondary syphilis — especially if there is palmar or plantar involvement. The rash is variable but may involve macules, papules, pustules, and plaques and often affects the palms and soles (where it resembles pustular psoriasis). There may be a history of painless oral or genital chancre [Ashton and Leppard, 2005; Meier and Sheth, 2009].

Bacterial infection (creases) — can appear similar to flexural psoriasis [Meier and Sheth, 2009].

Eczema — in adults, often presents as dry, itchy skin, particularly in the flexures. Vesicles can occur if there is a flare-up. In chronic eczema, skin can be lichenified [NICE, 2007]. Chronic hand eczema can present as ill-defined psoriasiform plaques on the palms and soles [Meier and Sheth, 2009].

Cutaneous T-cell lymphoma is a rare but important differential diagnosis not to miss in people with a chronic, scaly, red rash that is not responding to treatment.

It presents with itchy, red, scaly patches; however, unlike psoriasis, the colour varies among patches [Ashton and Leppard, 2005]. Over several years, plaques form and tumours may develop.

Pityriasis rosea — similar appearance to guttate psoriasis. Psoriatic scale involves the whole lesion and is coarser than the finer localized ring pattern of the scale of pityriasis rosea. Pityriasis rosea often appears in a 'Christmas tree' distribution on the trunk after the initial appearance of a herald patch 2–3 cm in diameter, and resolves within 6–8 weeks without treatment. Guttate psoriasis lasts longer if untreated [Ashton and Leppard, 2005; Meier and Sheth, 2009].

Assessment

How should I assess someone with psoriasis?

Assess the sites of involvement in order to determine which type of psoriasis the person has and the most appropriate management.

Assess for systemic upset such as fever and malaise, especially in people who have erythrodermic psoriasis or generalised pustular psoriasis.

Acute erythrodermic psoriasis and generalised pustular psoriasis are medical emergencies and require same-day specialist assessment and treatment.

Assess and document the extent (amount of body surface area affected) of psoriasis.

The amount of body surface area affected can be estimated using the 'Rule of Nines'.

Referral to a dermatology specialist is required if more than 10% of the body surface area is affected.

Assess and record the severity of psoriasis by using a static Physician's Global Assessment (PGA) score.

The PGA uses a 7–point score to classify psoriasis as being: nearly clear; mild; moderate; severe; or very severe. A score of 0 is described as clear, and scores of 1-6 indicate increasing severity.

Referral to a dermatology specialist is required if the psoriasis is severe, or very severe as measured by the PGA.

Document the person's self assessment of the severity of their disease by using the static Patient's Global Assessment. This tool also uses a 7–point score to classify psoriasis as being: clear; nearly clear; mild; moderate; severe; or very severe. A score of 0 is described as clear, and scores of 1-6 indicate increasing severity.

Assess the impact psoriasis is having on the person, by:

Asking the following questions:

What aspects of daily living are affected by your psoriasis?

How are you coping with your skin condition and what treatments are you using?

Do you need further advice or support?

Is your psoriasis having an impact on your mood?

Is your psoriasis causing distress?

Is your psoriasis having any impact on your family or carers?

Using the Dermatology Life Quality Index (DLQI). This is a validated patient questionnaire with 10 questions, suitable to use in primary care.

The DLQI is available to download free from www.dermatology.org.uk along with instructions on how to use and interpret the results.

Assess at least annually for the presence of articular symptoms using a patient-administered questionnaire such as the Psoriasis Epidemiology Screening Tool (PEST).

This is a quick, easy to use, validated patient questionnaire (pdf), available to download for free from the SIGN website (Annex 5, of the guideline: Diagnosis and management of psoriasis and psoriatic arthritis in adults).

A score of three or more on the PEST questionnaire is indicative of psoriatic arthritis (back pain or axial arthritis is not captured by the PEST).

Assess the person's cardiovascular risk (particularly if their psoriasis is severe). Reassess the person's cardiovascular risk at least every 5 years.

For more information, see the CKS topic on CVD risk assessment and management.

Assess for the presence of other comorbidities such as:

Depression. For more information see, the CKS topic Depression.

Inflammatory bowel disease. For more information see, the CKS topics Ulcerative colitis, and Crohn's disease.

Non–melanoma skin cancer.

Measuring extent of body surface area affected

The extent of the body surface affected by psoriasis, in terms of total body surface area in adults, can be calculated using the Rule of Nines. This is normally used to calculate the body surface affected burns [Herndon, 1996]:

Arm — 9%.

Head — 9%.

Neck — 1%.

Leg — 18%.

Anterior trunk — 18%.

Posterior trunk — 18%.

For more information see the Lund and Browder chart (pdf) for calculating the percentage of total body surface.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidance published by the National Institute for Health and Clinical Excellence (NICE): Assessment and management of psoriasis [National Clinical Guideline Centre, 2012].

Assessing the impact and severity of psoriasis in primary care is a change in clinical practice, however none of the tools used for this assessment have been validated in primary care. The NICE guideline development group (GDG) have recommended the use of these tools in primary care because in specialist settings they have been associated with improved clinical outcomes (for example improved awareness of disease impact and ineffective treatments stopped).

Assessing the extent

NICE recommend measuring the extent of psoriasis by measuring body surface area. The GDG felt that it was important to take a baseline measurement of the extent of psoriasis, because people with extensive disease (body surface area greater than 10%) are likely to require specialist referral.

NICE did not recommend a specific tool for measuring the body surface area affected, however CKS have recommended using the 'Rule of Nines' as most clinicians would be familiar with this measure.

Assessing the severity

The gold standard for assessing the severity of psoriasis is the Psoriasis Area Severity Index (PASI). However, this may not be practical to use in primary care, therefore NICE have recommend using the Physician's Global Assessment (PGA) score.

NICE recommend self assessment using the Patient Global Assessment. The GDG felt that this would help to capture distress if the person's perception of severity was greater than the physician's assessment.

Assessing the impact

The questions for assessing the impact of psoriasis on the person are based on the expert opinion of the NICE guideline development group.

The GDG chose the Dermatology Life Quality Index (DLQI) as an alternative to the list of questions to assess impact of all types of psoriasis. It is a simple, practical tool that performed at least adequately in the prioritised outcomes, and there was no good evidence that other tools were better. However it may not always be practical to use in primary care.

Comorbidities

Depression — psoriasis is a complex long–term condition that places a particularly high psychological demand on the patient. People experience adverse emotional reactions to the diagnosis, including anxiety and depression [National Clinical Guideline Centre, 2012].

Non-melanoma skin cancer — community and hospital-based studies suggest that people with psoriasis, particularly those with severe disease, may also be at increased risk of non-melanoma skin cancer.

Cardiovascular risk

There is evidence from two UK-based observational studies that the risk of cardiovascular mortality is increased for people with psoriasis [Gelfand et al, 2006; Neimann et al, 2006]. However it is unknown if this increase is directly related to the psoriasis, or an increased incidence of cardiovascular risk factors reported in people with psoriasis [National Clinical Guideline Centre, 2012].

Management

Management

Scenario: Trunk and limbs : covers the management of chronic plaque psoriasis of the trunk and limbs and when to refer.

Scenario: Scalp psoriasis : covers the management of scalp psoriasis and when to refer.

Scenario: Facial/flexural/genital psoriasis : covers the management of facial, flexural, as well as genital psoriasis and when to refer.

Scenario: Guttate psoriasis : covers the management of guttate psoriasis and when to refer.

Scenario: Pustular psoriasis : covers the management of pustular psoriasis and when to refer.

Scenario: Erythrodermic psoriasis : covers the referral of people with erythrodermic psoriasis.

Scenario: Nail psoriasis : covers the management of nail psoriasis and when to refer.

Scenario: Trunk and limbs

Scenario: Trunk and limbs

216months3060monthsBoth

Management principles

What are the general principles of management of chronic plaque psoriasis of the trunk and limbs?

Offer treatment with topical preparations.

Discuss the advantages and disadvantages of each topical treatment, as well as the variety of formulations available. In general:

Creams, lotions or gels are suitable for widespread psoriasis.

Lotions, solutions or gels are suitable for the scalp or hair-bearing areas.

Ointments are suitable to treat areas of skin with thick scale.

Topical corticosteroids are only suitable for treating localized psoriasis.

Repeat prescriptions for topical corticosteroids should be carefully reviewed and supervised. This is in order to identify any adverse effects, and to avoid the use of corticosteroids on widespread psoriasis where the risks of destabilizing the disease become important.

When prescribing, take into account patient preference, cosmetic acceptability, practical aspects of application, as well as the site(s) and extent of psoriasis to be treated.

Give general advice and support regarding the correct use and application of topical treatments as well as general information about psoriasis.

Review the person within 4 weeks after treatment has started and regularly thereafter, as required. Use clinical judgment if earlier or more frequent reviews are required. At each review appointment:

Reassess the severity of psoriasis.

Reassess the impact of psoriasis.

Ask about how well the treatment is being tolerated, adverse effects to treatments and if there are any issues around compliance.

People who are using multiple courses of potent or very potent topical corticosteroids should also be assessed annually.

Basis for recommendation

Basis for recommendation

These recommendations are based on a guideline published by the National Institute for Health and Clinical Excellence: Assessment and management of psoriasis [National Clinical Guideline Centre, 2012].

Treatment

How should I treat chronic plaque psoriasis of the trunk and limbs?

Offer topical treatments with:

An emollient to reduce scale and help with other symptoms including itch.

A potent topical corticosteroid (applied once a day) plus a topical vitamin D preparation (applied once a day).

Advise the person to apply the topical corticosteroid at a different time of the day to the vitamin D preparations, for example if applying a topical corticosteroid in the morning, a vitamin D preparation should be applied at night time.

If scale is a particular problem, preparations containing salicylic acid may be useful, although evidence is lacking.

Discuss the adverse effects of topical corticosteroids and how these can be minimized.

Some people respond quickly to treatment with a topical corticosteroid. The person should be advised that once the skin is clear or nearly clear they can stop using a topical corticosteroid (this may be well before their follow-up appointment).

Offer referral for second and third-line treatments (e.g. phototherapy or systemic therapy) at the same time as offering topical treatments, if it is thought that topical treatments are unlikely control the person's psoriasis.

Topical treatments alone are unlikely to be effective if the person has:

Extensive disease (e.g. greater than 10% of body surface area affected).

A score of at least 'moderate' on the static Physician's Global Assessment.

Psoriasis that does not respond well to topical treatments (e.g. nail involvement).

Review after 4 weeks. If there has been a good initial response, continue treatment until the skin is clear or nearly clear.

Advise the person not to apply potent corticosteroids for more than 8 weeks at any one site. Treatment with a corticosteroid may be restarted after a 4 week 'treatment break'. During this time vitamin D preparations may be continued.

To maintain satisfactory disease control, courses of topical treatments (including topical corticosteroids) can be used as needed.

As discussed above, potent corticosteroids should not be applied for more than 8 weeks at any one site, but can be restarted after a treatment break of 4 weeks.

Offer a supply of topical treatments to be kept at home for self-management on a when-needed basis to maintain satisfactory control.

If there is a poor initial response after the first 4 weeks check compliance.

Ask the person if they have any difficulties with application, cosmetic acceptability or tolerability. Consider other possible reasons for non-adherence to ascertain if there is a reason for treatment failure.

If there is no obvious reason for treatment failure, consider:

Continuing treatment with a potent corticosteroid (once a day) plus a vitamin D preparation (once a day) for another 4 weeks or

Stopping the potent corticosteroid and only applying a vitamin D preparation twice a day for up to 12 weeks.

If there is a poor response after an additional 4 weeks of treatment with a potent corticosteroid (once daily) plus a vitamin D preparation (once daily), advise the person to stop the potent corticosteroid and only apply a vitamin D preparation twice a day.

The person will already have had 8 weeks treatment with a topical corticosteroid.

If there is still a poor response after 12 weeks of treatment with a vitamin D preparation alone twice a day, offer:

A potent corticosteroid, applied twice a day for up to 4 weeks, or

A coal tar preparation applied once or twice daily.

If these treatments fail consider, offering a potent corticosteroid and vitamin D combined preparation, applied once a day for up to 4 weeks.

For people with treatment-resistant psoriasis of the trunk or limbs, consider short contact dithranol.

If starting treatment with dithranol in primary care ensure that educational support is given to the person on how to use short contact dithranol.

For detailed prescribing information, see Prescribing information.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidance published by the National Institute for Health and Clinical Excellence (NICE): Assessment and management of psoriasis [National Clinical Guideline Centre, 2012].

Choice of treatment

The recommendations regarding the choice and sequencing of treatments are based on evidence from a clinical and cost effectiveness analysis conducted by NICE [National Clinical Guideline Centre, 2012]. The main results of this analysis were:

With the exception of very potent corticosteroids, a once daily topical potent corticosteroid plus a once daily vitamin D preparation (applied separately in the morning and evening) was the most cost effective and clinically sensible initial treatment for psoriasis. Very potent steroids were excluded owing to safety concerns.

A twice daily vitamin D preparation was found to be cost effective when used as a second or third treatment option.

Twice daily coal tar was potentially cost effective if other treatments failed to bring clearance or near clearance.

A combined product containing calcipotriol monohydrate and betamethasone dipropionate was found to be the most effective treatment. However, this was not cost effective and the NICE guideline development group (GDG) felt that the modest additional benefits it produced were insufficient to justify the extra cost of this product.

Emollients

NICE did not review the evidence for emollients. The GDG felt that the use of emollients in psoriasis was widespread and of accepted value, and a review of the evidence was unlikely to lead to a change in practice. NICE therefore limited their evidence review to active topical therapies in psoriasis.

CKS identified no good-quality evidence on the use of emollients for psoriasis. However, emollients are recommended on the basis of expert opinion [BAD, 2004b; Fluhr et al, 2008; Menter et al, 2009; SIGN, 2010; National Clinical Guideline Centre, 2012 ]. It is thought that emollients improve the skin's barrier function and reduce scale, and they may increase the effectiveness of some topical treatments [Fluhr et al, 2008].

Topical salicylic acid

NICE did not review the evidence for salicylic acid in people with trunk and limb psoriasis. However, CKS has offered salicylic acid as a treatment option because other published expert opinion states that it may be more effective at removing thick keratotic scales and may allow other topical treatments to penetrate more effectively [Chan et al, 2009].

Vitamin D preparation and potent corticosteroid combined in one product

As discussed above, NICE found that a combined product is not cost-effective for the average patient. However NICE recommended a once daily combined potent corticosteroid and vitamin D preparation for people in whom a twice daily potent corticosteroid or coal tar preparation could not be used. This was because for people not responding to other topical treatments, concordance is often a problem and a once-daily, well-tolerated topical preparation would be of benefit in achieving clearance, so avoiding hospital referral and saving cost in this small group.

Assessment at 4 weeks

NICE recommend an assessment 4 weeks after starting treatment because it is thought that the majority of people who are likely to respond to potent topical corticosteroids within 8 weeks usually do so by 4 weeks.

Corticosteroid treatment breaks

Potent to very potent topical corticosteroids are not recommended for regular use over prolonged periods (more than 8 weeks) because of concerns over long term adverse effects such as skin atrophy, and telangiectasia. The NICE Guideline Development Group recommend a four week treatment break from corticosteroids after 8 weeks continuous use, because they found data that suggested 3-4 weeks is needed for skin regeneration.

Treatments not recommended in primary care

Very potent corticosteroids

Very potent corticosteroids are not recommended for use in primary care for people who have psoriasis. The NICE Guideline Development Group did not consider very potent topical corticosteroids as a safe treatment option for the management of mild to moderate psoriasis in primary care. Specific concerns included: rebound effect; irreversible skin atrophy; and the risk of repeat prescriptions being issued without monitoring and lack of long-term safety data.

Tazarotene

NICE state that tazarotene may be unpleasant to use and causes burning and irritation of the skin. NICE found evidence from two trials that there was no significant difference between tazarotene (applied once a day) and placebo for people with psoriasis.

Information for patients

What information should I give about psoriasis?

Reassure the person that psoriasis is not infectious. Around 30% of people with psoriasis have a family history of psoriasis, and certain genes have been identified as being linked to psoriasis.

A trigger may be required for psoriasis to develop, such as a throat infection, injury to the skin, certain drugs, and physical or emotional stress.

It may take a few weeks for topical treatments to work and it is very important to persevere with treatments.

Psoriasis is a recurring condition. Once treatment is stopped relapse occurs in most people and multiple treatment courses are usually required over time to keep it under control.

People with psoriasis are at higher risk of developing:

Psoriatic arthritis — if unexplained joint pain or swelling occurs advise the person to seek medical advice. Psoriatic arthritis will require referral to secondary care.

Cardiovascular disease — offer advice on a healthy lifestyle (for example stopping smoking and avoiding excessive alcohol intake).

For more information, see the CKS topics on Smoking cessation and Alcohol - problem drinking.

Venous thromboembolism, especially if the psoriasis is severe. Offer advice on how to minimize the risk.

For more information see the CKS topic on Deep vein thrombosis and DVT prevention for travellers.

Discuss sources of support, such as:

The Psoriasis Association (www.psoriasis-association.org.uk).

The Psoriasis and Psoriatic Arthritis Alliance (www.papaa.org).

Basis for recommendation

Basis for recommendation

This information is based on a guideline published by the National Institute for Health and Clinical Excellence: Assessment and management of psoriasis [National Clinical Guideline Centre, 2012].

Referral

When should I refer a person with chronic plaque psoriasis of the trunk and limbs?

Refer for same-day specialist assessment and treatment anyone with erythrodermic psoriasis and generalised pustular psoriasis, these are medical emergencies and require same-day specialist assessment and treatment.

Refer the person for dermatology specialist advice if:

Diagnostic uncertainty exists.

Psoriasis is extensive, for example more than 10% of the body surface area is affected.

Psoriasis is severe as measured by the Physicians's Global Assessment.

Topical treatments have failed.

The person cannot tolerate the treatment options available in primary care.

There is a significant impact on physical, psychological or social well being.

Further information or education is needed (for example about application of topical treatments).

Refer to a rheumatologist if the person requires assessment for the management of associated arthropathy.

Assess the severity and impact of psoriasis before referral.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidance published by the National Institute for Health and Clinical Excellence; Psoriasis. Assessment and management of psoriasis [National Clinical Guideline Centre, 2012], the British Association of Dermatologists [BAD, 2004b], and a narrative review [Meier and Sheth, 2009].

Scenario: Scalp psoriasis

Scenario: Scalp psoriasis

216months3060monthsBoth

Management principles

What are the general principles of management of scalp psoriasis?

Offer treatment with topical preparations.

Discuss the advantages and disadvantages of each topical treatment, as well as the variety of formulations available. In general:

Creams, lotions or gels are suitable for widespread psoriasis.

Lotions, solutions or gels are suitable for the scalp or hair-bearing areas.

Ointments are suitable to treat areas of skin with thick scale.

Topical corticosteroids are only suitable for treating localized psoriasis.

Repeat prescriptions for topical corticosteroids should be carefully reviewed and supervised. This is in order to identify any adverse effects, and to avoid the use of corticosteroids on widespread psoriasis where the risks of destabilizing the disease become important.

When prescribing, take into account patient preference, cosmetic acceptability, practical aspects of application, as well as the site(s) and extent of psoriasis to be treated.

Give general advice and support regarding the correct use and application of topical treatments as well as general information about psoriasis.

Review the person within 4 weeks after treatment has started and regularly thereafter, as required. Use clinical judgment if earlier or more frequent reviews are required. At each review appointment:

Reassess the severity of psoriasis.

Reassess the impact of psoriasis.

Ask about, how well the treatment is being tolerated, adverse effects to treatments, and if there are any issues around compliance.

People who are using multiple courses of potent or very potent topical corticosteroids should also be assessed annually.

Basis for recommendation

Basis for recommendation

These recommendations are based on a guideline published by the National Institute for Health and Clinical Excellence: Assessment and management of psoriasis [National Clinical Guideline Centre, 2012].

Treatment

How should I treat scalp psoriasis?

Offer treatment with a potent topical corticosteroid (applied once a day).

Give advice on the adverse effects of topical corticosteroids and how these can be minimized.

Some people respond quickly to treatment with a topical corticosteroid. The person should be advised that once the skin is clear or nearly clear they can stop using a topical corticosteroids (this may be well before their follow-up appointment).

Coal tar shampoos may also be considered, however they should not be used alone for people who have severe scalp psoriasis.

For people who cannot use corticosteroids on their scalp or who have mild to moderate scalp psoriasis, consider treatment with a vitamin D preparation alone (applied once a day).

Offer referral for second and third-line treatments (e.g. phototherapy or systemic therapy) at the same time as offering topical treatments, if it is though that topical treatments are unlikely control the person's psoriasis.

Topical treatments alone are unlikely to be effective if the person has:

Extensive disease (e.g. greater than 10% of body surface area affected).

A score of at least 'moderate' on the static Physician's Global Assessment.

Psoriasis that does not respond well to topical treatments (e.g. nail involvement).

Review after 4 weeks of treatment. If there is a good initial response (clearance, near clearance or satisfactory control) after the first 4 weeks of treatment continue treatment until the skin is clear or nearly clear.

Advise the person not to apply potent corticosteroids for more than 8 weeks at any one site. Treatment with a corticosteroid may be restarted after a 4 week 'treatment break'.

To maintain satisfactory disease control, courses of topical treatments can be used as needed.

Offer a supply of topical treatments to be kept at home for self-management.

If there is a poor initial response to treatment:

Check compliance and ask about the presence of any adverse effects or any other issues to ascertain if there is a reason for treatment failure.

Consider offering:

A different topical formulation of a potent corticosteroid such as a shampoo or mousse and/or

A scalp treatment such as salicylic acid, olive oil, coconut oil, arachis oil, or an emollient to remove scale (before further applications of the potent corticosteroid).

If there is still a poor response to treatment after a further 4 weeks consider prescribing:

A combined topical preparation containing a potent corticosteroid and vitamin D (applied once a day for up to 4 weeks) or

A vitamin D preparation applied once a day (only for people who cannot use corticosteroids and have mild to moderate scalp psoriasis).

If these treatments do not control scalp psoriasis (up to 8 weeks of treatment) consider:

Prescribing a very potent corticosteroid applied up to twice a day for 2 weeks, or

Prescribing a coal tar preparation applied once or twice a day.

Referral to a specialist for help with topical applications or advice on other treatments.

Do not use coal tar shampoos such as Polytar®, Alphosyl 2:1®, or Capasal® alone for treating severe scalp psoriasis.

For more information on which product to choose and how to apply scalp preparations, see Prescribing information.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidance published by the National Institute for Health and Clinical Excellence (NICE): Assessment and management of psoriasis [National Clinical Guideline Centre, 2012].

Choice of treatment

The recommendations regarding the choice and sequencing of treatments are based on evidence from a clinical and cost effectiveness analysis of topical treatments used to treat scalp psoriasis conducted by NICE [National Clinical Guideline Centre, 2012]. The main results were:

Initial treatment with potent or very potent corticosteroids is likely to be most cost effective. However the NICE guideline development group (GDG) was concerned that very potent corticosteroids were an aggressive initial strategy because they have a higher risk of causing corticosteroid adverse effects. For this reason the GDG recommended potent corticosteroids first.

Topical vitamin D preparations are likely to be the next cost effective topical therapy after potent topical corticosteroids.

Very potent corticosteroids are likely to be most cost effective after unsuccessful trials of potent corticosteroids and vitamin D preparations. The GDG chose not to recommend once or twice daily very potent steroids as first-or-second-line treatments. Very potent topical corticosteroids were considered appropriate as a third-line treatment option. This is because the number of people exposed to the adverse effects of a very potent corticosteroid would be minimal.

NICE found no statistically significant difference between once daily coal tar poly therapy and twice daily placebo at inducing clearance or near clearance in people with scalp psoriasis.

For a brief summary of the results of the above analysis see the supporting evidence section on scalp psoriasis.

Coal tar preparations

The overnight application of coal tar preparations is recommended in a Scottish Intercollegiate Guidelines Network guideline on Diagnosis and management of psoriasis and psoriatic arthritis in adults, based on expert opinion [SIGN, 2010]. Expert opinion in narrative reviews suggests that although good-quality evidence is lacking, coal tar shampoos have a role in the treatment of scalp psoriasis (particularly for reducing itch) and have been used extensively for this purpose [Warren et al, 2008; Chan et al, 2009].

NICE recommend that coal tar treatments should not be used as the only treatment for severe scalp psoriasis. NICE found that coal-tar based shampoos were only slightly more effective than placebo or vehicle scalp solution and were far less effective than other topical treatments. In the cost effectiveness model this meant that more people ended up failing treatment in primary care and being referred for specialist consultations and treatments, thus making the true costs to the NHS of treatment with coal tar shampoos much higher than the acquisition cost alone. The GDG were aware that coal-tar based shampoos are regularly prescribed in primary care for treatment of scalp psoriasis and agreed that based on the evidence of clinical and cost-effectiveness trials, that they are not optimal for the treatment of scalp psoriasis. In order to ensure more efficient use of NHS resources, they considered it important to discourage GPs from using this treatment.

Factors limiting the use of coal tar include its messiness, offensive smell, and the potential to stain [Warren et al, 2008].

Referral

When should I refer a person with scalp psoriasis?

Refer for same-day specialist assessment and treatment anyone with erythrodermic psoriasis and generalised pustular psoriasis. These are medical emergencies and require same-day specialist assessment and treatment.

Refer the person for dermatology specialist advice if:

Diagnostic uncertainty exists.

Psoriasis is extensive, for example more than 10% of the body surface area is affected.

Psoriasis is severe as measured by the Physician's Global Assessment.

Topical treatments have failed.

The person cannot tolerate the treatment options available in primary care.

There is a significant impact on physical, psychological or social well being.

Further information or education is needed (for example about application of topical treatments).

Refer to a rheumatologist if the person requires assessment for the management of associated arthropathy.

Assess the severity and impact of psoriasis before referral.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidance published by the National Institute for Health and Clinical Excellence: Assessment and management of psoriasis [National Clinical Guideline Centre, 2012], the British Association of Dermatologists [BAD, 2004b], and expert opinion in a review article [Meier and Sheth, 2009].

Scenario: Facial/flexural/genital psoriasis

Scenario: Facial/flexural/genital psoriasis

216months3060monthsBoth

Management principles

What are the general principles of management of facial, flexural and genital psoriasis?

Offer treatment with topical preparations.

Discuss the advantages and disadvantages of each topical treatment, as well as the variety of formulations available. In general:

Creams, lotions or gels are suitable for widespread psoriasis.

Lotions, solutions or gels are suitable for the scalp or hair-bearing areas.

Ointments are suitable to treat areas of skin with thick scale.

Topical corticosteroids are only suitable for treating localized psoriasis.

Repeat prescriptions for topical corticosteroids should be carefully reviewed and supervised. This is in order to identify any adverse effects, and to avoid the use of corticosteroids on widespread psoriasis where the risks of destabilizing the disease become important.

When prescribing, take into account patient preference, cosmetic acceptability, and practical aspects of application, as well as the site(s) and extent of psoriasis to be treated.

Give general advice and support regarding the correct use and application of topical treatments as well as general information about psoriasis.

Review the person within 4 weeks after treatment has started and regularly thereafter, as required. Use clinical judgement if earlier or more frequent reviews are required. At each review appointment:

Reassess the severity of psoriasis.

Reassess the impact of psoriasis.

Ask about how well the treatment is being tolerated, adverse effects to treatments, and if there are any issues around compliance.

People who are using multiple courses of potent or very-potent topical corticosteroids should also be assessed annually.

Basis for recommendation

Basis for recommendation

These recommendations are based on a guideline from the Scottish Intercollegiate Guidelines Network on Diagnosis and management of psoriasis and psoriatic arthritis in adults [SIGN, 2010].

Treatment

How should I treat facial/flexural/genital psoriasis?

Offer topical treatment with:

An emollient, and

A short-term mild or moderate topical corticosteroid preparation (applied once or twice daily) for up to 2 weeks.

Give advice on the adverse effects of topical corticosteroids and how these can be minimized.

Some people respond quickly to treatment with a topical corticosteroid. The person should be advised that once the skin is clear or nearly clear they can stop using a topical corticosteroids (this may be well before their follow-up appointment).

Inform the person that topical corticosteroids when applied to the face, flexures and genitals may cause irritation and that there is a greater risk of adverse effects such as skin thinning at these areas.

Offer referral for second and third-line treatments (e.g. phototherapy or systemic therapy) at the same time as offering topical treatments, if it is though that topical treatments are unlikely control the person's psoriasis.

Topical treatments alone are unlikely to be effective if the person has:

Extensive disease (e.g. greater than 10% of body surface area affected).

A score of at least 'moderate' on the static Physician's Global Assessment.

Psoriasis that does not respond well to topical treatments (e.g. nail involvement).

If there is a good response to treatment advise the person that repeated short courses of topical corticosteroids may be used to maintain disease control, however:

Topical corticosteroids should only be used for 1–2 weeks each month.

A 'treatment break' of 4 weeks between courses of topical corticosteroids is required.

Do not use:

Potent or very potent corticosteroids on the face, flexures, or genitals.

An antifungal treatment unless there are signs suggestive of fungal infection (red to red-brown, sometimes itchy, flat or slightly raised plaques with active borders [pustules or vesicles]).

Refer to a dermatology specialist for further treatment options (for example a calcineurin inhibitor) if:

There is a poor response to treatment with a topical corticosteroid, or

Continuous treatment with topical corticosteroids is required to maintain control and there is serious risk of local corticosteroid-induced side effects.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidance published by the National Institute for Health and Clinical Excellence (NICE); Assessment and management of psoriasis [National Clinical Guideline Centre, 2012]. NICE found very few published studies (n = 3) that assessed the efficacy of topical treatments for facial, flexural and genital psoriasis.

Emollients

NICE did not review the evidence for emollients. The Guideline Development Group (GDG) felt that the use of emollients in psoriasis was widespread and of accepted value, and a review of the evidence was unlikely to lead to a change in practice. NICE therefore limited their evidence review to active topical therapies in psoriasis.

CKS identified no good-quality evidence on the use of emollients for psoriasis. However, emollients are recommended on the basis of expert opinion [BAD, 2004b; Fluhr et al, 2008; Menter et al, 2009; SIGN, 2010; National Clinical Guideline Centre, 2012 ]. It is thought that emollients improve the skin's barrier function and reduce scale, and they may increase the effectiveness of some topical treatments.

Mild to moderate topical corticosteroids

NICE did not find any published trials that assessed the effectiveness of topical corticosteroids for facial, flexural, or genital psoriasis. However mild to moderate topical corticosteroids have been used to treat facial and flexural psoriasis for decades. The recommendation to use mild to moderate corticosteroids is based on the clinical experience and expert opinion of the NICE guideline development group. This is consistent with current recommendations from the Scottish Intercollegiate Guidelines Network, which recommends moderately-potent corticosteroids [SIGN, 2010].

Topical corticosteroids are recommended for short-term use only (up to 2 weeks) because of their adverse effect profile (atrophy, striae, and telangiectasia), which may be exacerbated by their use in occluded skin folds [Yosipovitch and Tang, 2002; Kreuter et al, 2006; National Clinical Guideline Centre, 2012].

Calcineurin inhibitors

NICE found evidence from 2 randomized controlled trials that, compared with placebo, pimecrolimus and tacrolimus were more effective than placebo for treating facial and flexural psoriasis. The NICE guideline development group recommended that topical calcineurin inhibitors should only be initiated by healthcare professionals with expertise in treating psoriasis. Calcineurin inhibitors are not licensed for this purpose and they are not recommended for use in primary care unless on specialist advice.

Topical vitamin D, dithranol, tazarotene, and coal tar

There is a paucity of trial data to support the use of topical vitamin D, dithranol, tazarotene, and coal tar for the treatment of facial, flexural or genital psoriasis. NICE found no published evidence that dithranol, tazarotene, or coal tar are effective for the treatment of facial, flexural or genital psoriasis. There is limited evidence from one trial that topical vitamin D is as effective as tacrolimus.

Antibacterial and antifungal treatment

Antibacterial and antifungal medications have not been recommended because it is uncertain what the role of bacteria and fungi is in the pathogenesis of flexural psoriasis [van de Kerkhof et al, 2007]. CKS found no evidence to support their use (unless there is clear evidence of bacterial or fungal infection).

Referral

When should I refer a person with facial, flexural or genital psoriasis?

Refer for same-day specialist assessment and treatment anyone with erythrodermic psoriasis and generalised pustular psoriasis. These are medical emergencies and require same-day specialist assessment and treatment.

Refer the person for dermatology specialist advice if:

Diagnostic uncertainty exists.

Psoriasis is extensive, for example more than 10% of the body surface area is affected.

Psoriasis is severe as measured by the Physician's Global Assessment.

Topical treatments have failed.

The person cannot tolerate the treatment options available in primary care.

There is a significant impact on physical, psychological or social well being.

Further information or education is needed (for example about application of topical treatments).

Refer to a rheumatologist if the person requires assessment for the management of associated arthropathy.

Assess the severity and impact of psoriasis before referral.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidance published by the National Institute for Health and Clinical Excellence: Assessment and management of psoriasis [National Clinical Guideline Centre, 2012], the British Association of Dermatologists [BAD, 2004b], and a narrative review [Meier and Sheth, 2009].

Scenario: Guttate psoriasis

Scenario: Guttate psoriasis

216months3060monthsBoth

Management

How should I manage guttate psoriasis?

If lesions are widespread (e.g. greater than 10% body surface area), refer urgently to a dermatologist for consideration of phototherapy.

If lesions are not widespread:

Reassure the person that that guttate psoriasis is self limiting and usually resolves within 3–4 months.

No treatment may be an option, if the person is not concerned about the appearance and it is not having an impact on their physical, psychological, or social well being.

If treatment is required, consider topical treatments as for trunk and limb psoriasis.

Do not use anti-streptococcal antibiotics to treat guttate psoriasis triggered by a recent sore throat, or recurrent episodes of guttate psoriasis.

Basis for recommendation

Basis for recommendation

Referral of widespread psoriasis

This recommendation is based on guidance from the National Institute for Health and Clinical Excellence (NICE): Assessment and management of psoriasis [National Clinical Guideline Centre, 2012]. Referral is recommended so that the person can benefit from early phototherapy.

Option of no treatment

CKS offers the option of no treatment because guttate psoriasis is self limiting and typically resolves within 3–4 months of onset [Griffiths and Barker, 2007].

Emollients

The recommendation to offer an emollient is based on expert opinion from an NHS patient pathway [Centre for Change and Innovation, 2007]. Emollients soften the skin, reduce cracking and dryness, prevent itching, and help to remove scales [Skin Care Campaign and Psoriasis Association, 2005].

Topical treatments

There is no trial-based evidence to guide topical treatment choice for guttate psoriasis. The recommendation to consider topical treatments as for trunk and limb psoriasis is based on feed back from CKS expert reviewers.

Anti-streptococcal treatment

There is no trial-based evidence to support the use of antibiotics for guttate psoriasis, although some experts advocate their use [Meier and Sheth, 2009].

A Cochrane systematic review on anti-streptococcal interventions for guttate and chronic plaque psoriasis (search date: 2000) found no firm evidence to support the use of antibiotics or tonsillectomy in the management or prevention of guttate psoriasis after streptococcal sore throat. No good evidence was found to support the use of antibiotics or tonsillectomy for people with recurrent guttate psoriasis or chronic plaque psoriasis [Owen et al, 2000].

A subsequent small study of 43 men found no statistically significant improvement in streptococcus-associated guttate psoriasis with a course of oral penicillin or erythromycin [Dogan et al, 2008].

Referral

When should I refer a person with guttate psoriasis?

For people with guttate psoriasis:

Refer urgently if lesions are widespread, for consideration of phototherapy.

Also consider referring to a dermatologist if treatment is preferred, and:

Self-management is impractical.

The person cannot tolerate the treatment options available in primary care.

The person does not respond to topical treatment (phototherapy may be an option).

Consider referring to an ear, nose, and throat specialist if guttate psoriasis is exacerbated by recurrent tonsillitis.

For all other types of psoriasis

Refer for same-day specialist assessment and treatment anyone with erythrodermic psoriasis and generalised pustular psoriasis. These are medical emergencies and require same-day specialist assessment and treatment.

Refer the person for dermatology specialist advice if:

Diagnostic uncertainty exists.

Psoriasis is extensive, for example more than 10% of the body surface area is affected.

Psoriasis is severe as measured by the Physician's Global Assessment.

Topical treatments have failed.

The person cannot tolerate the treatment options available in primary care.

There is a significant impact on physical, psychological or social well being.

Further information or education is needed (for example about application of topical treatments).

Refer to a rheumatologist if the person requires assessment for the management of associated arthropathy.

Assess the severity and impact of psoriasis before referral.

Basis for recommendation

Basis for recommendation

Referral to a dermatologist

The recommendation on when to refer to a dermatologist is based on expert opinion from guidelines published by the National Institute for Health and Clinical Excellence: Assessment and management of psoriasis [National Clinical Guideline Centre, 2012], the Scottish Intercollegiate Guidelines Network on Diagnosis and management of psoriasis and psoriatic arthritis in adults [SIGN, 2010], the British Association of Dermatologists [BAD, 2004b], a patient pathway from NHS Scotland [Centre for Change and Innovation, 2007], and expert opinion in a review article [Meier and Sheth, 2009].

Referral to an ear, nose, and throat specialist

A Cochrane systematic review on anti-streptococcal interventions for guttate and chronic plaque psoriasis (search date: 2000) found no firm evidence to support the use of tonsillectomy in the management or prevention of guttate psoriasis after streptococcal sore throat. No good evidence was found to support the use of tonsillectomy for people with recurrent guttate psoriasis or chronic plaque psoriasis [Owen et al, 2000].

However, the CKS recommendation is based on expert opinion from the National Institute for Health and Clinical Excellence [NICE, 2001] and the British Association of Dermatologists [BAD, 2004b], which suggests that tonsillectomy may be considered for people with guttate psoriasis which seems to be exacerbated by recurrent episodes of tonsillitis.

Scenario: Pustular psoriasis

Scenario: Pustular psoriasis

216months3060monthsBoth

Management

How should I manage pustular psoriasis?

Generalized pustular psoriasis  — if the person has generalized pustular psoriasis, refer for same-day specialist assessment and treatment.

Generalized pustular psoriasis is a medical emergency that requires urgent hospital referral.

Pustular psoriasis localized to the hands or feet  — refer to a dermatologist. This is often difficult to control and usually requires systemic treatment.

While awaiting referral, consider seeking specialist advice regarding interim treatment.

Basis for recommendation

Basis for recommendation

Referral for generalized pustular psoriasis

This recommendation is based on expert opinion from a guideline published by the National Institute for Health and Clinical Excellence: Assessment and management of psoriasis [National Clinical Guideline Centre, 2012].

Topical treatments for palmoplantar pustular psoriasis

CKS found no good-quality trial-based evidence or guidelines to guide topical treatment choice for palmoplantar pustular psoriasis. However, a narrative review was identified in which experts state that topical corticosteroids are the most commonly prescribed treatment for palmoplantar pustular psoriasis and work by preventing the development of new pustules, especially when they are applied under occlusion [Adisen and Gϋrer, 2010]. However, no details of corticosteroid choice or duration of treatment were discussed. Given the particularly distressing nature of this type of psoriasis, CKS recommends seeking specialist advice while awaiting referral.

Scenario: Erythrodermic psoriasis

Scenario: Erythrodermic psoriasis

216months3060monthsBoth

Management

How should I manage erythrodermic psoriasis?

If a person develops erythrodermic psoriasis, arrange for same-day specialist assessment and treatment.

Erythroderma is associated with several potentially life-threatening complications.

Basis for recommendation

Basis for recommendation

This recommendation is based on expert opinion from a guideline published by the National Institute for Health and Clinical Excellence: Assessment and management of psoriasis [National Clinical Guideline Centre, 2012].

Scenario: Nail psoriasis

Scenario: Nail psoriasis

216months3060monthsBoth

Management

How should I manage nail psoriasis?

Advise the person to:

Keep their nails short — this avoids exacerbating onycholysis (detachment of the nail from the nail bed) and reduces the accumulation of material under the nail.

Avoid manicure of the cuticle — this may provoke paronychia (infection of the nail bed).

Avoid prosthetic nails.

If nail disease is mild and is not causing discomfort or distress, no treatment is required. Nail varnish can be used to disguise pitting, but the person should avoid abrasive acetone-based nail varnish removers.

If nail disease is severe, having a major functional or cosmetic impact, or the person requests treatment, refer to a dermatology specialist.

Nail disease responds poorly to topical treatment, and evidence to support treatment decisions is extremely limited.

Basis for recommendation

Basis for recommendation

Self-care advice

This recommendation is based on expert opinion in a review article [Edwards and de Berker, 2009].

No treatment

The recommendation that no treatment other than camouflage (if preferred) is required for mild disease is based on a patient pathway document from NHS Scotland [Centre for Change and Innovation, 2007].

Referral to a dermatology specialist

This recommendation is based on guidance published by the National Institute for Health and Clinical Excellence (NICE): Assessment and management of psoriasis [National Clinical Guideline Centre, 2012]. Expert opinion suggests that nail disease responds poorly to topical treatment [Centre for Change and Innovation, 2007; National Clinical Guideline Centre, 2012], and CKS found no good-quality evidence to support one treatment over another.

Referral to a dermatologist allows access to treatments not available in primary care for example systemic non-biological therapy such as methotrexate.

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).

Emollients

Emollients

Emollients are generally used as an adjunct to other topical treatments for psoriasis [Mason et al, 2009]. They form a film on the skin surface, which helps retain moisture in the stratum corneum [Dermatology UK, 2007]; this softens the skin, reduces cracking and dryness, prevents itching, and helps to remove scales [Skin Care Campaign and Psoriasis Association, 2005].

Availability and choice

Which emollients are available and how should I prescribe?

Several emollients are available in the UK in the form of creams, ointments, bath and shower additives, lotions, and sprays. There is no evidence that any one emollient is better than another.

In general, ointments are preferred for use on dry skin, whereas creams and lotions can be used on less dry skin. Ointments may be poorly tolerated compared with creams; this may affect their acceptability, and hence adherence to their use.

On first presentation, it may be useful to prescribe a trial of several emollients (of small pack size), so that the person can make an informed choice as to which suits them best.

The effectiveness and acceptability of a particular emollient may vary with time. If the person feels that a particular product has become unsuitable for them (or if they have developed sensitivity to it), they should be encouraged to return and another product prescribed instead.

Emollients may be prescribed to replace soap for people with dry skin requiring treatment.

Ointments dissolved in hot water are suitable soap substitutes.

Bath additives and shower products are an option for people with extensive areas of dry skin.

Emollients containing active ingredients are not generally recommended, but may be useful in some people (although they increase the risk of skin reactions).

Products containing urea may improve skin hydration and have a limited role in the treatment of skin with heavy scaling.

Basis for recommendation

These recommendations are based on the expert opinion from Best practice in emollient therapy published by the International Skin Care Nursing Group [Dermatology UK, 2007].

Adverse effects

What adverse effects are associated with emollients?

Emollients are usually well tolerated; the most common adverse effect is a rash caused by sensitivity to an ingredient in the emollient. This may be more common in people who are atopic.

If a skin reaction occurs, stop the product and use a different emollient. There is a higher risk of skin reactions with aqueous cream, especially in children.

If the person has had previous skin reactions to emollients, it may be prudent to test a small area of the skin first before widespread application.

The occlusive effect of ointments can cause folliculitis. If this occurs, stop the ointment and consider switching to a cream.

Paraffin-containing products (for example emulsifying ointment and liquid and white soft paraffin ointment) are highly flammable and should not be used near naked flames. Bath emollients can pose a slip hazard.

Basis for recommendation

These recommendations are based on the expert opinion from Best practice in emollient therapy published by the International Skin Care Nursing Group [Dermatology UK, 2007], and are in line with the clinical guideline Atopic eczema in children, published by the National Institute for Health and Clinical Excellence [NICE, 2007].

The fire risk from paraffin-containing emollients has prompted the National Patient Safety Agency to issue a warning about their use [National Patient Safety Agency, 2007].

A recent Medicines and Healthcare Product Regulatory Agency (MHRA) update warns that aqueous cream may be associated with skin reactions, especially in children with atopic eczema. These reactions may be due to the presence of sodium lauryl sulfate or other additives [MHRA, 2013].

Applying emollients

How should emollients be applied?

Emollients should be:

Used as a soap substitute when bathing or washing, and

Applied to the skin before anti-psoriasis treatment.

When applying an emollient advise the person:

To wait 30 minutes before applying any other treatments for psoriasis.

To smooth the emollient gently into the skin, following the line of the hair.

That they should not rub continuously until all the product is absorbed.

If emollients are used as soap substitutes, they should be applied to the skin using hands or a wash cloth, and then rinsed off.

Emollients can be applied as often as required.

Basis for recommendation

This information is based on published expert opinion from the British Association of Dermatologists [BAD, 2009] and the expert opinion in Best practice in emollient therapy, published by the International Skin Care Nursing Group [Dermatology UK, 2007].

Quantity

What quantity of emollient should I prescribe?

Large quantities may be required frequently. The amount of emollient prescribed will vary depending on the size of the person and the extent and dryness of the skin.

Up to 500 g to 600 g per week may be required for an adult. See Table 1 for more information.

The amount of emollient used should far exceed other topical treatments (such as corticosteroids) by a factor of at least 10.

Pump-dispensers should be prescribed when large quantities of cream or lotion are required, where possible.

Table 1 . Quantities of emollient required by an adult for twice-daily application for a month.
Area affected Creams and ointments (grams) Lotions (mL)
Face 60–120 400
Both hands 100–200 800
Scalp 200–400 800
Both arms or both legs 400–800 800
Trunk 1600 2000
Groin and genitalia 60–100 400
Data from: [Dermatology UK, 2007]
Basis for recommendation

These recommendations are based on published expert opinion from the expert opinion Best practice in emollient therapy published by the International Skin Care Nursing Group [Dermatology UK, 2007].

Pregnancy and breastfeeding

Can topical emollients be used in pregnancy and breastfeeding?

Emollients are suitable for use during pregnancy and breastfeeding [Weatherhead et al, 2007].

Topical corticosteroids

Topical corticosteroids

Topical corticosteroids cause scales to flatten and fade rapidly (within 3–7 days) [MeReC, 1999; Skin Care Campaign and Psoriasis Association, 2005]. They are anti-inflammatory, immunosuppressive, vasoconstrictive, and antimitotic [Menter et al, 2009].

Availablity potency and choice

What types of topical corticosteroids are available?

Topical corticosteroids are available in four potencies: mildly potent, moderately potent, potent, and very potent (see Table 1 for more details).

A potent topical corticosteroid is recommended as initial treatment for people who have chronic plaque psoriasis of the trunk and limbs and for people who have scalp psoriasis.

Treatment should only be continued for a maximum of 8 weeks at any one site. The patient should be advised to have a 4 week treatment break before applying more corticosteroids.

A mild or moderately potent topical corticosteroid is recommended for application to the face, flexures, or genitals for a maximum of 2 weeks.

Flexural areas are usually self occluded and skin on the face and neck is thin and therefore only requires lower-potency topical steroid treatment.

Very potent topical corticosteroids are not recommended for use in primary care. The exception to this is scalp psoriasis, where they may be considered after a number of treatment options have failed. They should only be used for a maximum of 2 weeks.

There are concerns about the rebound effect, irreversible skin atrophy, the risk of repeat prescriptions being issued without monitoring, and there is a lack of long term safety data. For more information see adverse effects.

There are a number of different formulations available to prescribe:

Ointments are generally preferred because psoriasis is a dry scaly condition; but they may not always be acceptable for cosmetic reasons.

Creams may be preferred on the hands, (for example if the person handles paper), on the face and neck (because of the greasy appearance of ointments), or if psoriasis is widespread.

Solutions, gels or lotions, are preferred for scalp psoriasis. However a more occlusive preparation such as a cream or an ointment may be considered in people with moderately severe psoriasis.

Table 1 . Topical corticosteroids listed in the British National Formulary.
Potency class Non-proprietary names and strengths Proprietary names Formulations
Mild Hydrocortisone 0.1%, 0.5%, 1.0%, 2.5% Generic hydrocortisone, Dioderm®, Efcortelan®, Mildison® Cream and ointment
Moderate Alclometasone dipropionate 0.05% Modrasone® Cream and ointment
Betamethasone valerate 0.025% Betnovate-RD® Cream and ointment
Clobetasone butyrate 0.05% Eumovate® Cream and ointment
Fluocinolone acetonide 0.001% Synalar 1 in 4 dilution® Cream and ointment
Fluocortolone 0.25% Ultralanum Plain® Cream and ointment
Fludroxycortide 0.0125% Haelan® Cream and ointment
Potent Betamethasone dipropionate 0.05% Diprosone® Cream, ointment, and lotion
Betamethasone dipropionate 0.05% plus calcipitriol 50 micrograms/gram Dovobet® Ointment
Betamethasone dipropionate 0.05% plus salicylic acid 3% Diprosalic® Ointment and scalp application
Betamethasone valerate 0.1% Generic betamethasone valerate, Betnovate® Cream, ointment, lotion, and scalp application; foam (0.12%)
Diflucortolone valerate 0.1% Nerisone® Cream, ointment, and oily cream
Fluocinolone acetonide 0.025% Synalar® Cream, ointment, and gel
Fluocinonide 0.05% Metosyn® Cream and ointment
Fluticasone propionate 0.05% Cutivate® Cream and ointment
Hydrocortisone butyrate 0.1% Locoid® Cream, ointment, lipocream, and scalp application
Mometasone furoate 0.1% Elocon® Cream, ointment, and scalp application
Very potent Clobetasol propionate 0.1% Dermovate®, Clarelux® Cream, ointment, and scalp application
Diflucortolone valerate Nerisone Forte® Ointment and oily cream
Data from: [BNF 64, 2012]
Basis for recommendation

These recommendations are based on guidance published by the National Institute for Health and Clinical Excellence (NICE): Assessment and management of psoriasis [National Clinical Guideline Centre, 2012], and from published expert opinion [Coulson, 1996; Menter et al, 2009; Ortonne et al, 2009]

Adverse effects

What are the adverse effects of topical corticosteroids?

Topical corticosteroids are associated with local and systemic adverse effects, as well as rebound psoriasis on discontinuation. The likelihood of adverse effects is directly related to the potency of the topical corticosteroid, the amount used, and the duration of treatment (longer than 4 weeks) [Coulson, 1996].

Local adverse effects are more common than systemic adverse effects. They are more commonly seen on the face, in skin folds, and in areas that are treated over the long-term. Adverse effects include:

Skin atrophy.

Telangiectasia.

Stretch marks.

Acne.

Folliculitis.

Purpura.

Exacerbation of pre-existing or coexistent dermatoses, such as rosacea, perioral dermatitis, and tinea infections.

Contact dermatitis.

Systemic adverse effects are rare but include adrenal suppression that can result in symptoms of Cushing's syndrome and (in children) growth retardation. They are more likely to occur when potent or very potent topical corticosteroids are used over a large surface area for a prolonged period (or when they are used under occlusion).

Rebound psoriasis (psoriasis that recurs worse than the pretreatment baseline when treatment is discontinued) is known to occur when corticosteroids are stopped abruptly. The severity and frequency of rebound psoriasis is not well documented.

Severe pustular psoriasis may be precipitated by sudden withdrawal.

Basis for recommendation

This information is based on published expert opinion [Menter and Griffiths, 2007; van de Kerkhof et al, 2008] and the manufacturers' Summary of Product Characteristics [ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2012a].

It is thought that subclinical cutaneous atrophy occurs in a substantial number of people who use potent or very potent topical corticosteroids for 4 weeks or longer [Menter and Griffiths, 2007]. However the National Institute for Health and Clinical Excellence (NICE) when reviewing the efficacy and safety of topical corticosteroids found that the levels of skin atrophy are not clinically harmful if potent corticosteroids are used for 8 weeks and very potent corticosteroids for more than 4 weeks [National Clinical Guideline Centre, 2012].

Minimizing adverse effects

How can I minimize the adverse effects of topical corticosteroids?

The adverse effects of topical corticosteroids may be minimized by:

Using the corticosteroid on a localized area only, for example on elbows and knees.

Limiting the application of potent (for example betamethasone valerate 0.1%) steroids for up to 8 weeks continuous use at any one site.

Having a treatment break of 4 weeks between courses of topical corticosteroids.

Basis for recommendation

Options for limiting the use of topical corticosteroids are based on published expert opinion [Coulson, 1996; Menter and Griffiths, 2007; van de Kerkhof et al, 2008; Menter et al, 2009].

CKS have not recommended 'stepping down' to a lower potency of topical corticosteroid in order to minimize adverse effects. Although this approach has been traditionally used in clinical practice, the National Institute for Health and Clinical Evidence (NICE) found no trials that assessed the stepped down approach and no good evidence that this would give better control of psoriasis or minimize adverse effects [National Clinical Guideline Centre, 2012]. In addition, stepping down may increase the person's exposure to a corticosteroid by prolonging its use at ineffective frequencies.

Applying corticosteroids

How should topical corticosteroids be applied?

Topical corticosteroids should ideally be applied sparingly to all the affected areas; no more than twice daily, and usually once daily. Improvement is usually seen rapidly (within 3–7 days).

Potent corticosteroids should not be applied for longer than 8 weeks at any one site and very potent corticosteroids should not be applied for longer than 4 weeks.

A treatment break of 4 weeks is recommended before corticosteroids can be restarted.

The approximate amount that should be applied for each area of the body is usually described as the 'number of finger tip units'. Table 1. shows the number of finger tip units needed to cover the different areas of the body. One finger-tip unit is equivalent to about 500 mg and is sufficient to treat a skin area about twice that of the flat of the hand with the fingers together.

Most products will be supplied with an information leaflet specifying the number of finger-tip units needed to treat specific body areas.

If an emollient is being used, the person should apply this first and then wait 30 minutes before applying the topical corticosteroid (only after the emollient has been fully absorbed) [BAD, 2004b].

Table 1 . Amount of topical preparation needed to cover different areas of the body in adults.
Body area Number of finger-tip units
Scalp 3
Face and neck 2.5
One hand (front and back including fingers) 1
One arm (including entire hand) 4
Elbows (large plaque) 1
Both soles (of feet) 1.5
One foot (dorsum and sole) including toes 1.5
One leg (including entire foot) 8
Buttocks 4
Knees (large plaque) 1
Trunk (front) 8
Trunk (back) 8
Genitalia 0.5
Data from: [Menter et al, 2009]
Basis for recommendation

These recommendations are based on guidance published by the National Institute for Health and Clinical Excellence [National Clinical Guideline Centre, 2012] and published expert opinion [MeReC, 1999; Dermatology UK, 2007; Menter et al, 2009].

Quantity to prescribe

How much topical corticosteroid should I prescribe?

Suitable quantities of topical corticosteroid creams and ointment to prescribe (for application twice a day for 2 weeks) are listed in Table 1.

These quantities should be sufficient for people who are applying topical corticosteroids once a day for 4 weeks.

Table 1 . Suitable quantities of corticosteroid to prescribe (for an adult, applying twice a day for 2 weeks).
Area of the body Suitable quantity to prescribe
Face and neck 15–30 g
Both hands 15–30 g
Scalp 15–30 g
Both arms 30–60 g
Both legs 100 g
Trunk 100 g
Groin and genitalia 15–30 g
Data from: [BNF 64, 2012]

Pregnancy and breastfeeding

Can topical corticosteroids be used in pregnancy and breastfeeding?

Pregnancy

Mildly potent, moderately potent, and potent topical corticosteroids, if used correctly, are thought to be suitable for use during pregnancy.

Very potent corticosteroids may be associated with low birthweight. If they are being considered for use during pregnancy, seek specialist advice.

Breastfeeding

Mildly potent, moderately potent, and potent topical corticosteroids are thought to be suitable for use during breastfeeding.

Basis for recommendation

Pregnancy

These recommendations are based on published expert opinion [Schaefer et al, 2007; Weatherhead et al, 2007] and a Cochrane systematic review [Chi et al, 2009].

The Cochrane systematic review identified two cohort studies and five case-control studies (with 659,675 participants) of women who were exposed to topical corticosteroids during pregnancy. These studies had several methodological weaknesses, which made the results difficult to interpret. The authors of the review considered the studies to be of low or very low quality. From these data, no association was found between use of topical corticosteroids during pregnancy and congenital abnormality, pre-term delivery, or stillbirth. Some evidence suggested that use of very potent topical corticosteroids might be associated with low birthweight.

Breastfeeding

Topical corticosteroids are considered suitable for use during breastfeeding [National Institutes of Health, 2012]. It is thought that the short-term application of topical corticosteroids pose a risk to the breastfed infant by passing into breast milk.

Vitamin D preparations

Vitamin D preparations

Vitamin D preparations bind to vitamin D receptors, which inhibits keratinocyte proliferation and enhances keratinocyte differentiation [Menter et al, 2009].

Availability

What types of vitamin D preparations are available?

Topical vitamin D preparations are available as ointments, gels, scalp solutions, and lotions.

Three vitamin D preparations are available for prescription in the UK:

Calcipotriol (Dovonex®) — available as an ointment. Calcipotriol is also available combined with betamethasone 0.5% (Dovobet® ointment and gel).

Calcipotriol (non-branded) — available as an ointment and scalp solution.

Calcitriol (Silkis®) — available as an ointment.

Tacalcitol (Curatoderm®) — available as an ointment or lotion.

[BNF 64, 2012]

Choice

Which vitamin D preparation should I prescribe?

Calcipotriol, calcitriol, or tacalcitol are all suitable as a first-line topical vitamin D preparation. Calcitriol and tacalcitol may be less irritating than calcipotriol.

Basis for recommendation

The National Institute for Health and Clinical Excellence (NICE) have reviewed the evidence for the efficacy of vitamin D and its analogues. NICE assumed a class effect for these medicines and have not recommended one preparation over another [National Clinical Guideline Centre, 2012].

Published expert opinion suggests that calcitriol and tacalcitol are less irritant than calcipotriol [BAD, 2004b].

Contraindications

Who should avoid vitamin D preparations?

Topical vitamin D preparations should be avoided in people with:

Calcium metabolism disorders because these agents can cause hypercalcemia [ABPI Medicines Compendium, 2011a]. For more information, see Adverse effects.

Severe liver and kidney disease.

Adverse effects

What adverse effects are associated with vitamin D preparations?

Local adverse effects — up to 35% of people may experience irritation of the skin; this includes burning, pruritus, oedema, peeling, dryness, and erythema (especially in flexural areas or on the face). The skin around the lesion may also be affected. If the person is able to continue with treatment, local adverse effects often reduce with time.

If there is significant irritation, stop the treatment.

Advise the person to wash their hands thoroughly after application, to avoid transfer of the product to other parts of the body.

Systemic adverse effects are rare and include hypercalcemia and parathyroid hormone suppression. These have been reported only in people using more than 100 g per week (greater than the recommended dose), in people who have renal disease or impaired calcium metabolism, and in people with generalized pustular or erythrodermic exfoliative psoriasis.

Photosensitivity has been reported with the use of topical vitamin D preparations (possibly caused by thinning of the epidermis). The manufacturers recommend that people who are using vitamin D preparations should avoid excessive sun exposure. However published expert opinion suggests that there are no contraindications to combining vitamin D preparations with ultraviolet B phototherapy. Vitamin D preparations are inactivated by ultraviolet A, and it is important to apply them after and not before ultraviolet A exposure.

Basis for recommendation

This information is based on published expert opinion [Menter et al, 2009] and the manufacturers' Summary of Product Characteristics [ABPI Medicines Compendium, 2011a].

Applying vitamin D preparations

How should vitamin D preparations be applied?

Vitamin D preparations are suitable for long-term use, but it may be 6–8 weeks before maximum benefit is seen.

Calcipotriol

Calcipotriol cream, ointment and gel — should be applied once or twice a day; to a maximum of 100 grams each week.

Calcipotriol scalp solution — should be applied once a day; to a maximum of 60 mL each week.

If the scalp solution and ointments are used together, the maximum dose is calcipotriol 5 mg each week, for example:

Scalp solution 60 mL plus cream or ointment 30 grams.

Cream or ointment 60 grams plus scalp solution 30 mL.

Calcipotriol and betamethasone

Calcipotriol combined with betamethasone ointment — should be applied once daily for 4 weeks.

Calcipotriol combined with betamethasone scalp gel — 1 g to 4 g should be applied once daily for 4 weeks (4 g is about one teaspoonful).

The total amount of a calcipotriol-containing product(s) applied should not exceed a maximum of 30% of body surface area, or 15 grams daily, or 100 grams each week.

Calcitriol

Calcitriol ointment — should be applied twice daily; to a maximum of 30 grams each day.

Tacalcitol

Tacalcitol ointment — should be applied once a day; to a maximum of 10 grams each day.

Tacalcitol lotion — should be applied once a day; to a maximum of 10 mL each day.

The total amount of tacalcitol should not exceed 280 micrograms/week (for example 30 ml of lotion plus 40 g of ointment).

If an emollient is being used, the person should apply this first and then wait 30 minutes before applying the vitamin D preparation (only after the emollient has been fully absorbed).

Basis for recommendation

The information on time taken to see clinical improvement is based on published expert opinion [Menter and Griffiths, 2007].

The information on how to apply vitamin D preparations is based on published information from the manufacturers [ABPI Medicines Compendium, 2010b; ABPI Medicines Compendium, 2010c; ABPI Medicines Compendium, 2011a].

Pregnancy and breastfeeding

Can topical vitamin D preparations be used in pregnancy and breastfeeding?

It is unknown whether topical vitamin D preparations, such as calcipotriol, are suitable for use during pregnancy and breastfeeding.

Basis for recommendation

CKS recommends seeking specialist advice if topical vitamin D preparations are being considered for use during pregnancy. There are no published studies or case reports to guide the decision on whether to use vitamin D preparations during pregnancy or breastfeeding. The manufacturer suggests that it should be used only if the benefits outweigh the risks [ABPI Medicines Compendium, 2011a].

Salicylic acid

Salicylic acid

Salicylic acid is a topical keratolytic agent that has been used for many years in the treatment of psoriasis. It reduces scaling and softens psoriatic plaques [Menter et al, 2009]. It is also thought to reduce keratinocyte-to-keratinocyte binding and reduce the pH of the stratum corneum.

Availability and choice

What types of salicylic acid preparations are available and which one should I prescribe?

Salicylic acid preparations are available as branded products combined with either coal tar or dithranol. A generic product combined with zinc oxide is also available (Lassar's paste).

Salicylic acid preparations are useful for extremely thick or scaly plaques.

The choice of preparation depends on the location of the psoriasis and the person's preference.

Products suitable for the scalp include:

Sebco® scalp ointment (coal tar 12%, salicylic acid 2%, sulphur 4%, coconut oil).

Psorin® scalp gel (dithranol 0.25%, salicylic acid 1.6%).

Capasal® shampoo (coal tar 1%, coconut oil 1%, salicylic acid 1%).

Meted® shampoo (salicylic acid 3%, sulphur 5%).

Products suitable for plaques on the trunk and limbs include:

Zinc and salicylic acid paste BP (Lassar's paste; zinc oxide 24%, salicylic acid 2%).

Psorin® ointment (dithranol 0.11%, coal tar 1%, salicylic acid 1.6%).

Basis for recommendation

The recommendation to consider using salicylic acid on thick scaly plaques is based on published expert opinion [Fluhr et al, 2008].

The recommendation to consider using a salicylic acid-containing formulation for people with scalp psoriasis is based on advice issued by the National Institute for Health and Clinical Evidence [National Clinical Guideline Centre, 2012].

Contraindications

Who should avoid using salicylic acid?

Do not prescribe topical salicylic acid preparations for people who are allergic to aspirin.

The person should not use it on inflamed or broken skin.

[MHRA, 2012]

Adverse effects

What adverse effects are associate with salicylic acid?

Topical salicylic acid may cause irritation and excessive drying of the skin. Advise the person to avoid contact with their mouth, mucous membranes, and eyes; and to wash their hands immediately after use.

Salicylate toxicity may occur if large areas of the skin are treated.

Salicylic acid preparations should not be applied to more than 20% of the body surface area.

The symptoms of salicylic acid toxicity include frontal headache, tinnitus, nausea, vomiting, and gastric symptoms.

Basis for recommendation

This information is from the British National Formulary [BNF 64, 2012] and published expert opinion [Fluhr et al, 2008].

Application

How should salicylic acid preparations be applied?

Salicylic acid preparations should not be applied to more than 20% of the body, because of the risk of systemic toxicity [Fluhr et al, 2008].

Sebco® scalp ointment should be applied in the following way:

The hair is parted in sections and the treatment rubbed along the exposed areas, working around the hair. Help may be required to apply it correctly to the top of the head.

It is left on for 1 hour, and then washed off with a detergent shampoo or a coal tar shampoo (for example Polytar®, Alphosyl 2:1®, or Capasal®).

If psoriasis is severe, advise the person it should be applied once a day for the first 3–7 days, and once a week thereafter.

If scale is thick and adherent the person should apply it, and leave it on overnight under occlusion (for example using a shower cap); it can then be washed off in the morning with a detergent shampoo or a coal tar shampoo. This method of application is unlicensed.

Other salicylic acid products should be used in the following way:

Psorin® scalp gel — applied every other day for 10–20 minutes (the maximum dose is daily application for 1 hour), then washed off.

Capasal® shampoo — used as a shampoo, daily if necessary.

Meted® shampoo — used as a shampoo, at least twice a week.

Zinc and salicylic acid paste BP (Lassar's paste) — applied twice a day.

Psorin® ointment — applied twice a day.

Basis for recommendation

The recommendation to use and Sebco® once a day for the first 3–7 days and once a week thereafter is based on published information from the manufacturer [MHRA, 2012]. The recommendation to use Sebco® under occlusion (unlicensed) is based on published expert opinion from the British Association of Dermatologists [BAD, 2004b].

Pregnancy and breastfeeding

Can topical salicylic acid preparations be used in pregnancy and breastfeeding?

Topical salicylic acid may be used during pregnancy and breastfeeding for a limited period on a limited area [Schaefer et al, 2007].

Coal tar products

Coal tar products

Coal tar is a distillation product of coal; it contains a mixture of thousands of compounds which may differ in composition from one preparation to another [Menter et al, 2009]. Coal tar has anti-inflammatory and anti-scaling properties.

Availablity and choice

What types of coal tar products are available and which one should I prescribe?

Several coal tar preparations are available in the UK; these include ointments, shampoos, and bath additives. Various preparations are combined with other topical treatments for psoriasis (for example salicylic acid).

The choice of coal tar preparation should take into consideration the availability, the location of the skin being treated, previous good response to particular treatments, and the person's preference.

Newer, branded products are preferred because older, non-branded products contain crude coal tar (coal tar BP), which is smellier than newer, branded products and usually messier to use. Newer, branded products contain cleaner extracts of coal tar and are usually easier to obtain.

Preparations containing salicylic acid are useful if the person has thick scales (for example scalp psoriasis).

Preparations suitable for treating scalp psoriasis include:

Alphosyl 2 in 1® shampoo (alcoholic coal tar extract 5%).

Capasal® shampoo (coal tar 1%, coconut oil 1%, salicylic acid 0.5%).

Polytar liquid® shampoo (coal tar 1%).

Psoriderm® — scalp lotion is also a shampoo (coal tar 2.5%, lecithin 0.3%).

T/Gel® shampoo (coal tar extract 2%).

Exorex® lotion (coal tar 1%).

Sebco® scalp ointment (coal tar solution 12%, salicylic acid 2%, sulphur 2%).

Preparations suitable for treating psoriasis on the body include:

Carbo-Dome® cream (coal tar solution 10%).

Exorex® lotion (coal tar 1%).

Psoriderm® cream (coal tar 6%).

Bath additives include:

Polytar Emollient® bath additive (coal tar solution 2.5%, peanut oil, extract of coal tar 7.5%, tar 7.5%, cade oil 7.5%, liquid paraffin 35%).

Psoriderm® bath emulsion (coal tar 40%).

Basis for recommendation

Coal tar preparations have been used to treat psoriasis for over 100 years. However there is no good trial evidence to indicate that any one is more effective than another.

The choice of preparation therefore depends on licensed indications and the person's preference. Non-branded coal tar products contain crude coal tar (coal tar BP) and are smellier and messier to use than branded products.

[BAD, 2004b; BNF 64, 2012; National Clinical Guideline Centre, 2012]

Adverse effects

What adverse effects are associated with coal tar products?

Coal tar preparations can cause [ABPI Medicines Compendium, 2011b; ABPI Medicines Compendium, 2011c]:

Photosensitivity — the person should be warned to minimize exposure to sunlight and avoid ultraviolet lamps after treatment (unless this is specifically intended).

Skin irritation.

Acneiform eruptions.

Folliculitis.

Staining of clothes.

Published expert opinion states that, at present, there is no firm epidemiological evidence that coal tar products cause cancer [BAD, 2004a]. Coal tar contains several carcinogenic compounds, and animal studies and observational studies in humans (occupational exposure only) have shown an increased risk of cancer after exposure to coal tar. However, not all of these studies were controlled for confounding factors, such as smoking and alcohol intake. A large cohort study (with 13,200 participants) of people with eczema and psoriasis who were treated with coal tar preparations found no evidence that coal tar was associated with an increased risk of cancer [Roelofzen et al, 2010].

Contraindications

Who should not receive coal tar preparations?

Coal tar preparations cause skin irritation and should not be used in people with [ABPI Medicines Compendium, 2011b; ABPI Medicines Compendium, 2011c]:

Broken or highly inflamed skin.

Sore, acute, or pustular psoriasis.

Skin infection.

Avoid using coal tar around the eyes.

Applying coal tar preparations

How are coal tar preparations applied?

Coal tar preparations are suitable for long-term use [Psoriasis Association, 2009].

Creams ointments and pastes — these are generally applied by wiping onto the entire plaque once or twice a day (away from the flexural areas) [BNF 64, 2012].

Scalp preparations — these are applied once a week, left on for 1 hour and then shampooed off [MHRA, 2012]. For severe psoriasis, this can be repeated daily for the first 3–7 days; thereafter, they are usually applied once a week (and shampooed off after 1 hour).

Bath additives — directions for use vary but, in general, a measured amount is added to the bath and the person soaks in the bath for 5–20 minutes.

Shampoos — directions for use vary. Some preparations may be used daily, and others are restricted to use once or twice a week.

Pregnancy and breastfeeding

Can coal tar products be used during pregnancy and breastfeeding?

Avoid the use of coal tar preparations in the first trimester of pregnancy. They are thought to be suitable for use during the second and third trimesters if used for short periods or on localised areas such as the scalp.

Coal tar preparations are best avoided during breastfeeding. If coal tar preparations cannot be avoided then advise the woman to:

Treat the smallest area of skin possible.

Ensure the baby does not come into direct contact with the areas of skin that have been treated.

Basis for recommendation

Pregnancy

Coal tar contains polycyclic aromatic hydrocarbons (pyrene). The amount of absorption and the risk to the unborn baby from pyrenes is not known, however coal tar products are thought to be safe if used for short periods or on localised areas such as the scalp [DermNet NZ, 2012].

The recommendation to avoid coal tar in the first trimester is based on expert opinion [Weatherhead et al, 2007] and information from the manufacturers [ABPI Medicines Compendium, 2010a]

Although there are very few published data on the use of coal tar in pregnancy, a high risk of congenital anomalies is thought to be unlikely [Micromedex, 2011], as this product has been in widespread use for many years without apparent adverse consequence[ABPI Medicines Compendium, 2010a].

Breastfeeding

It is thought that coal tar when applied topically to maternal skin results in pyrene absorption by the infant. This probably occurs by skin-to-skin or skin-to-mouth contact with the mother. Alternative treatments are preferred during breast feeding. lf a coal tar product is used, it would be prudent to treat the smallest area of skin possible. It is particularly important to ensure that the infant's skin does not come into direct contact with the areas of skin that have been treated [LactMed, 2012].

Dithranol (short contact)

Dithranol (short contact)

Dithranol is thought to prevent T-lymphocyte activation and normalize keratinocyte differentiation [Menter et al, 2009].

Availablity and choice

What types of dithranol preparations are available and which one should I prescribe?

Dithranol treatments are available as branded and non-branded products (dithranol ointment [BP] and paste [BP]). Branded preparations are most suitable and include:

Dithrocream® (dithranol 0.1%, 0.25%, 0.5%, 1%, and 2%).

Micanol® cream (dithranol 1% and 3%).

Psorin® ointment (dithranol 0.11%, coal tar 1%, salicylic acid 1.6%).

Psorin ® scalp gel (dithranol 0.25%, salicylic acid 1.6%).

Creams are particularly suitable because they wash off more easily than ointments.

Basis for recommendation

Branded preparations are recommended because they are easier to obtain, and cream preparations are recommended because they are easier to wash off [BAD, 2004b].

Contraindications

Who should avoid dithranol?

Dithranol should not be used in people with acute or pustular psoriasis or inflamed psoriasis.

Avoid using dithranol on the face.

[ABPI Medicines Compendium, 2012b]

Adverse effects

What adverse effects are associated with dithranol?

Topical dithranol may cause:

Skin irritation.

A burning sensation (if left too long on the skin).

Staining of the skin or hair (temporary).

Staining of fabric and bathroom fittings (permanent).

[ABPI Medicines Compendium, 2012b]

Application

How should dithranol be applied?

Dithranol can cause skin irritation and a burning sensation. Treatment should be started with the lowest strength (0.1%) cream and gradually increased over approximately 4 weeks to the highest tolerated strength that produces the optimum therapeutic effect. Clinical improvement may take up to 6 weeks.

Always start with the lowest strength dithranol cream (0.1%); it should be applied once a day to psoriasis areas only.

It should not be applied to the normal skin between plaques.

The cream is left on for 30–60 minutes, and then washed off.

This is continued for at least 1 week, and if necessary increased at weekly intervals to the 0.25% strength, followed by the 0.5%, the 1.0%, and finally the 2.0% strength.

The optimum strength varies from person to person and depends on the thickness of the plaques and the person's tolerance to adverse effects.

If the areas being treated become inflamed, stop the treatment. When the inflammation settles, restart the treatment at a lower concentration.

If an emollient is being used, the person should apply this first and then wait 30 minutes before applying the dithranol (only after the emollient has been fully absorbed).

Once lesions are palpably flat, dithranol should be discontinued.

[ABPI Medicines Compendium, 2012b]

Pregnancy and breastfeeding

Can topical dithranol be used in pregnancy and breastfeeding

It is not known whether dithranol is suitable for use during pregnancy and breastfeeding.

Basis for recommendation

There are no published studies or case reports to guide the decision on whether to use dithranol during pregnancy or breastfeeding. The manufacturers state that although no experimental evidence supports the safety of the drug in pregnancy or during lactation, no adverse effects have been reported [ABPI Medicines Compendium, 2012b].

Evidence

Evidence

Supporting evidence

Chronic plaque psoriasis (trunk and limb)

Evidence on topical treatments for chronic plaque psoriasis (trunk and limb)

CKS has provided a summary of the results of a clinical and cost effectiveness analysis on the topical treatments for chronic plaque psoriasis of the trunk and limbs, performed by the National Institute for Health and Clinical Excellence [National Clinical Guideline Centre, 2012]. A detailed review of the evidence can be viewed in the NICE guidance Assessment and management of psoriasis (pdf)

Clinical effectiveness of active treatments vs placebo

NICE found evidence from a network meta-analysis that, compared with twice daily treatment with either vehicle or placebo, the following interventions were significantly more effective at inducing clearance or near clearance:

Once and twice daily very potent corticosteroid.

Once and twice daily potent corticosteroid.

Once and twice daily vitamin D preparation.

Once daily dithranol.

Twice daily coal tar.

Vitamin D preparation and potent corticosteroid (combined in one product).

Vitamin D preparation and potent corticosteroid (applied separately – one in the morning, one in the evening).

Clinical effectiveness of active treatments vs each other

NICE found that when treatments were compared with each other, very few trials showed a statistically significant difference between treatments, except:

A once-daily combined product containing calcipotriol monohydrate and betamethasone dipropionate was found to be more effective than once-daily vitamin D preparations, once-daily potent corticosteroid and once-daily retinoid.

Twice-daily very potent corticosteroid was found to be more effective than once-daily retinoid and once-daily dithranol.

A twice-daily vitamin D preparation, twice-daily potent corticosteroids, twice-daily very potent corticosteroids, combined and concurrent vitamin D preparation were all found to be more effective than once-daily coal tar.

Cost effectiveness analysis

NICE found that:

A once-daily topical potent corticosteroid plus a once-daily vitamin D preparation (applied separately in the morning and evening) was the most cost effective and clinically sensible initial treatment for psoriasis (once very potent steroids had been excluded owing to safety concerns).

A twice-daily vitamin D preparation was found to be cost effective when used as a second or third treatment option.

Twice-daily coal tar was potentially cost effective if other treatments failed to bring clearance or near clearance.

A combined product containing calcipotriol monohydrate and betamethasone dipropionate was found to be the most effective treatment. However this was not cost effective and the NICE guideline development group felt that the modest additional benefits it produced were insufficient to justify the extra cost of this product.

Emollients

NICE did not review the evidence for emollients. The NICE Guideline Development Group felt that the use of emollients in psoriasis was widespread and of accepted value, and review of the evidence was unlikely to yield important data that would justify recommending a change in practice. NICE therefore limited their evidence review to active topical therapies in psoriasis.

Evidence is lacking to support the use of emollients for people with psoriasis. CKS identified no good-quality evidence on the use of emollients for psoriasis. Emollients are recommended on the basis of expert opinion [BAD, 2004b; Fluhr et al, 2008; Menter et al, 2009; SIGN, 2010; National Clinical Guideline Centre, 2012].

Salicylic acid

NICE did not review the evidence for salicylic acid for use in limb and trunk psoriasis. Evidence is lacking to support the use of salicylic acid preparations for people with psoriasis, but these are frequently used in addition to other topical treatments to reduce thickness and scaling of psoriatic plaques. Data to guide the choice of salicylic acid preparation are lacking.

A Cochrane systematic review (search date: April 2008) assessed the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis compared with placebo, and the effectiveness of vitamin D compared with other topical treatments (vitamin D preparations were included as a comparator because they are used as first-line treatments in many countries) [Mason et al, 2009]. This review identified only one very small trial (in 20 people) that assessed the effectiveness of salicylic acid compared with placebo. Salicylic acid was better than placebo for treating psoriasis: standardized mean difference –0.96 (95% CI –1.89 to –0.02). However, this result was of borderline statistical significance.

CKS identified no randomized controlled trials assessing the efficacy of salicylic acid after publication of the above Cochrane systematic review.

Scalp psoriasis

Evidence on scalp psoriasis

CKS has provided a summary of the results of a clinical and cost effective analysis on topical treatments for scalp performed by the National Institute for Health and Clinical Excellence is provided [National Clinical Guideline Centre, 2012]. A detailed review of the evidence can be viewed in the NICE guidance Assessment and management of psoriasis (pdf).

Clinical effectiveness of active treatments vs placebo

NICE found evidence from a network meta-analysis of randomized controlled trials, that compared with vehicle/placebo the following treatments were statistically significantly more effective at inducing clearance or near clearance as measured.

Once-and-twice daily very potent corticosteroid.

Once-and-twice daily potent corticosteroid.

Once-and-twice daily vitamin D preparations.

Once-daily combined product containing calcipotriol monohydrate and betamethasone dipropionate.

NICE found no statistically significant difference between once-daily coal tar poly therapy and twice-daily placebo at inducing clearance or near clearance.

Clinical effectiveness of active treatments vs each other

NICE found that when treatments where compared with each other very few trials showed a statistically significant difference between treatments, with the exception of :

Once-daily potent corticosteroid, this was more effective than once-daily vitamin D preparations.

Once-and-twice daily very potent corticosteroids this was more effective than once-and-twice daily vitamin D preparations and once-daily coal tar polytherapy.

Once-daily combined product containing calcipotriol monohydrate and betamethasone dipropionate. This was more effective than once-daily vitamin D preparations and once-daily coal tar polytherapy.

Cost effectiveness analysis

NICE found evidence from a cost effectiveness analysis that:

Initial treatment with potent or very potent corticosteroids is likely to be most cost effective. However the NICE guideline development group (GDG) was concerned that very potent corticosteroids were an aggressive initial strategy because they have a higher risk of causing corticosteroid adverse effects. For this reason the GDG recommended potent corticosteroids first.

Topical vitamin D preparations are likely to be cost effective topical therapy after potent topical corticosteroids.

Very-potent corticosteroids are likely to be most cost effective after unsuccessful trials of potent corticosteroids and vitamin D or vitamin D analogues. The GDG chose not to recommend once or twice daily very potent steroids as first or second-line treatments. Very-potent topical corticosteroids were considered appropriate as a third-line treatment option. This is because the number of people exposed to the risks of corticosteroid adverse effects would be fewer but the need for efficacy more urgent.

A combined product containing calcipotriol monohydrate and betamethasone dipropionate may be cost effective, but only after potent and very-potent corticosteroids have not worked.

Facial, flexural, and genital psoriasis

Evidence on topical treatments for facial, flexural and genital psoriasis

CKS has provided a summary of the results of a clinical and cost effectiveness analysis on the topical treatments for psoriasis of the face, flexures and genitals, performed by the National Institute for Health and Clinical Excellence [National Clinical Guideline Centre, 2012]. A detailed review of the evidence can be viewed in the NICE guidance Assessment and management of psoriasis (pdf).

NICE found very few trials (n = 3) that assessed the efficacy of topical treatments for psoriasis of the face, flexural, and genital sites. These trials assessed the effectiveness of topical calcineurin inhibitors (treatments that are recommended by dermatology specialists). No trials assessed the efficacy of topical corticosteroids. The recommendation to use topical corticosteroids are based on expert opinion from the NICE guideline development group.

Guttate psoriasis

Evidence on topical treatments for guttate psoriasis

Evidence is lacking upon which to make recommendations on topical treatments for guttate psoriasis.

In a recent systematic review performed by the National Institute for Health and Clinical Excellence no published trials were identified that assessed the efficacy of topical treatments for guttate psoriasis [National Clinical Guideline Centre, 2012].

CKS identified one Cochrane systematic review (search date: November 1999) which assessed the effectiveness of treatments for guttate psoriasis [Chalmers et al, 2000]. This review did not find any published randomized controlled trials of topical treatments for this condition.

Chronic palmoplantar pustulosis

Evidence on topical treatments for chronic palmoplantar pustular psoriasis

Weak evidence suggests that short-term treatment with triamcinolone acetonide 0.1% cream under a hydrocolloid dressing is more effective than clobetasol 0.1% cream used alone in the treatment of palmopustular psoriasis.

A Cochrane systematic review (search date: February 2003) [Chalmers et al, 2006] identified one open-label study of 19 people which compared a regimen of moderately potent corticosteroid under hydrocolloid occlusion with a very potent corticosteroid [Kragballe and Larsen, 1991].

Triamcinolone acetonide 0.1% cream with a hydrocolloid dressing was applied to one hand or foot every third day for 4 weeks, and clobetasol 0.1% cream was applied twice daily to the other hand or foot for 4 weeks. The two sides were compared after a wash-out phase of 2 weeks.

Both treatments improved skin lesions.

After 4 weeks, 12 of 19 (63%) cases in the moderately potent corticosteroid plus hydrocolloid dressing group cleared completely, compared with 3 of 19 (16%) cases in the very potent corticosteroid group (p = 0.001). The rate difference was 0.47 (95% CI 0.20 to 0.75).

No clinically important adverse effects were reported or observed during the study period.

Nail psoriasis

Evidence on topical treatments for nail psoriasis

There is a lack of good-quality trial evidence upon which to base treatment decisions for people with nail psoriasis.

A Cochrane systematic review (search date: April 2008) assessed the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis (including nail psoriasis) [Mason et al, 2009]. This review compared topical treatments with placebo, and the effectiveness of topical vitamin D preparations with other topical treatments. Topical vitamin D preparations were included as a comparator because they are used as first-line treatments in many countries.

This review included only one trial in the efficacy analysis that assessed treatments for nail psoriasis. This trial found that topical ciclosporin solution was more effective than placebo for treating nail psoriasis. This preparation is not available for prescription in the UK.

Systemic antibiotics

Evidence on systemic antibiotics for guttate psoriasis

There is no evidence that erythromycin or penicillin is effective for treating streptococcus-associated guttate psoriasis.

One Cochrane systematic review on anti-streptococcal interventions for guttate and chronic plaque psoriasis identified only one small trial [Owen et al, 2000]. This trial compared the use of phenoxymethylpenicillin or erythromycin in 20 people with psoriasis (most of whom had guttate psoriasis) who had evidence of colonization with beta-haemolytic streptococci. The participants received either rifampicin or placebo at the end of the antibiotic treatment. At the end of the study period, none of the participants were improved.

After publication of this review, CKS identified one randomized controlled trial in 43 men which assessed the effectiveness of antibiotics in the treatment of streptococcus-associated guttate psoriasis [Dogan et al, 2008]. The men (who had serological evidence of recent streptococcal infection) were randomized to receive placebo, erythromycin, or penicillin for 14 days. Four weeks after treatment, there was no significant difference among the treatment groups, suggesting that antibiotics may not be useful for treating streptococcus-associated guttate psoriasis.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of psoriasis with additional searches in the following areas:

Penicillin for streptococcal infections associated with psoriasis

Search dates

March 2010 - November 2012

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.

exp Psoriasis/, guttate psoriasis.tw., pustular psoriasis.tw., erythrodermic psoriasis.tw.

exp Penicillins/, streptococcus-associated.tw., streptococcus associated.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Clinical Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NHS Evidence

Health Protection Agency

World Health Organization

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

NHS Scotland National Patient Pathways

New Zealand Guidelines Group

Agency for Healthcare Research and Quality

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Singapore Ministry of Health

National Resource for Infection Control

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

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