1. Psoriasis By Anna Hodge 19.12.12

2. Objectives Recognise psoriasis Know the first line treatments for psoriasis Use topical corticosteroids safely Know when to refer

3. Psoriasis What is it? What does it look like? How do I treat it? When should I refer?

4. What is Psoriasis? Immune-mediated disease affecting the skin Causes over production of new skin cells Genetic component and can be triggered by stress Also affects nails and joints

5. What does it look like? Red scaly patches Well defined Symmetrical

6. Plaque psoriasis Scalp psoriasis Guttate psoriasis

7. NICE guidance Topical therapy is first line Offer referral for phototherapy or systemic therapy –Extensive disease (<10% of body affected) –Where topical Rx is ineffective

8. How to use topical steroids safely Risks –Irreversible skin atrophy or striae –Unstable psoriasis –Systemic side effects

9. How to avoid s/e Very potent corticosteroids –4 weeks max Potent corticosteroids –8 weeks max 4 week break between courses Use non-steroid based Rx in the break eg Vitamin D or coal tar preparations Do not use potent or v. potent topical steroid on face, flexures, genitals Or in children

10. Topical Corticosteroids Very potent (600x Hc) –Clobetasol dipropionate (Dermovate) Potent (100-150x Hc) –Betamethasone Valerate (Betnovate) –Mometasone Furoate (Elocon) Moderate (20-50x Hc) –Betamethasone Valerate 1:4 (Betnovate RD) –Clobetason Butyrate (Eumovate) Mild –Hydrocortisone

11. Management Step 1 –Potent steroid mane –Vitamin D nocte –For 4-8 weeks Step 2 –Vit D BD –8-12 weeks

12. Management continued Step 3 –Potent corticosteroid BD for up to 4 weeks OR –Coal tar preparation OD or BD Offer once daily combined Steroid and Vit D if this would improve compliance

13. Reviewing Rx Review 4 weeks after starting a new topical treatment –Evaluate tolerability, initial response –Reinforce importance of adherence –Reinforce importance of 4 week break between potent and v potent steroid courses Patients should have annual rv

14. Review Ensure patients understand that relapse occurs in most people after treatment stopped Topical treatments can be used when needed to maintain satisfactory disease control If psoriasis cannot be controlled with topical therapy alone- specialist referral

15. 2 nd and 3 rd Line Therapy Phototherapy Systemic therapy- methotrexate, ciclosporin etc Biologics- Infliximab etc

16. Summary Psoriasis is an immune mediated condition affecting skin, nails, joints Topical treatment is 1 st line –Potent steroids and Vit D –Coal tar preparations Effective communication with patient to aid compliance with treatment Refer for Phototherapy/systemic therapy if not responding