Psoriasis Treatments

Psoriasis is an inflammatory skin condition which causes an increased production of skin cells. Typically, skin cells are replaced every 3-4 weeks, but in psoriasis, this process occurs every 3-7 days. This results in a buildup of skin cells, which creates patches. The long-lasting skin condition tends to have no symptoms, followed by periods when symptoms are more severe (flare-ups) and can affect your nails and joints. The inflammatory response causes flaky patches of skin, which form silvery scales. They can look pink or red, and in some darker skins, you may notice purple or darker brown with grey scales. The patches are most prevalent on your elbows, knees, scalp and lower back but can appear anywhere. The majority of the population with psoriasis suffer from a mild form with small patches which can become itchy and sore; however, for some, it can have a big impact on their quality of life.

Psoriasis affects around 1-3% of the worlds population. In the UK we have around 2% of the population with psoriasis. Onset can occur at any age but evidence suggests incidences occur more often between 20-30 years of age and 50-60 years of age. Men and women are equally affected. Psoriasis is more common in white Caucasians than other ethnic groups.

Many patients find that psoriasis gets worse following a certain event called a trigger. Identifying and avoiding the triggers may help avoid flares of psoriasis. Common triggers include:

• Throat infections: Particularly a streptococcal infection, which can trigger guttate psoriasis.
• Medication: lithium, antimalarial drugs such as chloroquine, beta-blockers, NSAIDs, ACEi, Trazadone, terfenadine, and antibiotics such as tetracycline and penicillin. Sudden withdrawal of oral or topical corticosteroids can precipitate a severe rebound phenomenon.
• Trauma such as scratching, piercings, tattoos, burns or surgery to the unaffected skin can lead to psoriasis 7-14 days later.
• Hormonal changes: increased risk during puberty, postpartum and during menopause.
• HIV infection and AIDs
• Psychological stress
• Smoking
• Drinking excessive amounts of alcohol.

Patients may find psoriasis quite challenging to comprehend, and psychological distress is not directly associated with worsening symptoms. Patients have been seen to suffer from anxiety, depression, relationship difficulties, negative body image and low self-esteem. These patients shouldn’t suffer alone and should see their local teams for referral to psoriasis groups or talking therapies.

Erythrodermic psoriasis: It can be life-threatening as it can increase the risk of heart failure, malabsorption, hypothermia, dehydration, and mild anaemia.

Generalised pustular psoriasis: It can be life-threatening and can cause fever, tiredness, fast heartbeat, weight loss and hypothermia.

Psoriasis can be diagnosed without the need to see a dermatologist. However, a referral may be needed in severe cases or when the clinician is unsure of the diagnosis.

Psoriasis often occurs on elbows, knees, trunks, flexures, behind the ears or near the belly button. The size, shape, and number of lesions differ depending on the type of psoriasis.

• Plaque psoriasis: Most common form. Silvery-white scale plaques are usually found on the scalp, behind the ears, elbows, knees, forearms, shins and lower back. Lesions are typically distributed symmetrically and can merge to form a large lesion. Most lesions can be oval or irregular and are 1cm to several cm in diameter. The thickness of the scale varies, and you may notice glossy, raw red skin with pinpoint bleeding if you gently remove the scale. You may notice broken skin if the plaque is over a joint line or on the palm or sole.

• Scalp psoriasis: Around eight people in 10 tend to suffer from scalp psoriasis if they suffer from psoriasis anywhere else in the body. The severity varies; however, the whole scalp can be affected. Plaques can be very thick, particularly around the back of the head. Some people can be very itchy and cause discomfort. In severe cases, you may notice hair loss, but this is usually temporary.

• Nail psoriasis: This condition can occur in half the patients with psoriasis and can affect all or parts of the nail and surrounding structures. The incidence of nail psoriasis increases with the duration of psoriasis. Nails may develop tiny dents or pits, become discoloured, or grow abnormally. They may also become loose and fall out, and in severe cases, the nail may crumble.
  Guttate psoriasis: This usually presents as less than 1cm drop-shaped sores scattered around your chest, arms, legs, and scalp. It can be a sign of the first presentation of psoriasis (following a throat infection) or as an acute flare-up of plaque psoriasis.

• Flexural psoriasis: itchy, large, smooth patches of the skin affecting the groin, genital area, armpits, between the buttons and under the breasts. It can get worse by friction and sweating, so it can be precipitated during hot weather. You may notice broken skin in the creases. Most commonly found in the elderly, immobile and people who are overweight or obese.
  Pustular or erythrodermic psoriasis: a potentially life-threatening medical emergency. You may notice puss-filled blisters on your skin with systemic illnesses such as fever, tiredness, weight loss, fast heartbeat, and joint stiffness. Erythrodermic psoriasis is a diffuse, widespread, severe psoriasis affecting 90% of your body. It can appear gradually or abruptly, even in mild psoriasis. It can cause intense itching or burning and cause your body to lose proteins and fluid, leading to infections, dehydration, heart failure, hypothermia, and malnutrition. If you experience any of the symptoms above, you need to visit a hospital immediately.

The treatment is generally aimed at controlling the symptoms rather than the cure. Topical treatments are usually first line, and it is essential to note that it can take several weeks to work, and there is a risk of relapse if treatment is stopped suddenly. Topical treatments should only be used on small areas of psoriasis, and if you experience widespread psoriasis (more than 10% of body surface area), you must seek emergency medical treatment.

Psoriasis treatment varies depending on the type or types of psoriasis you are suffering from, the location on your body, and the severity of the condition. Treatments typically fall into three categories:

• Topical: creams, ointments and gels applied directly to the affected area
• Phototherapy: specialist treatments where your skin is exposed to ultraviolet light
• Oral or injected medicines that work throughout the entire body.

Topical treatments are used for mild to moderate psoriasis.

Lifestyle changes such as weight loss, smoking cessation, alcohol and managing psychological comorbidities have been shown by several studies to reduce psoriasis symptoms.

Treatment should always be directed on reducing the scale first by using ketolytic treatments that contain salicylic acid or emollients, which soften the scale and debride. This allows topical treatments like vitamin D and a corticosteroid to be absorbed into the skin and reduce scaling, inflammation, and redness.

Treatment should be reviewed by a clinician every four weeks. You may need treatment to descale first, or you may not be using the correct creams/treatments. If there is poor or no response after eight weeks of topical treatment, then you should stop using the topical treatment and reconsider the diagnosis and arrange a referral to a dermatologist for special assessment and management. Topical corticosteroids should not be used for longer than 8 weeks at any one site.

Emollients

Emollients are used on patients with mild psoriasis and help reduce water loss and form a protective barrier over the skin.  Their benefits include moisturising the skin, reducing itching, and scaling and aiding the delivery of other topical treatments. Emollients are available over the counter and from The Family Chemist and come in creams, ointments, gels, lotions, sprays, washes and bath and shower additives. Some emollients can also be used as soap substitutes, as the skin is particularly vulnerable to drying and cracking following a hot shower/bath. Different emollients may be required for different areas of the skin, different flare stages, different times of the day and in different locations. Other topical treatments should only be applied 30 minutes after applying an emollient.

Cream and lotions are preferred for red inflamed skin areas because water-based products’ evaporation cools the skin. They are also generally accepted during the day as they are less greasy. Examples include:

Cetraben cream

Diprobase cream

Zerobase cream

E45 cream

Ointments are preferred for non-inflamed thick, scaled skin because they are more effective than creams however are more poorly tolerated due to their greasy formula. They are beneficial to use at night. Examples include:

Cetraben ointment

Diprobase ointment

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

Vitamin D preparations and/or Steroids

Vitamin D analogues come in various preparations: gels, creams, ointments, and foams. These prescription-only medicines are recommended for patients with mild to moderate psoriasis. They come alone or in combination with a topical steroid. They should not be used on the face, genitals, armpits, or groin. Their mode of action is to slow the production of skin cells. They also have an anti-inflammatory effect. There are few side effects if you do not use more than the recommended amount. Examples of Vitamin D analogues include:

Dovonex Ointment

Dovobet Gel

Dovobet Ointment

Enstilar Foam

Coal Tar Preparations

Coal tar preparations have been used widely for psoriasis for many years, but its significance in psoriasis treatment has diminished over time. However, some patients still find Coal tar shampoos help treat scalp psoriasis. Their mode of action is unknown, but we know they reduce scales, inflammation, and itchiness. Coal tar can be found in combination with a keratolytic agent called salicylic acid which help remove thick scale.

Coal tar preparations include:

Polytar shampoo

Capasal Shampoo (Coal Tar and Salicylic Acid)

Salicylic Acid Preparations (Keratolytic)

Salicylic acid is classified as a keratolytic, or peeling agent. It works by causing the outer layer of skin to shed. It is a common and effective treatment for various skin problems. As a psoriasis treatment, it acts as a scale lifter, helping to soften and remove psoriasis scales.

Do not use topical salicylic acid preparations if:

• you are allergic to aspirin, or any other of the ingredients in the topical preparation.
• you have inflamed or broken skin.
• you have acute local infections, or acute pustular psoriasis.

Salicylic acid preparations should not be applied to more than 20% of the body surface area, due to the risk of systemic salicylate toxicity.

Salicylic Acid preparations include:

Sebco

Cocois Ointment

Capasal Shampoo

https://www.psoriasis-association.org.uk/media/InformationSheets/Moisturising.pdf

https://www.papaa.org/shop/emollients-and-psoriasis/

https://www.psoriasis-association.org.uk/media/InformationSheets/Vitamin_D.pdf

https://www.psoriasis-association.org.uk/media/InformationSheets/Coal_Tar.pdf

Patients should seek urgent treatment if they suffer from pustular psoriasis or erythrodermic psoriasis. Symptoms for pustular psoriasis include: white bumps filled with pus near or inside red skin blotches. They can hurt and be scaly, flaky or itchy. Erythrodermic psoriasis disrupts your bodys normal temperature and fluid balance. This can cause severe redness/discolouration and shedding of skin over a large area of the body, exfoliation often occurs in large sheets instead of smaller scales, skin looks as if it has been burned, heart rate increases, severe itching and pain, and fever.

Patients should see a specialist if:

• You have never been diagnosed of psoriasis before.
• Psoriasis is extensive for example more than 10% of your body surface area.
• Psoriasis is moderately severe or more. Measured by the physicians global assessment.
• Psoriasis is resistant to topical drug treatments or treatments are not tolerated.
• There is significant impact on your physical, psychological, or social wellbeing.

A URGENT referral is recommended to a rheumatologist if you are suffering from psoriatic arthritis.

If topical treatments have proven unsuccessful, consider contacting The Family Chemist clinician so he/she can discuss the next steps. If all else fails, a referral to a dermatologist who can offer phototherapy or oral or injectable medication will be needed.