Transcript Diagnosis and Management of Psoriasis and Psoriatic Arthritis

Diagnosis and Management of
Psoriasis and Psoriatic Arthritis
SIGN November 2010
Objectives
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According to this new guideline:
 Be
able to diagnose psoriasis
 Know the recommended treatment in primary
care
 Have an understanding of psoriasis
management in secondary care.
What are the characteristics of
psoriasis?
What risks are associated with
psoriasis or psoriatic arthritis?
Co Morbidities associated with
psoriasis
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Diabetes
Hypertension
Hyperlipidaemia
Metabolic syndrome
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Obesity
MI – young pt with
severe disease.
Low mood
Treatment - Topical
Short term potent steriod or potent steriod
plus calcipotriol gain improvement in
plaque psoriasis.
 Long term treatment is a Vit D Analogue.
 If unsuccessful then consider dithranol,
coal tar solution or tazaotene gel.
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Vitamin D analogues
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Calcipotriol and talcalcitol.
 Dovonex,
silkis, curatoderm.
 Dovobet (with betamethasone)
Analogues of vit D and affect cell division
and differentiation
 Do not smell or stain
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Coal Tar
Anti-inflammatory properties and antiscaling properties.
 Crude coal tar most effective, but not
tolerated due to smell and mess.
 Contact allergy or folliculits may occur.
 Polytar, alphosyl HC, Cocois
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Tazarotene
For plaque psoriasis.
 A retinoid.
 Less effective and more irritation than
calcipotriol.
 Use sparingly on plaques only.
 Clean and odourless.
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Dithranol
Effective treatment for plaque psoriasis.
 Irritation and staining of the skin.
 Only on plaques.
 Not in flexures or on the face.
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Wear gloves to apply and wash afterwards.
Best used by specialist nursing staff.
Topical therapy
Therapy Efficacy
Remission Maintanence Patient
Coal tar
X
-
-
Steriods XXXX
XXX
X
XX
Dithranol XX
XX
-
-
Tazarotene
XX
XX
XX
XXX
XXX
XX
X
XX
Vit D
XXX
analogues
acceptability
Special Sites
Scalp – scalp preparations – salicylic acid
/ tar preparations. Vit D analogues and
steriods
 Face and Flexures – more easily irritated.
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 Moderate
steriods short term
 Vit D Analogues or tacrolimus ointment.
Assessing Psoriasis
 PASI
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- calculated based on
severity, intensity,
and surface area
Requires experience
at calculating the
score.
 DLQI
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Simple 10 questions,
assess effect on life.
Dermatology Life Quality Index
0-1 = no effect at all on patient's life
2-5 = small effect on patient's life
6-10 = moderate effect on patient's life
11-20 = very large effect on patient's life
21-30 = extremely large effect on patient's
life
Referral to dermatology
Diagnostic problem
 Extensive disease
 Occupational disability / time lost
 Difficult places
 Failure of topical therapy
 Adverse reaction to topical
 DLQI above 6
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Generalised Pustular Psoriasis
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Life threatening
complications.
May have
erythroderma.
Requires
hospitalisation.
Secondary Care
Erythroderma or generalised pustular
psoriasis need emergency referral to
dermatology.
 These patients should have inpatient care.
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Secondary Care - Phototherapy
Narrow band UVB phototherapy should
be offered if failure to topical therapy.
 Three times weekly where practical
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Systemic
In general poor studies to go on and of
short duration. However,
 Severe or refractory psoriasis pt should be
offered tx with ciclosporin, methrotrexate,
acitretin.
 If respond – shared care with primary
care.
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Biological
Strong evidence base for infliximab (NNT
2) adalimumab, and etanercept (NNT 4).
 Should be offered to pt who do not
respond to systemic therapies.
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