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Effective diagnosis & management

Other circumstances that may need specialist referral include acute guttate psoriasis, which requires phototherapy, nail disease causing major functional or cosmetic impact, and involvement of sites that are difficult to treat, such as the face, palms, soles or genitalia.2,6,7


or generalised pustular psoriasis is a dermatological emergency and must be referred to a dermatology service immediately.2,6,7

Management strategies Emollients A patient should be referred

to a rheumatology specialist for the diagnosis and treatment of psoriatic arthritis.6 This analysis categorises three treatment and management strategies: emollients, soap substitutes and moisturisers; medical therapy; and psychological intervention (see Figure 1).

Emollients, soap substitutes and moisturisers Emollients, soap substitutes and moisturisers such as emulsifying ointment and paraffin gel are used together with the medical therapy to reduce the dryness and scaling caused by psoriasis.7

Medical therapy

Medical therapies for psoriasis can be divided into topical therapy, phototherapy and systemic therapy. The treatment goal is to achieve complete clearance of the disease and to prevent suboptimal treatment.8 Treatment doses may have to be adjusted for individual patients, depending on the severity of their psoriasis. Physicians should consider that dose adjustment can be off-label. PASI 75 response (at least 75% improvement from baseline PASI) and DLQI of 0–1 is the recommended treatment goal.8

An improvement of DLQI of five or more is considered to be a good response to treatment.9

A DLQI score of ten or more

indicates severe disease requiring admission, phototherapy or second-line therapy.9

Topical therapy

Topical therapy is used in patients with psoriasis affecting less than 20% body surface area.10

Moderate-to-high-potency topical corticosteroids may be used short term, ideally in combination with other topical agents (see below). These are useful in controlling inflammation and itching.10 Non-fluorinated topical steroids should be used short term on the face and flexures. Excessive use can lead to skin atrophy and telangiectasia.10

Long-term potent

topical corticosteroids may cause adrenal suppression.11

Topical calcipotriol (vitamin D3 Phototherapy The use of phototherapy9,10 dates back to

the time of the Ancient Greeks. There is a dose-related risk of skin cancer. Lifetime therapy should not exceed standard guidelines. It should not be combined with methotrexate or cyclosporine, due to the theoretical risk of carcinogenesis.12 UVB narrowband (TLO1) is easy to use. There is no need for photosensitisers and it has a lower incidence of side effects.1 PUVA is ultraviolet light A (UVA) combined with photosensitisers (oral/ topical psoralen).10

In combination with

acitretin, it has a synergistic effect. Eyes are protected to rule out the risk of cataracts. Patients wear UV400 wraparound sunglasses on the day of treatment.

Medical therapy Psychological


Corticosteroids Calcipotriol Coal tar Dithranol

Figure 1: Treatment and management strategies

analogue) acts by inducing differentiation and suppressing proliferation of keratinocytes. Burning sensation and irritation are common, and it can cause hypercalcaemia. The recommended maximum dose for adults is 100g/week.10 Betamethasone/calcipotriol ointment is a combination of a moderate-to-high-potency cortical steroid and a topical calcipotriol. Coal tar has an anti-inflammatory effect and is effective, especially when used with topical corticosteroids.10

It is usually used

in scalp psoriasis. The problem with use is compliance, as the preparations tend to stain and are smelly.9

It may be used in

combination with ultraviolet light B (UVB) phototherapy (Goeckermann regimen). Dithranol9

and tar baths can be

combined with UVB phototherapy (Ingram regimen) to treat psoriasis.

Systemic therapy

Methotrexate (dihydrofolate reductase inhibitor) causes suppression of DNA synthesis and also has immunosuppressive activity, possibly as a result of inhibition of lymphocyte multiplication.10,13


starting dose is usually 2.5mg/week and titrated up. The side effects are bone marrow suppression, hepatotoxicity and gastrointestinal upset.10

The therapeutic

dose is 15–25mg/week as a single dose once weekly. Lower doses are used in patients with renal impairment.14 Cyclosporine inhibits T-lymphocyte transcription of cytokine interleukin (IL)-2. The dose is 3–5mg/kg/day.10



Methotrexate Cyclosporine Retinoids

Fumaric acid esters Biologics


most common side effects are hypertension and nephrotoxicity.10 Retinoid (acitretin) is used alone or in combination with phototherapy 0.3–1mg/kg or less as tolerated. Baseline renal and liver profile, fasting glucose and lipids are usually measured prior to starting the medication. The side effects are teratogenicity, dry mucous membranes and hypertriglyceridaemia. It should not be used in a female patient who plans to conceive within two years of stopping medication.15

Fumaric acid esters, a

licensed oral treatment for psoriasis in some countries in Europe, have also been shown to be effective for psoriasis.9,16,17 Biologic agents are used in moderate- to-severe plaque psoriasis where previous treatments have failed or are contraindicated in a patient. The decision is based on disease severity, and the patient’s medical history and preference. Biologics approved in Europe for the treatment of plaque psoriasis are


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