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randomised, controlled trials. Potent topical corticosteroid formulations were more effective than calcipotriol and a combination of calcipotriol and a potent topical corticosteroid was found to be more effective than either agent alone (p=0.011 for comparison with betamethasone dipropionate alone, p<0.0001 for calcipotriene alone). The vehicle used to deliver topical corticosteroids did not alter the outcome.10

Where there is thick scaling of the scalp, the Scottish Intercollegiate Guidance Network guidelines recommend initial treatment with overnight application of salicylic acid, tar preparations or oil preparations (for example, olive oil, coconut oil).10


Despite, being familiar from long years of use, it is important to note that these conventional systemic treatment are generally highly non-specific in their mechanism of action and consequently can have significant safety drawbacks.4,5

Methotrexate ● Associated with hepatotoxicity and bone marrow suppression

● Contraindicated in renal impairment, in women and men attempting conception, and in individuals who have excessive alcohol consumption.

Cyclosporin ● Impaired renal function ● Hypertension ● Cutaneous malignancies and possible lymphoma.

Acitretin ● Negatively affects triglycerides and cholesterol

● Teratogenic.

More recently, biologics have become available as valuable new resources in the treatment of psoriasis, providing additional therapeutic options that are not associated with cumulative toxicity for the liver, kidneys and bone marrow being more adequate for long-term control of the disease.6


In Europe, biologic therapies including adalimumab, etanercept, infliximab or ustekinumab can be offered to patients with moderate to severe psoriasis who do not respond to conventional systemic treatments. The range of systemic treatments for psoriasis is also being

enriched by drugs binding at new therapeutic targets, such as interleukin (IL)-17A, and new small molecule drugs, including Janus kinase inhibitors and phosphodiesterase 4 inhibitors.7

Scalp psoriasis

Scalp psoriasis can place an emotional burden on patients, not least because of the visibility of lesions, which can adversely affect self-esteem and social interactions.8

These problems are

compounded because scalp psoriasis is difficult to treat, in part because of the cosmetic effect of treatment on hair, which some patients may find difficult to accept and therefore may not adhere to their treatment. In addition, percutaneous absorption of the active ingredients of topical medicines varies widely between individuals.9 NICE recommends initial treatment for up to four weeks with a potent corticosteroid. If the psoriasis is not cleared or controlled satisfactorily after four weeks’ treatment a different formulation of potent corticosteroid (for example, shampoo or mousse) and/or a topical formulation containing salicylic acid, emollients or oils to remove scales and/or combination treatment with calcipotriol monohydrate and betamethasone dipropionate once daily for eight weeks should be considered. Monotherapy with topical vitamin D derivates can be offered to people who cannot tolerate or use topical corticosteroids or have mild to moderate scalp psoriasis.1

Topical corticosteroids, calcipotriol and combinations of the two treatments have been compared in a number of

Nail psoriasis

Patients with nail psoriasis should be advised to keep their nails short to help avoid exacerbating onycholysis (detachment of the nail from the nail bed) and reduce the accumulation of material under the nail.11

They should avoid manicure of the cuticle as this may provoke paronychia, and false nails should not be worn.11 If nail disease is very mild and is not causing discomfort or distress, treatment is not required. Nail varnish can be used to disguise pitting, but abrasive acetone-based nail varnish removers should be avoided in order to prevent Koebner phenomenon.11 Therapy of nail psoriasis is challenging because anatomical characteristics of nails make it difficult to achieve therapeutic concentrations of drug at the affected site (that is, nail matrix or nail bed), and slow rate of growth means treatment needs to be used for a considerable time – usually months – to be successful. Compliance issues may have affect on the success of treatment as some patients may find they cannot continue treatment for the length of time required. Some options available to overcome this issue, such as steroidal injections, can be painful and therefore rejected by patients.

There are relatively few controlled trials of treatments for nail psoriasis to guide clinicians. Where clinical trial data are available, the outcomes are not standardised and so it is difficult to compare treatments.

Best practice recommendations Recognising the need for guidance, the Medical Board of the National Psoriasis Foundation has published best practice

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