Diagnosis and Management of Psoriasis and Psoriatic Arthritis

1. Diagnosis and Management of Psoriasis and Psoriatic Arthritis SIGN November 2010

2. Objectives • 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.

3. What are the characteristics of psoriasis?

10. What risks are associated with psoriasis or psoriatic arthritis?

11. Diabetes Hypertension Hyperlipidaemia Metabolic syndrome Obesity MI – young pt with severe disease. Low mood Co Morbidities associated with psoriasis

12. 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.

13. Vitamin D analogues • Calcipotriol and talcalcitol. • Dovonex, silkis, curatoderm. • Dovobet (with betamethasone) • Analogues of vit D and affect cell division and differentiation • Do not smell or stain

14. Coal Tar • Anti-inflammatory properties and anti-scaling properties. • Crude coal tar most effective, but not tolerated due to smell and mess. • Contact allergy or folliculits may occur. • Polytar, alphosyl HC, Cocois

15. Tazarotene • For plaque psoriasis. • A retinoid. • Less effective and more irritation than calcipotriol. • Use sparingly on plaques only. • Clean and odourless.

16. Dithranol • Effective treatment for plaque psoriasis. • Irritation and staining of the skin. • Only on plaques. • Not in flexures or on the face. • Wear gloves to apply and wash afterwards. • Best used by specialist nursing staff.

17. Topical therapy

18. Special Sites • Scalp – scalp preparations – salicylic acid / tar preparations. Vit D analogues and steriods • Face and Flexures – more easily irritated. • Moderate steriods short term • Vit D Analogues or tacrolimus ointment.

20. Assessing Psoriasis • PASI • - calculated based on severity, intensity, and surface area • Requires experience at calculating the score. • DLQI • Simple 10 questions, assess effect on life.

21. 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

22. Referral to dermatology • Diagnostic problem • Extensive disease • Occupational disability / time lost • Difficult places • Failure of topical therapy • Adverse reaction to topical • DLQI above 6

25. Generalised Pustular Psoriasis • Life threatening complications. • May have erythroderma. • Requires hospitalisation.

27. Secondary Care • Erythroderma or generalised pustular psoriasis need emergency referral to dermatology. • These patients should have inpatient care.

28. Secondary Care - Phototherapy • Narrow band UVB phototherapy should be offered if failure to topical therapy. • Three times weekly where practical

29. 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.

30. 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.