SKIN CARE TODAY
2015,Vol 1, No 1
69
FOCUS ON PSORIASIS
i
patients to be adherent to treatment
by talking with them about side-
effects and mode of action.
Primary care nurses are in a great
position to work with patients to
ensure that they have the optimum
treatment regimen and that they have
realistic expectations as to how it will
work. An optimum regimen should
always include an emollient, a topical
product to treat plaques on the body,
along with topical treatments for scalp,
face and flexures as necessary.
REFERENCES AND WEBSITES
American National Psoriasis Foundation.
Available online at: www.psoriasis.org/
about-psoriasis/related-conditions
Boehncke WH, Boehncke S, Tobin AM
(2011)
Exp Dermatol
303–7
Dermatology Life Quality Index. Available
online at: www.dermatology.org.uk/
quality/dlqi/quality-dlqi.html
Langley RG, Ellis CN (2004)
J Am Acad
Dermatol
563–9
NHS Choices (2014)
Psoriasis
. Available
online at: www.nhs.uk/conditions/
psoriasis/pages/introduction.aspx
(accessed 23 January, 2015)
National Institute for Health and Care
Excellence (2012)
NICE guidelines CG
153
. Available online at: www.nice.
org.uk/guidance/cg153 (accessed 23
January, 2015)
National Psoriasis Foundation (2009)
Report on the psycho-social impacts of
psoriasis
. National Psoriasis Foundation,
London
Penzer R (2012)
Dermatological Nurs
s1–19
Penzer R, Mitchell T (2000)
Psoriasis at
your fingertips
. Class, London
Psoriasis Association. Available online at:
https://www.psoriasis-association.org.
uk/pages/view/about-psoriasis
the exposed area. It is always easier
if someone else can do this for the
person with psoriasis (
Table 2
).
Treating sensitive areas
Treating facial and flexural psoriasis
in adults poses different challenges.
These areas tend to be more sensitive
and therefore the treatments which
can be used on the rest of the body
are not always suitable. The second
challenge for prescribers is that two
of the main treatments recommended
by NICE for use on these areas, are
not licensed for the suggested use.
NICE recommend that first-line
treatment should be a moderate
potency topical steroid for up to
two weeks, however, moderate
potency steroids are not licensed for
this use. They should not be used
for more than one to two weeks
in a month and, therefore, if more
prolonged use is necessary, topical
calcineurin inhibitors (e.g. Elidel
®
[pimecrolimus], Novartis) can be
used on a twice-daily basis. As
i
Practice point
If psoriasis is in an active phase,
topical treatments will not halt the
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lesions are cleared new ones will
appear. Patients also need to know
that most treatments take some
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minimum of two weeks.
topical calcineurin inhibitors are not
currently licensed for the treatment
of psoriasis, NICE apply the caveat
that they should only be prescribed
by those who have expertise in
treating psoriasis.
As a community practitioner,
these limitations may mean that
these options are not available. A
practical approach would be to:
i
Ensure that the patient is making
optimal use of emollients
i
Use one of the vitamin D
analogues that can be applied
to the face with caution, e.g.
Silkis
®
(calcitriol) (Galderma),
Curatoderm
®
ointment (tacalcitol)
(Almirall).
In practice, it is common to
see moderate topical steroids (e.g.
eumovate
®
, GlaxoSmithKline)
prescribed for facial psoriasis. As
flexural psoriasis often has an
infective element to it, a moderate
potency topical steroid combined
with an antifungal/antibacterial is
commonly chosen (e.g. Trimovate
®
,
GlaxoSmithKline). As yet, calcineurin
inhibitors are rarely prescribed in
primary care for psoriasis, however,
this is likely to change as practitioners
become more experienced with them.
CONCLUSION
The NICE guidance for the treatment
of psoriasis provides some much
needed advice which is documented
in a user-friendly way. It reminds
clinicians of the importance of
assessment (both physical and
psychological), and of helping
Table 2:
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6WHS
5DWLRQDOH DQG DSSOLFDWLRQ
6LGH HIIHFWV UHVWULFWLRQV
Coconut oil/salicylic
acid/tar (e.g. Sebco
®
,
Derma UK)
Useful on thickened, adherent plaques to loosen
and thin out
Apply and leave in for a couple of hours or overnight
i
Very greasy
Topical steroid
Once plaques are thinned these can be useful to treat
plaques further
Apply once a day, application technique depends
on product
i
Should not be used
for more than four weeks
i
Some products may
sting on application
Combined vitamin
D analogue and
betamethasone gel
Once plaques are thinned as above
If psoriasis on body as well, same treatment can be
used reducing prescription costs
i
Review after four weeks
Tar-based shampoo Use 2–3 times per week during treatment and as
maintenance once other treatment stopped
i
Distinctive smell
SCT
Red Flag
Psychosocial aspects
The impact that psoriasis can
have on patients’wellbeing and
mental health should not be
underestimated. A survey by the
National Psoriasis Foundation
(2009) found that more than 50%
of people said that the condition
affected their wellbeing, and 63%
felt self-conscious about it. Links
to depression and suicidal ideation
have also been found (National
Psoriasis Foundation, 2009).
