Psoriasis the latest recommendations for management: where can primary care make a real difference?

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1 Dermatology Psoriasis the latest recommendations for management: where can primary care make a real difference? Dr Stephen Kownacki Executive chair, Primary Care Dermatology Society (PCDS) This session is independent

2 Dr Stephen Kownacki Executive chair, Primary Care Dermatology Society (PCDS)

3 PCDS Psoriasis Guidance Dr Stephen Kownacki Executive Chair Primary Care Dermatology Society (PCDS)

4 Why is a pathway or guidance needed? Psoriasis affects approximately 2% of the population 1 Care for patients with psoriasis is largely a primary care responsibility Management is difficult, especially for some affected areas According to patients, we do not do well 1. Parisi R et al. J Invest Dermatol 2013; 133:

5 Psoriasis: the various clinical manifestations

6 Psoriasis 80 90% have chronic stable plaque psoriasis % have some degree of scalp involvement 1 50% have some nail involvement (may be subtle) 1 94% can be adequately managed topically % psoriatic arthritis 2 2% or more on systemic therapies (should be more?) 1. van de Kerkhof P et al, ed. Textbook of psoriasis. Oxford: Blackwell Publishing, Zachariae H. Am J Clin Dermatol 2003; 4: 441.

7 Psoriasis statistics Affects 2% of UK population 1 Males and females equally affected 2 Two peaks of presentation years old and years old 3 But can start any age Inherited in at least 50% of cases 4 Triggers can be infection, drugs, stress, friction/trauma Health burden: 35 million spent on psoriasis topical treatments a million prescriptions in UK in Papp K et al. J Eur Acad Dermatol Venereol 2007; 21: Smith A. Dermatology 1993; 186: Henseler T, Christopher E. J Am Acad Dermatol 1985; 13: van de Kerkhof P, ed. Textbook of psoriasis. Oxford: Wiley Blackwell, Prescribing Support Centre. Prescription cost analysis NHS Information Centre, 2008.

8 Lifestyle factors Patients with severe psoriasis more at risk of metabolic syndrome 1 Patients with psoriasis are more at risk of diabetes, hypertension and hyperlipidaemia and more likely to be obese and smoke 2 Strong correlation between smoking and plantar/palmar psoriasis 3 Encourage healthier lifestyle 1. Kourosh A. Skin Therapy Letter 2008; 13: Neimann A. J Am Acad Dermatol 2006; 55: O Doherty C, MacIntyre C. BMJ 1985; 291:

9 Types of psoriasis Chronic stable plaque psoriasis Guttate Scalp Flexural/genital (hidden areas) Nails Palmar plantar pustular psoriasis Erythrodermic/generalised pustular

10 Psoriasis: primary care treatment pathway What is Psoriasis? Psoriasis is a chronic, relapsing, inflammatory condition affecting the skin, scalp, nails and joints, with cardiovascular and psychological co-morbidities 1 It is not contagious and there is often a family history Psoriasis typically manifests with sharply demarcated dull red plaques with silvery scales, which shed easily It can be well controlled and treatment aims are to minimise skin manifestations, co-morbidities and improve quality of life Contributors Dr Kash Bhatti Dr Timothy Cunliffe Dr Angela Goyal Dr Vicky Jolliffe Dr Stephen Kownacki Dr George Moncrieff Reviewed by the Psoriasis Association Triggers and Exacerbating Factors Assessment Management Stress Smoking, alcohol and obesity Skin injury/surgery Infections Streptococci, HIV Drugs; including lithium and antimalarials (such as hydroxychloroquine) q An holistic approach is essential Examine the skin:- Body Special sites scalp and nail involvement and specifically ask about genital areas Joints be alert to signs of inflammatory arthritis including tendonitis and heel pain Cardio-metabolic risk (e.g. modified Q-risk) Explore wellbeing (e.g 'how are you coping?') q Explore expectations and discuss treatment options initially using topical therapies Emphasise benefits of lifestyle changes and provide support Arrange follow up and consider primary healthcare team s role in review of psoriasis and management of co-morbidities Lifestyle-Directed Advice Providing advice on managing stress, smoking, alcohol and obesity (in accordance with local resources), physical activity and Mediterranean diet Safe natural sunlight exposure depending on individual risks and benefits. Patients are especially vulnerable to suboptimal lifestyles due to the cardiovascular and metabolic risk and a negative impact on psoriasis itself. A dietary plan and physical exercise has been shown to reduce psoriasis severity Obesity, excess alcohol, smoking also are associated with worsening psoriasis Skin-Directed Treatment We strongly advocate the use of emollients both as soap substitutes and leave on preparations for all patients, alongside active topical therapies. Emollients soften scale, relieve itch and reduce discomfort and should be prescribed in large quantities, (e.g. a 70kg adult is likely to need at least 500g/month). When choosing an emollient, patient preference is crucial for adherence Active topical treatments should be used daily during a flare, during remissions improvement should be sustained by using less frequent active topical treatment, for example, weekend therapy Immediate referral if: Routine/urgent referral if: Secondary Care Other Information Erythroderma Unstable or pustular Poor response to treatment Severe Psychological distress Treatments available in secondary care: Phototherapy Systemic therapy e.g. methotrexate, Cyclosporin Apremilast Biologics (TNF and interleukin blockers) DLQI, PEST Advice re: prepayment season ticket Further information for patients can be found at and PCDS psoriasis guideline. PCDS September 2017

11 Psoriasis: clinical features and treatment PCDS psoriasis guideline. PCDS September 2017

12 Important messages Complete emollient therapy should be your first-line treatment for psoriasis Plaques of psoriasis produce inflammatory chemicals that not only accelerate arteriosclerosis but also aggravate psoriasis Keeping psoriasis controlled is much easier than regaining control Psoriasis in remission needs emollient therapy

13 Psoriasis looks different in some areas and needs different treatment

14 Patient no 1 A 55-year-old male office worker with a 30-year history of plaque psoriasis on knees, elbows, and sacrum stable Gave up with treatments years ago too messy and time consuming Reason for attending now new relationship

15

16 Assessment An holistic approach is essential Examine the skin Body Special sites scalp and nail involvement and specifically ask about genital areas Joints be alert to signs of inflammatory arthritis including tendonitis and heel pain (PEST score) Cardio-metabolic risk (e.g. modified Q-risk) Explore wellbeing (e.g. 'how are you coping?') PEST, psoriasis epidemiology screening tool. PCDS psoriasis guideline.

17 Skin-directed treatment We strongly advocate use of emollients both as soap substitutes and leave-on preparations for all patients, alongside active topical therapies Emollients soften scale, relieve itch, and reduce discomfort and should be prescribed in large quantities (e.g. a 70 kg adult is likely to need at least 500 g/month): When choosing an emollient, patient preference is crucial for adherence Active topical treatments should be used daily during a flare During remissions, improvement should be sustained by using less frequent active topical treatment for example, weekend therapy PCDS psoriasis guideline.

18 Calcipotriol/betamethasone combination product should be used first line, once daily until lesions flatten: Differs from NICE guidance but is more patient centred and clinically effective using once daily dosage If the response is suboptimal at 8 12 weeks: Review adherence Very thick scale can act as a barrier to topical therapies and consider using a salicylic acid preparation to descale (e.g % w/w betamethasone dipropionate with 3.00% w/w salicylic acid ointment once daily) Consider other therapies such as tar products (e.g. 5% v/w coal tar solution), tazarotene, or dithranol: See for more details During remissions improvement should be sustained with emollients and by using less frequent active topical treatment, for example, weekend therapy PCDS psoriasis guideline.

19 Before and after 6 weeks of topical calcipotriol/betamethasone Copied with kind permission of Dermatoweb The closed eyes test

20 NICE or PCDS Topical treatment of psoriasis affecting the trunk and limbs Offer a potent corticosteroid applied once daily plus vitamin D or a vitamin D analogue applied once daily (applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment for adults with trunk or limb psoriasis If once-daily application of a potent corticosteroid plus oncedaily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance or satisfactory control of trunk or limb psoriasis in adults after a maximum of 8 weeks, offer vitamin D or a vitamin D analogue alone applied twice daily NICE guideline

21 If twice-daily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance or satisfactory control of trunk or limb psoriasis in adults after 8 12 weeks, offer either: a potent corticosteroid applied twice daily for up to 4 weeks or a coal tar preparation applied once or twice daily If a twice-daily potent corticosteroid or coal tar preparation cannot be used or a once-daily preparation would improve adherence in adults offer a combined product containing calcipotriol monohydrate and betamethasone dipropionate applied once daily for up to 4 weeks NICE guideline

22 So for patient no 1 Education and manage expectations Lifestyle advice as necessary Emollient (suitable for his lifestyle) in adequate quantities Calcipotriol/betamethasone gel or foam + clobetasone (Eumovate) for flexures Follow up consider maintenance therapy Suggest

23 Patient no 2 Age 25 years Has had problems with her scalp for many months Severe dandruff, no benefit from standard dandruff shampoos Problems at hairdressers Mildly itchy Rash around hairline Family history of psoriasis

24 Scalp psoriasis History of patient, including treatments tried and how used Examination of the patient not just the scalp Severity of scale

25 Pityriasis amiantacea

26 PCDS. Psoriasis primary care treatment pathway. Guidelines summary.

27 But what about the margins? Beware potent steroid on facial skin Emollient to soften scale 0.05% v/w clobetasone butyrate cream or ointment once (or twice) a day Consider 'off-label' topical calcineurin inhibitor (e.g. 0.1% tacrolimus monohydrate ointment twice daily or pimecrolimus 1% cream twice daily)

28 And the nails? Keep them short and smooth If not a problem, leave alone Nail varnish and gel nails ok to use Trickle potent topical steroid scalp application or apply betamethasone dipropionate/calcipotriol monohydrate gel under the onycholytic nail Note: terbinafine can make psoriasis worse!

29 Patient no 3 18-year-old girl with sudden onset widespread small scaly lesions No previous skin history but recently unwell Now asymptomatic No other problems with hair, nails, or mouth

30 Guttate psoriasis Options include no treatment lasts months Refer to secondary care for light therapy and in the interim consider treating with tar lotion (Exorex lotion) 2 3 times a day Insufficient evidence for routine use of antibiotics; however, in cases of recurrent guttate psoriasis with proven streptococcal infections, consider early use of antibiotics and/or referral for tonsillectomy May represent a future risk of recurrent guttate or plaque psoriasis

31 Patient no 4 A 59-year-old lady attending for smear check noted to have flexural rash in groins and umbilicus by nurse colleague Also has moist rash in submammary areas Too embarrassed to bring to male GP s attention!

32 Flexural (inverse) psoriasis Differentiate from intertrigo due to other causes e.g. Candida or erythrasma Emollients Moderate topical steroids, e.g. clobetasone (Eumovate) short term Consider Canesten or Daktacort hydrocortisone cream if coexisting candida suspected Calcitriol ointment (Silkis) may be tried cautiously Beware potent topical steroids, which have increased potency in flexural areas

33 When to refer Immediate Erythroderma Pustular or unstable psoriasis Urgent or routine Severe disease Very widespread e.g. >40% Psychological distress Poor response to treatment

34 Severe pustular psoriasis Copied with kind permission of Dermatoweb.

35 Psoriatic arthritis

36 Remember DLQI: PEST: Advice regarding NHS prescription prepayment certificate DLQI, dermatology life quality index; PEST, psoriasis epidemiology screening tool.

37 Hospital No: Name: Address: DERMATOLOGY LIFE QUALITY INDEX Date: Diagnosis: Score: DLQI The aim of this questionnaire is to measure how much your skin problem has affected your life OVER THE LAST WEEK. Please tick one box for each question. DLQI 1. Over the last week, how itchy, sore, Very much painful or stinging has your skin A lot been? A little Not at all 2. Over the last week, how embarrassed Very much or self conscious have you been because A lot of your skin? A little Not at all 3. Over the last week, how much has your Very much skin interfered with you going A lot shopping or looking after your home or A little garden? Not at all Not relevant 4. Over the last week, how much has your Very much skin influenced the clothes A lot you wear? A little Not at all Not relevant 5. Over the last week, how much has your Very much skin affected any social or A lot leisure activities? A little Not at all Not relevant 6. Over the last week, how much has your Very much skin made it difficult for A lot you to do any sport? A little Not at all Not relevant 7. Over the last week, has your skin prevented Yes you from working or studying? No Not relevant If "No", over the last week how much has A lot your skin been a problem at A little work or studying? Not at all 8. Over the last week, how much has your Very much skin created problems with your A lot partner or any of your close friends A little or relatives? Not at all Not relevant 9. Over the last week, how much has your Very much skin caused any sexual A lot difficulties? A little Not at all Not relevant DLQI, dermatology life quality index. 10. Over the last week, how much of a Very much problem has the treatment for your A lot skin been, for example by making A little your home messy, or by taking up time? Not at all Not relevant Please check you have answered EVERY question. Thank you. ã AY Finlay, GK Khan, April this must not be copied without the permission of the authors.

38 PEST PEST, psoriasis epidemiology screening tool.

39 Useful websites For patients g.uk/skininformation/atozof Skindisease/Psoriasis.aspx Dermatology websites patient leaflets DLQI questionnaires DLQI, dermatology life quality index.

40 Questions

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