Psoriasis is a chronic, inflammatory skin condition characterized by red, scaly plaques. It has various clinical presentations including plaque, guttate, pustular, and erythrodermic forms. Treatment involves targeting the dual processes of inflammation and rapid skin cell turnover, using topical agents for mild disease and phototherapy or systemic drugs for more severe cases. Management requires a personalized approach considering disease characteristics and patient factors.

1. PSORIASIS MANAGEMENT IN
THE COMMUNITY
BY
DR U.B.BUHARI
GPwER
FRCGP
MHA

2. What is psoriasis?
Classic definition
– Primary Care Dermatology Society (UK)
PCDS Psoriasis Guideline. Available from: http://www.pcds.org.uk/clinical-guidance/psoriasis-an-overview. Last accessed: September 2018.
Psoriasis is a common, genetically
determined, inflammatory and proliferative
disorder of the skin, the most characteristic
lesions consisting of chronic, sharply
demarcated, dull-red, scaly plaques,
particularly on the
extensor prominences and in the scalp.

3. What is psoriasis?
Modern definition –
Not just a skin disease
Reich K et al. J Eur Acad Dermatol Venereol 2012;26 (Suppl 2):3–11.
Psoriasis is a systemic, immune-mediated
disorder, characterised by inflammatory
skin and joint manifestations. Psoriasis is
associated with a range of comorbidities
including metabolic diseases, such as
diabetes, and psychological disorders.

4. • Psoriasis is an inflammatory skin disease in which skin cells
replicate at an extremely rapid rate. New skin cells are produced
about eight times faster than normal--over several days instead of
a month--but the rate at which old cells slough off is unchanged.
This causes cells to build up on the skin's surface, forming thick
patches, or plaques, of red sores (lesions) covered with flaky,
silvery-white dead skin cells (scales).

5. Factors affecting psoriasis
Triggers Affect disease severity
Trauma2
•Köbner phenomenon
Infection1
•Streptococcal throat infection
strongly associated with the
onset/flaring of guttate PsO
Smoking1
•Risk factor for palmoplantar
pustulosis
Pregnancy3
•PsO may improve in pregnancy
Drugs1
•Wide range of medicines reported
to exacerbate PsO
Stress1
•May worsen symptoms
•The data is conflicting
Alcohol1
•Heavy drinking more common in
psoriasis patients
•Resulting reduction in compliance
HIV1
•Higher incidence of PsO in HIV
patients
Sunlight2
•Generally beneficial – advice
caution!
1. Neimann AL et al. Expert Rev Dermatol 2006;1:63-75
2. Buxton PK. BMJ 1987;295:904-906.
3. Murase JE et al. Arch Dermatol 2005;141:601-606.

6. Aetiology – lifetime risk1
1. Neimann AL et al. Expert Rev Dermatol 2006;1:63-75.
Sibling with psoriasis
(Lifetime risk 8%)
One parent affected
(Lifetime risk 16%)
Both parents affected
(Lifetime risk up to 50%)

7. Epidemiology
In the UK, the prevalence of psoriasis is estimated
to be ~1.3–2.2%1
In Ireland, the prevalence is estimated to be 1.6%2
The cause of psoriasis is not fully understood but a
number of risk factors are recognised, such as family
history and stress3,4
Psoriasis can develop at any age, but it is
uncommon in children and a majority of cases occur
before 35 years of age1
Both sexes are equally affected3
1. NICE Psoriasis Clinical Guideline CG153. Available from: https://www.nice.org.uk/guidance/cg153. Last accessed: September 2018.
2. Irish Skin Foundation. The Burden of Psoriasis 2015. Available from https://irishskin.ie/wp-content/uploads/2016/08/Burden_of_Psoriasis_Report_final.pdf. Last accessed:
September 2018.
3. PCDS Psoriasis Guideline. Available from: http://www.pcds.org.uk/clinical-guidance/psoriasis-an-overview. Last accessed: September 2018.
4. Parisi R et al. J Invest Dermatol. 2013;133:377–385.

8. Initial presentation and diagnosis of chronic
plaque psoriasis
Symmetrically distributed, red,
scaly plaques with well-defined
edges
Scale is typically silvery white,
except
in skin folds where plaques appear
shiny
Most common sites are
scalp, elbows and knees
Itch is mostly mild but may be
severe in some patients, leading
to scratching and lichenification
DermNet New Zealand. Psoriasis. Available from: https://www.dermnetnz.org/topics/psoriasis. Last accessed: September 2018.
Images from DermNet NZ,
www.dermnet.org.nz

9. Clinical Presentation
• Erythematous, raised patches with
silvery scales
• Symmetric
• Pruritic/ Painful
• Pitting Nails
• Arthritis in 10-20% of patients

10. • Chronic plaque psoriasis is the most common psoriasis
variant, but others also exist
Clinical presentation of psoriasis variants
Flexural
• Thin, sharply demarcated
and shiny erythmatous
plaques
• Scale is minimal to absent
Pustular
• Uncommon manifestation
• Eruption of sterile pustules
Guttate
• Acute eruption of
monomorphic, pink, oval
papules with silvery scale
Ladizinski B et al. Adv Skin Wound Care 2013;26:271–284.
Images reproduced with the permission of the Primary Care Dermatology Society © PCDS 2015

11. • Psoriasis patients can show signs of psoriatic arthritis
and be localised to specific areas
Psoriasis can be highly localised or
associated with arthritis
Palmoplantar
• Localised to the palms or soles
• Red, scaly plaques or patchy thickening of
entire surface of palm or sole
Psoriatic arthritis
• A painful, inflammatory condition of the
joints, sometimes leading to joint deformity
• Usually occurs in association with skin
psoriasis
DermNet New Zealand. Psoriasis. Available from: https://www.dermnetnz.org/topics/psoriasis. Last accessed: September 2018.

12. • Eczema and plaque psoriasis can sometimes look similar.
Key differences between plaque psoriasis
and eczema
In eczema1
• Diffuse patches
of erythema,
often dry and
lichenified
• In adults,
commonly
localised on
hands, eyelids
and flexures but
can occur
elsewhere
• Sometimes fine
scaling but is not
a key feature
In psoriasis2
• Plaques are well-
defined, dull red
with scale layer
of varying
thickness
• Most commonly
on the scalp and
extensor surface
of elbows and
knees
• Silvery-white
layer of adherent
scales is a key
feature
VS
1. PCDS Eczema Guideline. Available from: http://www.pcds.org.uk/clinical-guidance/atopic-eczema. Last accessed: September 2018.
2. DermNet New Zealand. Psoriasis. Available from: https://www.dermnetnz.org/topics/psoriasis. Last accessed: September 2018.
Image from DermNet NZ, www.dermnet.org.nz Image from DermNet NZ, www.dermnet.org.nz

14. Types of Psoriasis
• Scalp psoriasis
• Nail psoriasis
• Chronic plaque psoriasis
• Genital psoriasis
• Palmoplantar psoriasis
• Guttate psoriasis
• Flexural psoriasis
• Erythrodermic psoriasis
• Pustular psoriasis – PPP, Acropustulosis and
generalised (Von Zumbusch)
• Psoriatic Arthropathy

15. Targeting dual disease processes
1. Ryan S. Br J Nurs 2010;19:822-5
Two key disease processes underlie psoriasis1
Cell proliferation
AIM:
Prevent the infiltration of
inflammatory cells into the
epidermis
AIM:
Reduced cell turnover
time and reduce scale
Inflammation

16. Management of Psoriasis
• Reinforce the fact that whilst we cannot cure the
problem, we can at least manage it.
• As a general rule in treating psoriasis; mild-to-
moderate psoriasis can often be managed with
topical agents, while moderate-to-severe disease
may need phototherapy or systemic therapy.
• NICE defined severe disease as a PASI ≥10 with a
DLQI > 10; where PASI is not applicable, a BSA
≥10% or a disease associated with significant
functional or psychological morbidity (acral, facial,
palmoplanter, head, neck and genital psoriasis.

17. Treatment options
• There can be substantial variation between individuals in
the effectiveness of specific psoriasis treatments. Because
of this, dermatologists often use a trial-and-error
approach to finding the most appropriate treatment for
their patient.
• The decision to employ a particular treatment is based on
the type of psoriasis, its location, extent and severity. The
patient’s age, gender, quality of life, comorbidities, and
attitude toward risks associated with the treatment are
also taken into consideration.

18. • 80% of patients with psoriasis
will develop scalp disease
• The occipital or frontal margins
or behind the ears are the best
sites to find scalp psoriasis.
• Pityriasis Amianatacea large
bran like flakes are seen.
Scalp Psoriasis

19. Scalp Psoriasis
Cocois Ointment
Etrivex Shampoo
Diprosalic scalp application
-Leave overnight
-Use shower cap
-Twice a week/daily
-If itchy
-Leave for 5 minutes
- Twice a day
for 2 weeks

20. From the 3rd week :
Cocois Ointment
Capasal / Alphosyl 2:1 /
Dermax / Ceanel
Dovobet gel applicator
- Once a day for 2
months
-Once a week

21. Long Term :
Cocois Ointment
Shampoo as
above regularly
-Once a month
In the event of flare
up, restart as above

22. Nail Changes
• In 78% of psoriatic patients
• Fingernails>Toenails
• Four changes
1. Onycholysis (= separation from nail bed)
2. Pitting*
3. Subungual debris accumulation
4. Colour alterations- Salmon patch
*Pitting rules out a fungal infection

23. Nail psoriasis
Daily for 1-2 weeksDermovate ointment
Dovobet gel
Once a day for 4
weeks
Twice a week
for ~ 3 months
• Apply to nail fold edge
• Under distal nail plate
• Under occlusion overnight
• Refer 2⁰ care if no better
Switch
to
Then

24. Acrodermatitis Continua of
Hallopeau
–Although this is an entity in itself, most
dermatologists consider it to be a form of
Psoriasis.
–Chronic pustulation of the
distal digits.
–peeling of the skin which
is typically very painful.
–Treated with methotrexate
or biologics.

25. Chronic Plaque Psoriasis

26. Chronic plaque psoriasis
• Commonest type of psoriasis
(75 - 80%).
• The plaques are clearly
demarcated, hyperkeratotic
with a silvery scale on a
salmon pink base
demonstrated
• It affects scalp in 80% of
cases.
• Remember also to ask about
genital involvement

27. Trunk & Limbs Psoriasis
Dovobet ointment
/ Enstar foam
Diprosalic
ointment mocte
for thick plaques
Dovonex ointment
o.d / bd
NB
Refer to 2⁰ care for
resistant cases
4 – 8 weeks
For 4 weeks
Long term
+
Switch to
Flares

28. Genital psoriasis
30 - 40% of patients
with psoriasis may
develop genital
lesions at sites
including the vulva,
scrotum and penis

29. Flexural / Genital psoriasis
Eumovate
ointment
Silkis ointment
Protopic ointment
0.1%
Silkis ointment
Protopic ointment
0.1%
am
evening
night
am
Twice a week at
night
2 – 3
months
2 – 4
weeks
2 weeks
Then
Then
+
+

30. Chronic Plantar Psoriasis

31. Palmoplantar pustulosis
• Often over 50s
• Females more
• Smokers
• 25% have plaque psoriasis
• Hard to treat
• Occluded Betnovate or Dermovate if fails
• Refer for light or drugs

32. Palmoplantar Psoriasis
Dermovate
ointment
Dovobet oint am &
Diprosalic ointment nocte
Dovonex ointment
o.d / B.D
NB
Refer to 2⁰ care for
resistant cases
Under occlusion
for 2 weeks
For 4 weeks
Long term
Switch to
Switch to
Flares

33. Guttate Psoriasis

34. Guttate psoriasis
Use twice a day
Emollients
apply 30ml in bath
& Soak for 5 mins
- Exorex lotion or
- Psoriderm
cream or
- Alphosyl HC
Psoriderm bath
emollient
* Refer to 2⁰ care in
widespread or unresponsive
cases for narrow bond UVB
phototherapy
+
+

36. Facial psoriasis
Mid – moderate
topical steroids
Use morning
1-2 weeks
Use night
1-2 weeks
Vitamin D analogues
- curatoderm
lotion/oint
- Silkis oint.
Use morning
Vitamin D
analogues
Use night
Twice a week for
2-3 weeks
Use night
Protopic ointment
0.1%
*Protopic
ointment 0.1%
2 - 4
weeks
+
+
Then
Then
* Off
label

37. FLEXURAL PSORIASIS

38. Flexural (Inverse) Psoriasis
• Develop lesions in the axillae, natal clefts,below
breasts, umbilicus and medial aspects of thighs.
• Use mild topical steroids. Beware of risk of atrophy
and striae formation.
• Calcitriol (silkis) ointment is effective in
intertriginous areas.
• In the gluteal cleft it is worth trying a short burst of
Betnovate
• Topical immunomodulators are also
effective but warn about irritation.

39. Flexural / Genital psoriasis
Eumovate
ointment
Silkis ointment
Protopic ointment
0.1%
Silkis ointment
Protopic ointment
0.1%
am
evening
night
am
Twice a week at
night
2 – 3
months
2 – 4
weeks
2 weeks
Then
Then
+
+

41. Sebopsoriasis
• Overlap between two separate conditions -
seborrhoeic dermatitis and psoriasis.
• Most common in childhood/adolescence and then
increases in patients older than 50 years of age.
• Associated with - Immunosuppression
(eg chronic liver disease, HIV/AIDS, medication)
• Neurological and psychiatric diseases, including
Parkinson disease
• Disseminated malignant disease (cancer)

42. Sebopsoriasis - Mx
• Emollient – Act as a topical keratolytics.
• Topical Antifungal - Combination therapy
of topical corticosteroid and ketoconazole
shampoo is more effective than
ketoconazole shampoo alone.
• Oral antifungal agents
such as itraconazole may help some patients
with sebopsoriasis.

43. 43
Erythrodermic Psoriasis
Urgent referral

44. Generalised pustular
psoriasis
• This is a very unstable form
of psoriasis
• topical steroids should be
used at very weak
concentrations with care
• Pustular psoriasis may arise
when a patient
discontinues or reduces
doses of oral steroids.
• it may be fatal and progress
into ARDS and multiorgan
failure, sepsis etc.
• Urgent referral

45. • Joints are involved in ~ 7%
of individuals with psoriasis
• Rheumatoid Arthritis like
changes
• Joint involvement ranging
from mono arthropathy of
large joints.
• Require urgent referral
rheumatology/Dermatology
Joint Disease

46. Outcomes
• Outcomes can be difficult to quantify as they need
to take into account patient satisfaction and QOL
improvements
• DLQI forms – Derm life quality index used as
standard
Never forget psychological impact of this disease ….

47. Psoriasis Summary Management
Flexural / Genital Facial
Silkis oint (pm)
Trunk & Limb
Protopic oint 0.1%
(pm)
Hydrocortisone
oint 1% (am)
Dovobet / Enstilar
Diprosalic oint.
for Thick plaques
Dovonex oint o.d / bd
Protopic oint 0.1%
Twice a week
Eumovate oint
(am)
Silkis oint (am)
Silkis oint (pm)
Protopic oint 0.1%
(pm)
Protopic oint 0.1%
Twice a week
+
Switch
+
Silkis oint (am)
+
+
+
Then
Then
Then
Then

48. Psoriasis Summary management
Guttate Nail
Psoriderm cream
Scalp
Psoriderm bath
emollient
Dermovate oint.
Cocois oint.
Etrivex shampoo
Diprosalic scalp
application
Cocois oint
Capasal shampoo
(tar shampoo)
Dovobet gel
applicator
Emollients
Dovobet gel
+
+
Then
+
+
+
+

49. • Psoriasis is a lifelong condition.
• There is currently no cure but various treatments can help
to control the symptoms. Many of the most effective
agents used to treat severe psoriasis carry an increased
risk of significant morbidity including skin cancers,
lymphoma and liver disease.
• Psoriasis does get worse over time but it is not possible to
predict who will go on to develop extensive psoriasis or
those in whom the disease may appear to vanish.
• Individuals will often experience flares and remissions
throughout their lives. Controlling the signs and
symptoms typically requires lifelong therapy.
• Remember to sign the prescription with your HEART.
Summary