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13.5.2 Preparations for psoriasis

Topical Preparations
Calcipotriol / betamethasone ointment, gel, cutaneous foam
Diprosalic ointment
Dithranol cream, in Lassar's paste
Dithrocrem
Dovonex cream
Leeds pomade
Liquid paraffin in w.s.p 50%
Tacalcitol ointment
Tazarotene gel
Salicylic acid ointment BP
Zinc and salicylic acid (Lassar's) paste/half-strength Lassar's paste
8-methoxypsoralen tablets, lotion, gel (consultant dermatologist use only)
5-methoxypsoralen tablets (for patients intolerant of 8-methoxypsoralen) (consultant dermatologist use only)

 

Oral preparations for psoriasis
Acitretin capsules - link to Drug Safety Update June 2013 - oral retinoids pregnancy prevention reminder

 

Notes:

1. For mild conditions, treatment, other than reassurance and bland emollients may be unnecessary.

2. Mild or chronic plaque psoriasis can be treated with preparations of salicylic acid, coal tar, calcipotriol or low strength dithranol (e.g. 'Dithrocream'), all of which are fairly cosmetically acceptable.


3. Salicylic acid may be used for all hyperkeratotic and scaling conditions to enhance the rate of loss of surface scale.

4. Coal tar is more active than salicylic acid and has anti-inflammatory and antiscaling properties. The formulation and strength depends on patient acceptability and severity of the condition; the 'thicker' the patch of eczema or psoriasis the stronger the concentration required.

5. Dithrocream ('dithranol) is very effective and convenient if applied for short contact applications (e.g. 30-60 minutes). Apply sparingly to the lesions only, starting with the lowest strength and progressing to higher strengths if necessary.

6. Unaffected skin around lesions should be protected with soft paraffin. Cream or ointment should be applied for 10 minutes daily before washing off. Increase application time by 10 minutes every 3 days (providing there is no excessive skin irritation) until application is 30 minutes daily. If tolerance to dithranol is unknown, commence with lowest strength. Some patients are intolerant to dithrano even in low concentrations; it is important to recognise them early in treatment because continued use can result in their psoriasis becoming unstable. Fair skin is more sensitive than dark skin.

7. Calcipotriol a vitamin D analogue which is the treatment of first choice in mild to moderate psoriasis affecting up to 40% of skin area. Patient acceptability of calcipotriol is high, as it is better tolerated by 'normal' skin, is odourless and does not stain skin and clothing. It should not be applied to the face where it can cause dermatitis, and limited to not more than 100g weekly.

8. Tacalcitol is reserved for patients who cannot tolerate the irritant side effects of calcipotriol, and those with lesions at sites where calcipotriol/steroids cannot be used: flexures, genitalia and face.

9. Very active or severe psoriasis requires hospital-based treatment under the supervision of a dermatologist. These include acitretin methotexate and ciclosporin.

10. Dovobet is reserved for patients with stable plaque psoriasis covering less than 30% of the body surface who have not responded to other topical treatments including Dovonex. It should be prescribed once daily for 4 weeks only, with review at that time. If skin is clear, then Dovobet should be stopped and emollients prescribed. If improved, but not clear, switch to Doxonex. If no better, stop Dovobet and refer. An interval of at least 4 weeks is recommended between courses of Dovobet treatment.

Scalp Psoriasis

For scalp psoriasis combination therapy is usual; choices include a tar shampoo, Sebco / Cocois scalp ointment, leeds pomade, and topical steroid scalp lotions. A steroid/salicylic acid combination may also be used e.g. betamethason0.05% with salicylic acid 3% (Diprosalic scalp application).

Sebco / Cocois scalp ointment is often useful for removing the thick scales of scalp psoriasis. Calcipotriol scalp application appears less effective than steroid treatments for scalp psoriasis.

For link to BNF section: 13.5.2 Preparations for psoriasis