The Psoriasis Consultation

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1 The Psoriasis Consultation This section of the Psoriasis Consultation is designed to be used with the patient and for both the pharmacist and patient to refer to during the consultation. Remember that you must use your professional judgement when talking to patients and that they may raise issues that are not addressed in this consultation guide. Questions and prompts How are you getting on with your medicines? Talk me through your medicines. Do you ever take medicines that you have purchased, either from a pharmacy or anywhere else? How do you use each of these medicines? How do you apply each preparation? When and how often do you apply each preparation? How long do you use each preparation for? Key messages Discuss the condition being managed as well as medicines. 10,15 Take care whilst communicating with patients to discuss in terms of on-going management and control rather than cure. 6-8 Counsel patients not to use a quinine-based anti-malarials, e.g. doxycycline, for trips to malarial areas. Counsel patients with chronic pain, such as those with psoriatic arthropathy, on pain management strategies to reduce the need for NSAIDs. Discuss when and where to apply each treatment, how much and how often for how long. 6-8 Reinforce the important role continuous use of emollient therapy and medicated shampoos play in soothing skin and improving effectiveness of other treatments. 1,6,8-10 Rubbing topical preparations vigorously into plaques may be painful and will cause itchiness, instead wipe smoothly into plaques. 15 Remission is achieved when plaques are flat and cannot be felt by running a finger over them, at this point step down from emollient therapy (and medicated shampoo) and topical treatment to emollient therapy (and medicated shampoo) only. Any remaining discolouration will disappear on its own after a few weeks. 1 Counsel on the use of topical corticosteroids in terms of finger-tip units. 6 With vitamin D analogues, advise in terms of the number of tubes per week. 6 Use emollient/vehicle testers to demonstrate the application of different treatments. 10,15 Emollients should ideally be applied every three hours, 9 so where not already supported by a patient's repeat prescription, consider recommending a range of emollients: larger quantities; ointments at night, whilst many patients will want less greasy preparations for use during the day; and a range of container sizes so compact containers are available for use during the day in handbag, rucksack, etc. Do you have any problems or concerns with your medicines? How do you feel about using these preparations/medicines? Do you have any concerns about using these preparations/medicines? Steroid phobia can be overcome by reassuring patients of their safety. This is also is a good opportunity to advise on finger-tip units and using emollients to enhance effectiveness and reduce discomfort. Do you think they are working? Is this different from what you were expecting? Do you know why this medicine/preparation has been prescribed to you? Tell me in your own words what you think it is for. Do you think it works? Do you know how it works? Ensure treatments and emollients are being used regularly. Remission varies from person to person. Cont d The production of this document has been made possible by an educational grant from LEO Pharma. The company has had no editorial input into the content

2 The Psoriasis Consultation Questions and prompts Do you think you are having any side-effects or unexpected effects? Describe those effects for me. Key messages Use the SPC (from to discuss with patient. People often miss applications of their medicines at times for a wide range of reasons. Have you missed an application of your medicine or changed when, or how often, you apply it? How and when do you use/apply your medicines/preparations? How often have you not applied your medicines in the last two weeks? Why? Do you ever change the way in which you use it? When do you change it and why? If adherence to topical treatment is limited by cosmetic acceptability, use emollient/vehicle testers to help patients find acceptable alternatives. Do you have anything else that you would like to ask about your medicines or is there anything that you would like me to go over again? Are you happy with the information you have about your condition and medicines? Have you been given any written information about your condition and medicines? Have you got information on your condition and medicines from any other source (for example, the internet)? Read the leaflets provided with each preparation. Signpost to the support groups and resources on the main document. Reinforce verbal advice with written information, educational literature, and details of other resources including websites and support groups. 1,6-10,15 Images can help facilitate explanations: the PCDS website, Danderm and DermNet NZ are also useful resources for images of skin conditions. Stress can trigger flare-ups, stress management and relaxation guidance may therefore help. 8 Patients need social support: friends, family and colleagues may harbour misconceptions about the condition or even falsely perceive psoriasis as infectious, a simple explanation can change these misconceptions. 8 There is a correlation between high alcohol intake, smoking, and psoriasis: smoking cessation and reducing alcohol intake will aid health and wellbeing and could improve psoriasis. 6-8 Sun exposure helps clear flare-ups of psoriasis, but overexposure can trigger flare-ups and there is also the risk of skin cancer; avoidance of UV lamps and overexposure to sunlight is strongly advised. 6-8 No dietary modifications have been shown to improve psoriasis; a normal, healthy diet is advised. 8

3 Treatments prescribed for psoriasis Treatments How it works Advantages Disadvantages Optimisation Emollient therapy Use continuously and long-term with leave-on emollients being prescribed in large quantities to support liberal and regular use, and soap substitutes being used in place of cleansing products. Emollients are used in addition to active treatments and regardless of the type of psoriasis. 10 Reduces itching and scaling, softens cracked skin, and supports the maintenance of remission. 6-9 Extremely safe and important to achieving treatment aims. 6,7 Very mild flare-ups may be managed with emollients alone. 15 Emollients can improve absorption of other treatments. 6-9 Limited efficacy, except white soft paraffin in light liquid paraffin 50/50 which can be more effective than other emollients in reducing scaling. 7 Using ointments or very rich creams in the evening to reduce dryness and cracking during the night. Creams can be refrigerated to better soothe itching. Apply creams liberally to affected areas 30 minutes before other topical anti-psoriasis treatments are used so they better penetrate hard plaques. 6-9 Ensure the richest/greasiest emollient is prescribed, and that the patient is happy to apply liberally and frequently. Prescribe enough volume to encourage copious use. 1 Ideally, the goal is to apply emollients every three hours (around six times a day). 9 Topical Corticosteroids As plaques are thick, weaker steroids are only of use on the face and flexures, also there is a tendency for plaques to return when treatment is stopped; this means side-effects to topical corticosteroids are more common in psoriasis as long courses of potent steroids are needed to prevent rebound psoriasis. 6-9 Moderate potency topical corticosteroids (or more potent on the scalp, palms or soles) are recommended for localised plaque psoriasis, but may be inappropriate for widespread lesions due to the risk of side-effects. 10 Reduce inflammation and itching, and thin plaques. Effective, clean and convenient. 7 Rebound psoriasis on discontinuation necessitates regular treatment, leading to high risk of cutaneous atrophy. 7 Potent topical steroids should not be used regularly for more than 8 weeks and very potent topical steroids should not be used regularly for more than 4 weeks. Topical corticosteroids should be alternated with a non-corticosteroid treatment during a 4 week break. 12 No unsupervised repeats should be allowed and patients should be reviewed every 3 months. Not more than 100g of moderately potent/stronger corticosteroids should be used in a month. Patients should be advised how much corticosteroid to apply in terms of finger-tip units: the amount squeezed from the tip of the index finger to the first crease being applied to an area the size of the flat of both hands with the fingers together. 6,15 Salicylic acid Ingredient in some emollients, scalp treatments and topical corticosteroids. 8,9 Keratolytic: reduces heavy scaling. 8,9 Effectively reduces heavy scaling, allowing other treatments to penetrate. 8,9 Irritates unaffected surrounding skin. 8,9 Where there is heavy scaling, de-scaling is important before applying treatments, as they cannot penetrate this. Coal tar Ingredient in some emollients, scalp treatments and topical corticosteroids. 8,9 Reduces skin cell turnover, reduces itching and inflammation as well as reducing and preventing scaling. Effective and safe (carcinogenicity risk is theoretical). 7 Very good at removing heavy scaling and reducing itching. 6-9 Newer, milder formulations like Exorex for thin plaques that are large or widespread (recommended first line). 1 Inconvenient due to long contact time, can be messy and smelly. It can stain clothing (not a problem with newer, milder formulations). 6-9 For scalp psoriasis a coal tar based shampoo should be used continuously and long-term to improve treatment and maintain remission. Should be left in for at least 10 minutes before rinsing off and used at least 3 times a week. 6-9 Short-contact dithranol Short-contact dithranol is still the most effective topical treatment for psoriasis, but is not commonly used due to very limited patient acceptability. 1 NB. Recommended contact time varies from minutes depending on source of guidance. 6-9 Dithranol slows down cell turnover by inhibiting DNA replication and key enzymes; it is rubbed in gently then washed from hands and removed after a short period of time. Very effective and safe with prolonged remission. 2,7 Staining of skin, clothing, linen, bath and upholstery. 6-9 Irritation may limit efficacy and can cause sensitivity to sunlight. 7 Dithranol stains clothes and linen, and can permanently stain bath or shower if not washed off immediately after contact occurs. 8,9 It irritates healthy skin so should only be applied to plaques, and should not be used on the face, flexures or for widespread small lesions The concentration is increased every 3-5 days as tolerated and is stopped temporarily if inflammation occurs, restarted when inflammation settles down, and discontinued when plaques can no longer be felt, which should take about 6 weeks. Dithranol stains plaques brown, this will fade over a couple of weeks when treatment has been completed. 6-9 Cont d

4 Treatments prescribed for psoriasis Treatments How it works Advantages Disadvantages Optimisation Vitamin D analogues Vitamin D analogues are the most popular first-line treatment for psoriasis as they are clean, non-staining, and can be used safely long-term. The main side-effect is skin irritation, particularly of the face, flexures, buttocks and genitals. 6-9 Calcitriol and tacalcitol are less irritant than the more commonly prescribed calcipotriol, and hence may be better tolerated on these areas. 6,10 Improve cell differentiation and slow down cell turnover. 6-9 Effective, clean and convenient. 7 Constant treatment required due to short duration of remission. 7 Irritation, particularly with calcipotriol (calcipotriol not appropriate for facial, flexural or genital psoriasis). 7 Risk of hypercalcaemia with overuse of tacalcitol. 7 Tacalcitol is applied once daily whilst calcipotriol and calcitriol are applied twice daily. Due to their effects on calcium homeostasis the vitamin D analogues can only be used on a maximum of a third of the body s surface, and the amount applied weekly needs to be limited: calcipotriol 100g (15g/day), calcitriol 210g (30g/day), tacalcitol 70g (10g/day). 6,9 Dovobet gel contains betametasone and calcipotriol, it is recommended first-line for non-widespread psoriasis, as it is more effective than vitamin D analogues or topical steroids individually whilst only needing to be applied once daily. 1 Due to the addition of the corticosteroid, it is recommended that Dovobet is used for no longer than 8 weeks at a time (4 weeks for scalp treatment), with repeated treatments after medical review and application limited to small quantities (15g/day, 100g/week). 6,8,9,14 Vitamin A analogues (Retinoids) Tazarotene (Zorac ) may be prescribed where other topical treatments are unsuitable or ineffective. 1,6 Improve cell differentiation and slow down cell turnover. 6 Clean and convenient. 7 Irritant, teratogenic and limited efficacy. 7 Should not be used on more than 10% of the body so should not be prescribed for psoriasis affecting more than 10% of the body. 1,6 As with the use of other topical retinoids, patients need to avoid UV lamps and overexposure to sunlight due to photosensitivity; using sunscreen and applying at night reduces this risk. Women of child-bearing age need to use adequate contraceptive protection due to the risk of teratogenicity. 6,8,9 Tazarotene can cause significant irritation, particularly to uninvolved skin surrounding plaques, a topical corticosteroids may need to be applied at the other end of the day (corticosteroid in the morning and tazarotene at night) to reduce this irritation 1,6 Topical calcineurin inhibitors Psoriasis is an unlicensed indication for calcineurin inhibitors; however, there is growing clinical experience in their use for the management of face, flexural and genital psoriasis to prevent prolonged treatment with topical corticosteroids and avoid the irritation caused by vitamin D analogues on such areas where the skin is thinner and more sensitive. 1,7 Reduce inflammation and itching. 1,7 Better tolerated than vitamin D analogues and avoids prolonged corticosteroid treatment on relatively thin, delicate skin. 1 Unlicensed indication and relatively limited experience of efficacy and safety. 1,7 Use is unlicensed and any problems or concerns should be reported immediately to the prescriber. A list of references can be found at the end of the Psoriasis Consultation Toolkit. This table is correct at the time of writing and should be used in conjunction with the patient information leaflet for the medicine(s). You should refer to the latest Summary of Product Characteristics for full drug information, including dosing, and use other reference sources such as the British National Formulary and current NICE guidance.

5 References 1. Psoriasis. Primary Care Dermatology Society. 20th January Available at: <accessed 24th January 2013> 2. Scottish Intercollegiate Guidelines Network. Diagnosis and management of psoriasis and psoriatic arthritis in adults. Clinical Guideline 121. Edinburgh: SIGN, Available at: <accessed 25th May 2013> 3. The All Party Parliamentary Group on Skin. An Investigation into the Adequacy of Service Provision and Treatments for Patients with Skin Diseases in the UK. London: The Stationery Office, NHS Primary Care Commissioning. Quality Standards for Dermatology: Providing the right care for people with skin conditions. NHS PCC; Available at: <accessed 24th January 2013> 5. The Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions London: Department of Health, Available at: https://www.gov.uk/government/publications/pharmaceutical-services-advanced-and-enhanced-services-england-directions Clark C, Langleben D. The management and treatment of skin conditions: An open learning course for pharmacists. CPPE. HMSO, Berth-Jones J. Psoriasis. Medicine 2009;37(5): Psoriasis an Overview. The British Association of Dermatologists. March Available at: <accessed 24th January 2013> 9. Topical Treatments for Psoriasis. The British Association of Dermatologists. September Available at: <accessed 24th January 2013> 10. British Association of Dermatologists and Primary Care Dermatology Society. Recommendations for the initial management of psoriasis. eguidelines 2009;39: Available at: <accessed 24th January 2013> 11. Psoriasis. Medscape. 22nd April Available at: <accessed 28th July 2013> 12. National Institute for Health and Clinical Excellence. Psoriasis: The assessment and management of psoriasis. Clinical Guideline 153. London: NICE, Available at: <accessed 25th May 2013> 13. National Patient Safety Agency. Improving compliance with oral methotrexate guidelines. Patient Safety Alert 13. London: NPSA, Available at: <accessed 28th July 2013> 14. Summary of Product Characteristics. Dovovet Gel. 28th March Available at: <accessed 24th January 2013> 15. National Prescribing Centre. Using topical corticosteroids in general practice. MeReC Bulletin 1999;10(6): Guidelines for the management of psoriasis. Journal of Dermatological Treatment 1997;8: This Psoriasis consultation knowledge update, psoriasis consultation brief and psoriasis consultation record form are Copyright protected under UK and international law. We produced this document to help increase the knowledge, confidence and skills of pharmacists and other health professionals in best practice treatment of psoriasis, in order to improve patient care. This fact sheet may be reproduced for personal use, and the psoriasis patient record form can be reproduced to be used for the purpose of patient consultation in a one to one patient health professional consultation. You may not use this work for any commercial purposes, nor may it be used as supporting content for any commercial product or service. You may not alter, transform, or build upon this work. All copies of this work must clearly display the original copyright notice and website address:

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