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Chronic Plaque Psoriasis

Depending on patients' wishes, appropriate management includes the option of no active treatment. If active treatment is required, most patients can be adequately managed with topical agents of proven efficacy including the use of a simple emollient, dithranol, corticosteroids and vitamin D analogues. Each patient must be individually assessed. Large individual psoriatic plaques can be treated with dithranol, tar or vitamin D analogues. Smaller and more numerous lesions are more difficult to treat with  dithranol, but vitamin D analogues, mild tar preparations and corticosteroid are still appropriate. The effect of topical treatments can usually be enhanced by UVB phototherapy.

Care is needed when a patient's psoriasis is in an inflammatory, eruptive or unstable phase. In these circumstances, the skin may show general, non-specific irritancy to topical agents, and treatment should be confined to emollients or low concentrations of tar, corticosteroids or dithranol.

Guttate Psoriasis

In most cases, guttate (exanthematous papulosquamous) psoriasis is a self-limiting condition. Many patients who have one attack of guttate psoriasis have no further relapses. The general principles for treatment outlined above are applicable to guttate psoriasis. Erupting guttate psoriasis is commonly less tolerant of topical therapy, and therefore calcipotriol, mild or moderately potent corticosteroids, or low concentrations of tar and dithranol should be used. UVB phototherapy may be helpful. A proportion of patients with acute guttate psoriasis have evidence of recent streptococcal infection, which can be confirmed by culture examination of a throat swab and by determination of the serum antistreptolysin O titre. Evidence does not support a therapeutic benefit from antibiotic therapy. However, repeated attacks of guttate psoriasis after well documented episodes of tonsillitis represent an indication for tonsillectomy.

Localised Pustular Psoriasis of Palms and Soles

Pustular psoriasis of the palms and soles is a relatively rare form of chronic psoriasis typified by multiple sterile pustules. Treatment is unsatisfactory but calcipotriol or a potent topical corticosteroid may help. Topical coal tar and dithranol may also be of some benefit and some success can be achieved with the systemic agent acitretin or with photochemotherapy (8 methoxypsoralen-UVA phototherapy; PUVA). In disabling palmoplantar psoriasis systemic therapy may be required with acitretin or methotrexate.

Generalised Pustular and Erythrodermic psoriasis

For the small group of patients with these forms of psoriasis, initial management usually consists of admission to hospital and the use of systemic agents.

Psoriasis of the Scalp

This form of plaque psoriasis can be difficult to manage especially in a domiciliary setting. Thick scale should be softened, by olive, coconut or arachis oil, ideally applied under occlusion (e.g. using a plastic shower cap or cling film), then removed using a detergent shampoo. This can be followed by applications of a coal tar, dithranol, or a topical steroid or vitamin D analogue preparation. Topical salicylic acid preparations, e.g. 2% salicylic acid in a cream base such as Unguentum M, or coconut oil ointment (e.g. Cocois scalp ointment), can be used to remove thick scale from the scalp.

This information forms part of the current BAD guidance document for the general management of psoriasis.  Other sections in the document comprise: