July 29, 2024 • 24 mins
Do you ever wonder if you are managing your psoriasis in the best way?
This episode will give you a comprehensive overview of what treatments are available for your GP to prescribe to you. Listen along to also hear:
- The general lifestyle principles you should be applying at home
- Why it’s important to get your psoriasis under control, quickly
- Which areas are tricky to treat, including the nails, face and scalp
- Why you should always tell your doctor about aches and pains when you have psoriasis
- When psoriasis is too severe to be treated at the doctor's surgery and when you might need to be referred to a specialist
Thank you to our kind sponsor AproDerm, who provide a range of emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
Everyone’s skin is unique and what works for one person, may not work for another. That’s why AproDerm has developed the AproDerm Emollient Starter Pack. This pack contains all four of their emollients varying in their formulation, consistency and hydration, giving you the choice to find a routine which suits you.
Find out more here.
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We hope you find this podcast interesting and helpful. Please leave us a review or email info@aproderm.com with any feedback on this episode or suggestions on skin-related topics that you would like to hear about in future podcasts.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:10):
Hello and welcome to this Skin Deeppodcast where we look at skin-related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP although I've now retiredfrom my practice and I was the Chair
of the Dermatology Council for England.
(00:31):
Now, today, George and I are goingto be talking about the management
of psoriasis and discussing thepossible options that are available
to you if you suffer from psoriasis.
This is the second of two podcasts aboutthis very common condition and if you
were with us for the first one, wherewe talked about the basics of psoriasis,
I do hope that you found it helpful.
(00:56):
But to kick off this week'spodcast, let's not dive into
medication straight away, George.
Let's chat first about generaltreatment principles that
people should be thinking of.
And I think we need to remember we'retalking mainly, in our practices,
about people that we're seeing withchronic stable plaque psoriasis,
scalp psoriasis, and sometimes whatwe call guttate psoriasis, aren't we?
(01:19):
Right, yes.
Well, thank you very much.
Last time we talked about someof the things that can aggravate
and trigger flares of psoriasis.
So, really important to think aboutthose and do what you can to avoid those.
I'm thinking here about smoking andalcohol and whether some medication
that you're on by mouth might bemaking things worse, and so on.
(01:40):
But I think it's really important,I think doctors don't understand
this well enough, but psoriasis isa dry skin condition and dry skin
conditions are made worse by detergents.
So, when I see somebody with chronicstable plaque psoriasis, that's
psoriasis on the backs of their elbows,predominantly, the fronts of their knees.
(02:02):
It's fairly symmetrically, often ontheir buttocks and all over their body,
covering quite large areas sometimes.
No one has actually sat down and toldthem, "tell me, how do you wash?"
You mustn't wash with soaps and showergels and detergents on your skin.
They will degrease the skin.
They will make this dry skin conditionmore dry and they will make things worse.
(02:24):
Instead, you should be washingwith an emollient soap substitute.
For example, the AproDerm® Gelor the AproDerm® Cream will
be absolutely ideal for that.
They're buffered to the normal pHof the skin, and they are regreasing
the skin rather than degreasing it,and they're moisturising the skin.
So really, really important message there.
(02:46):
And when you use a shampoo,shampoos are potent detergents.
So, if you allow that to washover your skin, it will dry
out the skin significantly.
So, ideally wash your hair but don't getthe shampoo then rinsing over your body.
At the very least, lean rightforward in the shower and rinse it
off your body, not onto your body.
(03:07):
Very important message there.
But then coming on to the sort oftreatments we can use, they have
improved dramatically during my career.
When I was a young doctor we didn'thave any of the vitamin D analogues.
These are creams and ointments thathave a vitamin D-like agent in them.
We only had tars and dithranoland things like that, which are
(03:28):
messy and stained and smelt.
But, vitamin D's transformedthe landscape, in the mid 1990s
or early 1990s, with Dovonex®,the first one, calcipotriol.
Quite irritant.
It can certainly make things like eczemaworse, but the vitamin D analogues really
deal very, very well with the excess scaleand the background problems in psoriasis.
(03:55):
And they're clean, they don'tsmell and they're highly effective,
so they're definitely an option.
It's an inflammatory skin condition, andso just as in other inflammatory skin
conditions, like for example, eczema,topical steroids are highly effective.
So sometimes people want to use avitamin D once in the morning, for
(04:16):
example, and a topical steroid at night.
It's not a regime I go for tobe honest, it means two separate
prescriptions, it's a bit confusing.
It just generally, is more complicated.
We now have combination treatments.
They've been around sincethe start of this century.
And when they first came out, thecombination of vitamin D and a
(04:36):
potent topical steroid, we suddenlydiscovered that these have a synergy.
They are massively more effectivethan these two agents used
separately, on the same patient.
So, almost overnight movedto using combinations.
And the one that we had for along time was called Dovobet®
ointment and Dovobet® gel.
A very, very good treatment for chronicstable plaque psoriasis, it works a treat.
(05:03):
But about eight years ago, the companywho make Dovobet® gel reformulated it into
a foam, which is called Enstilar® foam.
And I have to say, I don't know aboutyou Roger, but I think that of all
the topical treatments that we havedeveloped this century, that is up
there as one of my absolute favourites.
(05:24):
Yes, me too.
I found it really, really helpful.
Obviously, as GPs, we have the luxuryof having some choice over what we
prefer to prescribe for our patients.
We all have our own particularfavourites, but with that one,
I'm absolutely in accord with you.
It's a game changer,absolute game changer.
It works very fast because theactive ingredients can penetrate
(05:46):
the plaques of psoriasis.
Whereas in the gel, the Dovobet® gel,they're in a crystalline state and
so they can't penetrate so easily.
And I find it can work onchronic stable plaque psoriasis.
It starts working within a week.
And, I've seen phenomenalimprovement by four weeks.
The other nice thing about the foam,the Enstilar® foam, its got a licence
(06:09):
for long-term maintenance therapy.
So you only need to use it oncea day, put it on at bedtime.
It's quite, quite greasy stuff.
And you basically, you give thecanister a good vigorous shake, and
then you spray from about two inchesfor two seconds, and that gives a
little foam ball, which is enough totreat about 1% of your body's surface
area, which is the size of one palm.
So you can work outroughly how much you need.
(06:31):
You only need to use it once a day.
It soaks in quite nicely,although it leaves an oily film.
After about four weeks, the chances arethat your psoriasis has melted away.
You'd be unlucky if it hasn't.
Definitely the vast majority of patientssee marked improvement by four weeks.
And then you can drop down to maintenancetreatment, which is using it just twice
a week on two non-consecutive nights.
(06:52):
So, for example, Wednesday nightand Sunday night and keep the
psoriasis completely at bay.
One of the things about plaquesof psoriasis is that they make the
chemicals that feed psoriasis and so,getting psoriasis under control starves
the psoriasis, if that makes sense.
So you can break that vicious cycle.
(07:14):
And so I'm very eager, when I seesomeone with psoriasis, to knock
back this inflammation, because it'sbad for their body, it's bad for
their arteries, it's bad for theirpsychology, it's bad for everything.
So I want to hit it hard, get control,and break that cycle if I can, and
then hopefully try and keep things atbay, with soap avoidance, emollients,
(07:36):
and I love sunlight, non-burning,non-peeling, sensible sunlight.
We use that as a treatment for alot of skin conditions, but some
sensible, natural sunlight therapywill do wonders for psoriasis.
We even use it as a treatment.
So, a bit of sensible, natural sunlighttherapy can help to keep psoriasis at bay.
(08:00):
But if all that's not working, we can goback to the tars, which we used to use.
They're smelly.
You need to use themup to six times a day.
They can be a bit irritant.
I don't use dithranol anymore, but,when I was in practice, I was probably
prescribing it to a patient once a year.
In my practice, about 50 GPs usedto send all their patients with
difficult skin problems my way.
(08:21):
So I was seeing a lot of psoriasis.
Only then, once a year, was it an option.
But if all that fails, then you needto be talking to your doctor about
considering seeing a specialist becausethey've got a number of second-line
treatments, which have their drawbacks.
And if those aren't working, we have gotthe most amazing products, the biologicals
(08:42):
now, which have completely changed theexperience of patients with psoriasis.
Patients with severe psoriasis can havetheir psoriasis turned off completely
and so those are absolutely revolutionarythis century, and every year or so,
a new one comes out which is evenmore targeted, even more powerful,
(09:04):
even more dramatic, so, fantastic.
They are, it's probably worthmentioning that those are not treatments
that GPs have direct access to.
They are, from hospital specialists.
I think fortunately for you andI, George, facial psoriasis,
although it does, does occur, isn'tthat common, which is fortunate.
(09:27):
But an awful lot of what you've justsaid, general measures do apply, if
you do have facial psoriasis, butthere are one or two other potential
treatments if you do have it on the face.
Fortunately, it is pretty rare, isn't it?
Well again, soap avoidance and usingquality emollients, and I think
(09:49):
using a quality leave-on emollient,for example, the AproDerm® Colloidal
Oat [Cream] would be an excellentleave-on emollient to use on the face.
Try and limit the amount ofother chemicals and things
that are going on there.
Bit of natural sunlight therapy helpsbut often we're into using treatments
off-licence here, and you may need to usea potent topical steroid for the face.
(10:10):
I was anxious about using that, partlybecause you can aggravate some other skin
conditions around the face, as well asthe skin on the face being quite thin.
The treatment that really works,and I really think the company that
make it need to be asking for alicence, because it's not licensed.
But the treatment that works atreat for psoriasis on the face,
interestingly, is a treatment for eczemacalled Protopic®, topical tacrolimus.
(10:34):
And if I had psoriasis on my face,apart from some sensible natural
sunlight therapy and emollients and soapavoidance, I would be using Protopic®
ointment once a day off-licence.
And usually within two or threeweeks, you've controlled it.
And then you can go back to using theemollients and the soap avoidance.
But it's a tricky area and oftenyou need to ask the help of a
(10:58):
specialist, a dermatologist.
Talking of tricky areas, and people areoften surprised when you mention this,
is psoriasis of the nails, it's notjust, the big skin patches, we've got to
think about, sometimes it's the nails.
Now you and I both know these are reallytricky things to treat because you've got
a dirty great hard nail that doesn't wantstuff soaking into it all of the time.
(11:21):
Yes, they are, theyare notoriously tricky.
Often you need to use treatments bymouth, or, light therapy in the hospital,
what's called PUVA, which stands for,you give the patient psoralen which
makes their skin sensitive to sunlightand then you expose them to UVA.
So, PUVA.
Can be effective.
But yeah, if you've got a nailthat's lifted off from the nail bed.
(11:42):
And often has a bit of, quite a lotof scale under there, but if you can
trickle things like the Enstilar® Foamunder there, that can be effective.
Because the psoriasis is affectingthe nail bed, and the nail plate
is just getting in the way.
Yeah.
So, that's an optionthere, but it is tricky.
Remember, if you've got nail disease,that's a marker for psoriatic arthritis.
(12:03):
So, it's a situation where if you'vegot any hint of joint pains, you
must alert your doctor to that.
Yeah, I think for me, this is oneof the messages from the wayside
pulpit in this podcast, it's soimportant for people to take away.
Psoriatic arthritis is notjust minor aches and pains.
It is a sign of active jointinflammation and unfortunately
(12:26):
sometimes joint destruction.
So if you do have psoriasis and you dohave joint inflammation, if you've got
swollen joints, painful joints, back pain,as we've mentioned before, you must always
let your doctor know that, mustn't you?
You must, and you must make sure yourdoctor takes some action because, unlike
psoriasis on the skin, where it canreturn back to normal skin, and it usually
(12:48):
does, not always, but nearly alwaysreturns to normal skin, if you've got
arthritis due to psoriasis, in the joints,then it is causing permanent damage.
And if you don't address that andcontrol it fast, you'll end up
with permanently destroyed joints.
So, it demands, even if I was adermatologist, specialising in
(13:09):
psoriasis, if I had a patient, andI suspected psoriatic arthritis,
I'd be going around and talking toa rheumatologist there and then.
It needs urgent rheumatologicaljoint specialist involvement, and it
needs to be controlled definitively.
Which they can do normally.
So, the sort of drugs and treatmentsthat they have at their disposal,
(13:30):
will hopefully keep it controlled.
But it's not something tosay, let's see how it goes.
It's important to take action.
And that's a really good example,as to why we call this podcast 'Skin
Deep', because psoriasis is morethan just a skin deep condition.
It is a full body, top to toepotential condition, affecting,
(13:50):
so many parts of the body.
So if you are listening and do havejoint issues, then do let your GP know.
The same way the scalp is socommonly affected as well.
My back of an envelope calculationis about, four out of five
psoriasis patients I see do have,a degree of scalp psoriasis.
(14:11):
And this is, really tricky, because,and it's human nature, if you've
got psoriasis in your scalp,you don't want people to see it.
So you, if you're able to, unlikeyou and I, George, you grow a thick,
bushy head of hair to hide it.
But that can actually make treatmentslightly more difficult if we're using
it on, on thick, bushy heads of hair.
(14:32):
So, if we're not careful, we'vegot this Catch-22 going on.
So, how do you tend to managepeople with scalp psoriasis?
Well, as you say, it is very,very common and it often isn't
manifested because people hide it.
But it can be very itchyand very disabling.
Therefore it's really importantas doctors always to ask about
(14:53):
that and to examine for it.
Well, the old-fashioned treatmentsused to work, but they were messy.
Things like Cocois® and Sebco™and took a lot of effort to get
them onto the head and then to getthem out again the next morning.
An important message, none ofthese treatments work on the
hair, they work on the skin.
So, you've got to get them downonto that scalp, which often
(15:15):
means making a parting and thenmassaging them down onto the scalp.
And in the old days, I used to talk topeople and patients about the importance
of trying to get rid of the scale.
And we have descaling treatments.
One's called DiproSalic®.
Salicylic acid digests scale and so helpsto descale it, in the hope that then
other treatments would get through thescale and down onto the affected area.
(15:38):
But I found that Enstilar®works an absolute treat.
So this Enstilar® foam, if youmassage it down onto the scalp, last
thing at night, fairly generously.
Some will get on the hair,inevitably, it doesn't matter.
But get it down onto the scalpand then leave it there overnight.
In the morning, you'll need to wash itout with adding shampoo to dry hair.
(16:02):
If you wet your hair first,the water will just wash off.
So, you need to put shampoo, massagethat into the hair and then, then
rinse that off with plenty of water.
Don't leave the shampoo in the hair.
And I have to say, I think, if you canget hold of a tar shampoo, my favourite
used to be Alphosyl®2in1, 2 in 1, becauseit's got a conditioner, but I gathered
Alphosyl®2in1 is not currently beingmanufactured and is unavailable, but
(16:25):
there's T/Gel® and there's Polytar.
So, Enstilar® is absolutelybrilliant, in my experience.
If that fails, then we'reon to, second-line agents,
drugs by mouth and the like.
Light therapy isn't going to workbecause the hair gets in the way.
And there's a shampoo that has a potenttopical steroid in it, which you massage
(16:47):
that onto the scalp, leave it therefor a quarter of an hour, and then
you wash it out with plenty of soap.
But no, the scalp is trickybecause of wretched hair.
You and I are very lucky, aren't we,that we, don't have that problem.
[Inaudible] My mum used to saygrass doesn't grow on a busy road.
(17:08):
I think she was just being kind.
So, guttate psoriasis is something,that we often see in practice.
And again, we might need tolook at the treatment of this
in a particular logical way.
What's your normal take on that?
It's usually a young person and it'soften their first manifestation of
(17:29):
their genetic tendency to psoriasisand basically what happens here is they
have a really nasty, typically a sorethroat, but it doesn't have to be a
streptococcal infection in the throat.
And then 10 days to a fortnight later,they suddenly get these large number
of small plaques all over their body.
Little plaques of psoriasislooking like psoriasis elsewhere,
(17:51):
scaly, red, sharply demarcated.
And it can last for evenup to six months or longer.
But it's usually self-limiting.
Though in about a third ofpatients, it progresses to
chronic stable plaque psoriasis.
Although it's triggered by astreptococcal infection, usually
(18:12):
in the throat, antibiotics don'tmake any difference at all.
So I don't recommend those, unlessthe patient is remaining critically
ill from the streptococcal infection.
Obviously, emollients are reallyimportant, and I've been stressing
those all the way through.
So I think emollients have a very, veryimportant role here, and I won't go
into the details of how to use those.
(18:32):
Tar lotions are quite good.
They help to relieve the milditch and irritation it can cause,
but they smell and they stain.
But you can use those up to five or sixtimes a day and would be very effective.
The main stay, for treatment for this,if you want treatment, is to be referred
to secondary care for light therapy andthere's no point going to the routine
(18:57):
circle for that because you'll bewaiting for months and months and months.
By the time you get an appointment it'stoo late, so it's a situation where,
you're going to go down that road,you either unfortunately, have to go
privately or ask your GP to phone thehospital and see if they can slip you in.
Because it responds very,very nicely to, light therapy.
And with that in mind, I sometimes sayto patients, look, if you are prepared
(19:17):
to get in the back garden and take yourshirt off and get your skin exposed to the
sun, and not burn, and not peel, at all,but get some sensible natural sunlight
therapy, that would definitely help.
There is a treatment that I recommend formy patients, and it's not one that most
GPs would feel comfortable doing, becauseit's absolutely not licensed for this,
(19:40):
but the Enstilar® foam I've been speakingso highly about does work a treat.
And I think that it is areasonable option to consider.
But, your GP will say, "I'm sorry, I'mnot that familiar with it perhaps, and
I'm certainly not going to be usingit off-licence in this situation.
It's not in the guidance."
(20:01):
But, in my experience, it does workvery nicely indeed, and so, you can save
the patient having to be referred on tohospital, but the company who make it
are not going to be seeking a licence forthis particular use, but it's an option.
You can get guttatepsoriasis more than once.
I've seen one patient who had guttatepsoriasis three times, but more
usually, once you've had it once,when you next have a streptococcal
(20:22):
infection, it just aggravateschronic stable plaque psoriasis.
Yeah, and if someone's listening who'sgot psoriasis, on their flexures, if
I can use that term, again, similaradvice, but again, one or two,
slightly different possible optionsthat their doctor might think about?
(20:43):
Yes.
I mean, by flexures, we usually meanunder the breasts, in the armpits, in
the crack between the buttocks and inthe groin, those sort of areas, and
also the umbilicus, on the tummy button.
I can't overstress the importanceof avoiding soaps and detergents
and using quality emollientsand emollient soap substitutes.
That's such an important part of this.
(21:05):
Again, tars work quite well in thisarea, and less of a problem from the
smell because it's more covered up skin.
There's a treatment we usenormally for fungal infections
and thrush called Daktarin™.
Miconazole is the active ingredient.
Interestingly, that does seem to workquite nicely for flexural psoriasis.
(21:25):
So that's a nice gentletreatment that works there.
But occasionally you do need togo in with more powerful things
and so I would consider even amoderately potent topical steroid.
I'd probably use it as a creamin this area because it's often a
bit slippery and wet and moist andan ointment would just slip off.
I should have said when I talked aboutthe scalp that often scalp psoriasis
(21:46):
is complicated by some dandruff.
Doctors call this seborrhoeic dermatitis.
And dandruff seems to like theskin that psoriasis causes, and
psoriasis likes damaged skin thatseborrhoeic dermatitis causes.
So the two commonly go together.
So using an anti-dandruff shampoo, likeketoconazole, can be very effective.
(22:07):
And often in the flexures, you get someseborrhoeic dermatitis, the same sort
of condition, same yeast that causesdandruff, causes a rash in the flexures.
And psoriasis gets into that as well,and the two make each other worse.
So a treatment for seborrhoeic dermatitis,again, with something like an anti-yeast
(22:28):
cream, my favourite would be ketoconazolecream, can work really, really well there.
Occasionally it's thrushaggravating things, and so an
anti-thrush cream can help.
I have tried the off-licence Protopic®,I mentioned for the face, in the
flexures and it can help a little bit.
It's less effective, lessdramatic than it is on the face.
(22:49):
But that's another optionyou could consider.
But, if you've got difficult, andtroublesome flexural psoriasis, and
the diagnosis is correct, it's oftenmisdiagnosed and often missed, but
if it is flexural psoriasis, andit's not responding, then I think
that's a situation where it's veryreasonable to ask to see a specialist.
Yeah.
Agreed.
And we've pretty much sort of gonefrom the top of the head to the end
(23:11):
of the nails, here in this podcast.
So I think it's a good place to finishit and, to people listening, George and I
hope you found it interesting and helpful.
Roger and I do hope you'll join us againin two weeks time when we'll be discussing
another skin-related condition and we'dalso once again like to thank our sponsor
AproDerm® for all their help in puttingthese Skin Deep podcasts together.
(23:33):
We couldn't have done it without them.
So, until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
Hello and welcome to this Skin Deeppodcast where we look at skin-related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP although I've now retiredfrom my practice and I was the Chair
of the Dermatology Council for England.
(00:31):
Now, today, George and I are goingto be talking about the management
of psoriasis and discussing thepossible options that are available
to you if you suffer from psoriasis.
This is the second of two podcasts aboutthis very common condition and if you
were with us for the first one, wherewe talked about the basics of psoriasis,
I do hope that you found it helpful.
(00:56):
But to kick off this week'spodcast, let's not dive into
medication straight away, George.
Let's chat first about generaltreatment principles that
people should be thinking of.
And I think we need to remember we'retalking mainly, in our practices,
about people that we're seeing withchronic stable plaque psoriasis,
scalp psoriasis, and sometimes whatwe call guttate psoriasis, aren't we?
(01:19):
Right, yes.
Well, thank you very much.
Last time we talked about someof the things that can aggravate
and trigger flares of psoriasis.
So, really important to think aboutthose and do what you can to avoid those.
I'm thinking here about smoking andalcohol and whether some medication
that you're on by mouth might bemaking things worse, and so on.
(01:40):
But I think it's really important,I think doctors don't understand
this well enough, but psoriasis isa dry skin condition and dry skin
conditions are made worse by detergents.
So, when I see somebody with chronicstable plaque psoriasis, that's
psoriasis on the backs of their elbows,predominantly, the fronts of their knees.
(02:02):
It's fairly symmetrically, often ontheir buttocks and all over their body,
covering quite large areas sometimes.
No one has actually sat down and toldthem, "tell me, how do you wash?"
You mustn't wash with soaps and showergels and detergents on your skin.
They will degrease the skin.
They will make this dry skin conditionmore dry and they will make things worse.
(02:24):
Instead, you should be washingwith an emollient soap substitute.
For example, the AproDerm® Gelor the AproDerm® Cream will
be absolutely ideal for that.
They're buffered to the normal pHof the skin, and they are regreasing
the skin rather than degreasing it,and they're moisturising the skin.
So really, really important message there.
(02:46):
And when you use a shampoo,shampoos are potent detergents.
So, if you allow that to washover your skin, it will dry
out the skin significantly.
So, ideally wash your hair but don't getthe shampoo then rinsing over your body.
At the very least, lean rightforward in the shower and rinse it
off your body, not onto your body.
(03:07):
Very important message there.
But then coming on to the sort oftreatments we can use, they have
improved dramatically during my career.
When I was a young doctor we didn'thave any of the vitamin D analogues.
These are creams and ointments thathave a vitamin D-like agent in them.
We only had tars and dithranoland things like that, which are
(03:28):
messy and stained and smelt.
But, vitamin D's transformedthe landscape, in the mid 1990s
or early 1990s, with Dovonex®,the first one, calcipotriol.
Quite irritant.
It can certainly make things like eczemaworse, but the vitamin D analogues really
deal very, very well with the excess scaleand the background problems in psoriasis.
(03:55):
And they're clean, they don'tsmell and they're highly effective,
so they're definitely an option.
It's an inflammatory skin condition, andso just as in other inflammatory skin
conditions, like for example, eczema,topical steroids are highly effective.
So sometimes people want to use avitamin D once in the morning, for
(04:16):
example, and a topical steroid at night.
It's not a regime I go for tobe honest, it means two separate
prescriptions, it's a bit confusing.
It just generally, is more complicated.
We now have combination treatments.
They've been around sincethe start of this century.
And when they first came out, thecombination of vitamin D and a
(04:36):
potent topical steroid, we suddenlydiscovered that these have a synergy.
They are massively more effectivethan these two agents used
separately, on the same patient.
So, almost overnight movedto using combinations.
And the one that we had for along time was called Dovobet®
ointment and Dovobet® gel.
A very, very good treatment for chronicstable plaque psoriasis, it works a treat.
(05:03):
But about eight years ago, the companywho make Dovobet® gel reformulated it into
a foam, which is called Enstilar® foam.
And I have to say, I don't know aboutyou Roger, but I think that of all
the topical treatments that we havedeveloped this century, that is up
there as one of my absolute favourites.
(05:24):
Yes, me too.
I found it really, really helpful.
Obviously, as GPs, we have the luxuryof having some choice over what we
prefer to prescribe for our patients.
We all have our own particularfavourites, but with that one,
I'm absolutely in accord with you.
It's a game changer,absolute game changer.
It works very fast because theactive ingredients can penetrate
(05:46):
the plaques of psoriasis.
Whereas in the gel, the Dovobet® gel,they're in a crystalline state and
so they can't penetrate so easily.
And I find it can work onchronic stable plaque psoriasis.
It starts working within a week.
And, I've seen phenomenalimprovement by four weeks.
The other nice thing about the foam,the Enstilar® foam, its got a licence
(06:09):
for long-term maintenance therapy.
So you only need to use it oncea day, put it on at bedtime.
It's quite, quite greasy stuff.
And you basically, you give thecanister a good vigorous shake, and
then you spray from about two inchesfor two seconds, and that gives a
little foam ball, which is enough totreat about 1% of your body's surface
area, which is the size of one palm.
So you can work outroughly how much you need.
(06:31):
You only need to use it once a day.
It soaks in quite nicely,although it leaves an oily film.
After about four weeks, the chances arethat your psoriasis has melted away.
You'd be unlucky if it hasn't.
Definitely the vast majority of patientssee marked improvement by four weeks.
And then you can drop down to maintenancetreatment, which is using it just twice
a week on two non-consecutive nights.
(06:52):
So, for example, Wednesday nightand Sunday night and keep the
psoriasis completely at bay.
One of the things about plaquesof psoriasis is that they make the
chemicals that feed psoriasis and so,getting psoriasis under control starves
the psoriasis, if that makes sense.
So you can break that vicious cycle.
(07:14):
And so I'm very eager, when I seesomeone with psoriasis, to knock
back this inflammation, because it'sbad for their body, it's bad for
their arteries, it's bad for theirpsychology, it's bad for everything.
So I want to hit it hard, get control,and break that cycle if I can, and
then hopefully try and keep things atbay, with soap avoidance, emollients,
(07:36):
and I love sunlight, non-burning,non-peeling, sensible sunlight.
We use that as a treatment for alot of skin conditions, but some
sensible, natural sunlight therapywill do wonders for psoriasis.
We even use it as a treatment.
So, a bit of sensible, natural sunlighttherapy can help to keep psoriasis at bay.
(08:00):
But if all that's not working, we can goback to the tars, which we used to use.
They're smelly.
You need to use themup to six times a day.
They can be a bit irritant.
I don't use dithranol anymore, but,when I was in practice, I was probably
prescribing it to a patient once a year.
In my practice, about 50 GPs usedto send all their patients with
difficult skin problems my way.
(08:21):
So I was seeing a lot of psoriasis.
Only then, once a year, was it an option.
But if all that fails, then you needto be talking to your doctor about
considering seeing a specialist becausethey've got a number of second-line
treatments, which have their drawbacks.
And if those aren't working, we have gotthe most amazing products, the biologicals
(08:42):
now, which have completely changed theexperience of patients with psoriasis.
Patients with severe psoriasis can havetheir psoriasis turned off completely
and so those are absolutely revolutionarythis century, and every year or so,
a new one comes out which is evenmore targeted, even more powerful,
(09:04):
even more dramatic, so, fantastic.
They are, it's probably worthmentioning that those are not treatments
that GPs have direct access to.
They are, from hospital specialists.
I think fortunately for you andI, George, facial psoriasis,
although it does, does occur, isn'tthat common, which is fortunate.
(09:27):
But an awful lot of what you've justsaid, general measures do apply, if
you do have facial psoriasis, butthere are one or two other potential
treatments if you do have it on the face.
Fortunately, it is pretty rare, isn't it?
Well again, soap avoidance and usingquality emollients, and I think
(09:49):
using a quality leave-on emollient,for example, the AproDerm® Colloidal
Oat [Cream] would be an excellentleave-on emollient to use on the face.
Try and limit the amount ofother chemicals and things
that are going on there.
Bit of natural sunlight therapy helpsbut often we're into using treatments
off-licence here, and you may need to usea potent topical steroid for the face.
(10:10):
I was anxious about using that, partlybecause you can aggravate some other skin
conditions around the face, as well asthe skin on the face being quite thin.
The treatment that really works,and I really think the company that
make it need to be asking for alicence, because it's not licensed.
But the treatment that works atreat for psoriasis on the face,
interestingly, is a treatment for eczemacalled Protopic®, topical tacrolimus.
(10:34):
And if I had psoriasis on my face,apart from some sensible natural
sunlight therapy and emollients and soapavoidance, I would be using Protopic®
ointment once a day off-licence.
And usually within two or threeweeks, you've controlled it.
And then you can go back to using theemollients and the soap avoidance.
But it's a tricky area and oftenyou need to ask the help of a
(10:58):
specialist, a dermatologist.
Talking of tricky areas, and people areoften surprised when you mention this,
is psoriasis of the nails, it's notjust, the big skin patches, we've got to
think about, sometimes it's the nails.
Now you and I both know these are reallytricky things to treat because you've got
a dirty great hard nail that doesn't wantstuff soaking into it all of the time.
(11:21):
Yes, they are, theyare notoriously tricky.
Often you need to use treatments bymouth, or, light therapy in the hospital,
what's called PUVA, which stands for,you give the patient psoralen which
makes their skin sensitive to sunlightand then you expose them to UVA.
So, PUVA.
Can be effective.
But yeah, if you've got a nailthat's lifted off from the nail bed.
(11:42):
And often has a bit of, quite a lotof scale under there, but if you can
trickle things like the Enstilar® Foamunder there, that can be effective.
Because the psoriasis is affectingthe nail bed, and the nail plate
is just getting in the way.
Yeah.
So, that's an optionthere, but it is tricky.
Remember, if you've got nail disease,that's a marker for psoriatic arthritis.
(12:03):
So, it's a situation where if you'vegot any hint of joint pains, you
must alert your doctor to that.
Yeah, I think for me, this is oneof the messages from the wayside
pulpit in this podcast, it's soimportant for people to take away.
Psoriatic arthritis is notjust minor aches and pains.
It is a sign of active jointinflammation and unfortunately
(12:26):
sometimes joint destruction.
So if you do have psoriasis and you dohave joint inflammation, if you've got
swollen joints, painful joints, back pain,as we've mentioned before, you must always
let your doctor know that, mustn't you?
You must, and you must make sure yourdoctor takes some action because, unlike
psoriasis on the skin, where it canreturn back to normal skin, and it usually
(12:48):
does, not always, but nearly alwaysreturns to normal skin, if you've got
arthritis due to psoriasis, in the joints,then it is causing permanent damage.
And if you don't address that andcontrol it fast, you'll end up
with permanently destroyed joints.
So, it demands, even if I was adermatologist, specialising in
(13:09):
psoriasis, if I had a patient, andI suspected psoriatic arthritis,
I'd be going around and talking toa rheumatologist there and then.
It needs urgent rheumatologicaljoint specialist involvement, and it
needs to be controlled definitively.
Which they can do normally.
So, the sort of drugs and treatmentsthat they have at their disposal,
(13:30):
will hopefully keep it controlled.
But it's not something tosay, let's see how it goes.
It's important to take action.
And that's a really good example,as to why we call this podcast 'Skin
Deep', because psoriasis is morethan just a skin deep condition.
It is a full body, top to toepotential condition, affecting,
(13:50):
so many parts of the body.
So if you are listening and do havejoint issues, then do let your GP know.
The same way the scalp is socommonly affected as well.
My back of an envelope calculationis about, four out of five
psoriasis patients I see do have,a degree of scalp psoriasis.
(14:11):
And this is, really tricky, because,and it's human nature, if you've
got psoriasis in your scalp,you don't want people to see it.
So you, if you're able to, unlikeyou and I, George, you grow a thick,
bushy head of hair to hide it.
But that can actually make treatmentslightly more difficult if we're using
it on, on thick, bushy heads of hair.
(14:32):
So, if we're not careful, we'vegot this Catch-22 going on.
So, how do you tend to managepeople with scalp psoriasis?
Well, as you say, it is very,very common and it often isn't
manifested because people hide it.
But it can be very itchyand very disabling.
Therefore it's really importantas doctors always to ask about
(14:53):
that and to examine for it.
Well, the old-fashioned treatmentsused to work, but they were messy.
Things like Cocois® and Sebco™and took a lot of effort to get
them onto the head and then to getthem out again the next morning.
An important message, none ofthese treatments work on the
hair, they work on the skin.
So, you've got to get them downonto that scalp, which often
(15:15):
means making a parting and thenmassaging them down onto the scalp.
And in the old days, I used to talk topeople and patients about the importance
of trying to get rid of the scale.
And we have descaling treatments.
One's called DiproSalic®.
Salicylic acid digests scale and so helpsto descale it, in the hope that then
other treatments would get through thescale and down onto the affected area.
(15:38):
But I found that Enstilar®works an absolute treat.
So this Enstilar® foam, if youmassage it down onto the scalp, last
thing at night, fairly generously.
Some will get on the hair,inevitably, it doesn't matter.
But get it down onto the scalpand then leave it there overnight.
In the morning, you'll need to wash itout with adding shampoo to dry hair.
(16:02):
If you wet your hair first,the water will just wash off.
So, you need to put shampoo, massagethat into the hair and then, then
rinse that off with plenty of water.
Don't leave the shampoo in the hair.
And I have to say, I think, if you canget hold of a tar shampoo, my favourite
used to be Alphosyl®2in1, 2 in 1, becauseit's got a conditioner, but I gathered
Alphosyl®2in1 is not currently beingmanufactured and is unavailable, but
(16:25):
there's T/Gel® and there's Polytar.
So, Enstilar® is absolutelybrilliant, in my experience.
If that fails, then we'reon to, second-line agents,
drugs by mouth and the like.
Light therapy isn't going to workbecause the hair gets in the way.
And there's a shampoo that has a potenttopical steroid in it, which you massage
(16:47):
that onto the scalp, leave it therefor a quarter of an hour, and then
you wash it out with plenty of soap.
But no, the scalp is trickybecause of wretched hair.
You and I are very lucky, aren't we,that we, don't have that problem.
[Inaudible] My mum used to saygrass doesn't grow on a busy road.
(17:08):
I think she was just being kind.
So, guttate psoriasis is something,that we often see in practice.
And again, we might need tolook at the treatment of this
in a particular logical way.
What's your normal take on that?
It's usually a young person and it'soften their first manifestation of
(17:29):
their genetic tendency to psoriasisand basically what happens here is they
have a really nasty, typically a sorethroat, but it doesn't have to be a
streptococcal infection in the throat.
And then 10 days to a fortnight later,they suddenly get these large number
of small plaques all over their body.
Little plaques of psoriasislooking like psoriasis elsewhere,
(17:51):
scaly, red, sharply demarcated.
And it can last for evenup to six months or longer.
But it's usually self-limiting.
Though in about a third ofpatients, it progresses to
chronic stable plaque psoriasis.
Although it's triggered by astreptococcal infection, usually
(18:12):
in the throat, antibiotics don'tmake any difference at all.
So I don't recommend those, unlessthe patient is remaining critically
ill from the streptococcal infection.
Obviously, emollients are reallyimportant, and I've been stressing
those all the way through.
So I think emollients have a very, veryimportant role here, and I won't go
into the details of how to use those.
(18:32):
Tar lotions are quite good.
They help to relieve the milditch and irritation it can cause,
but they smell and they stain.
But you can use those up to five or sixtimes a day and would be very effective.
The main stay, for treatment for this,if you want treatment, is to be referred
to secondary care for light therapy andthere's no point going to the routine
(18:57):
circle for that because you'll bewaiting for months and months and months.
By the time you get an appointment it'stoo late, so it's a situation where,
you're going to go down that road,you either unfortunately, have to go
privately or ask your GP to phone thehospital and see if they can slip you in.
Because it responds very,very nicely to, light therapy.
And with that in mind, I sometimes sayto patients, look, if you are prepared
(19:17):
to get in the back garden and take yourshirt off and get your skin exposed to the
sun, and not burn, and not peel, at all,but get some sensible natural sunlight
therapy, that would definitely help.
There is a treatment that I recommend formy patients, and it's not one that most
GPs would feel comfortable doing, becauseit's absolutely not licensed for this,
(19:40):
but the Enstilar® foam I've been speakingso highly about does work a treat.
And I think that it is areasonable option to consider.
But, your GP will say, "I'm sorry, I'mnot that familiar with it perhaps, and
I'm certainly not going to be usingit off-licence in this situation.
It's not in the guidance."
(20:01):
But, in my experience, it does workvery nicely indeed, and so, you can save
the patient having to be referred on tohospital, but the company who make it
are not going to be seeking a licence forthis particular use, but it's an option.
You can get guttatepsoriasis more than once.
I've seen one patient who had guttatepsoriasis three times, but more
usually, once you've had it once,when you next have a streptococcal
(20:22):
infection, it just aggravateschronic stable plaque psoriasis.
Yeah, and if someone's listening who'sgot psoriasis, on their flexures, if
I can use that term, again, similaradvice, but again, one or two,
slightly different possible optionsthat their doctor might think about?
(20:43):
Yes.
I mean, by flexures, we usually meanunder the breasts, in the armpits, in
the crack between the buttocks and inthe groin, those sort of areas, and
also the umbilicus, on the tummy button.
I can't overstress the importanceof avoiding soaps and detergents
and using quality emollientsand emollient soap substitutes.
That's such an important part of this.
(21:05):
Again, tars work quite well in thisarea, and less of a problem from the
smell because it's more covered up skin.
There's a treatment we usenormally for fungal infections
and thrush called Daktarin™.
Miconazole is the active ingredient.
Interestingly, that does seem to workquite nicely for flexural psoriasis.
(21:25):
So that's a nice gentletreatment that works there.
But occasionally you do need togo in with more powerful things
and so I would consider even amoderately potent topical steroid.
I'd probably use it as a creamin this area because it's often a
bit slippery and wet and moist andan ointment would just slip off.
I should have said when I talked aboutthe scalp that often scalp psoriasis
(21:46):
is complicated by some dandruff.
Doctors call this seborrhoeic dermatitis.
And dandruff seems to like theskin that psoriasis causes, and
psoriasis likes damaged skin thatseborrhoeic dermatitis causes.
So the two commonly go together.
So using an anti-dandruff shampoo, likeketoconazole, can be very effective.
(22:07):
And often in the flexures, you get someseborrhoeic dermatitis, the same sort
of condition, same yeast that causesdandruff, causes a rash in the flexures.
And psoriasis gets into that as well,and the two make each other worse.
So a treatment for seborrhoeic dermatitis,again, with something like an anti-yeast
(22:28):
cream, my favourite would be ketoconazolecream, can work really, really well there.
Occasionally it's thrushaggravating things, and so an
anti-thrush cream can help.
I have tried the off-licence Protopic®,I mentioned for the face, in the
flexures and it can help a little bit.
It's less effective, lessdramatic than it is on the face.
(22:49):
But that's another optionyou could consider.
But, if you've got difficult, andtroublesome flexural psoriasis, and
the diagnosis is correct, it's oftenmisdiagnosed and often missed, but
if it is flexural psoriasis, andit's not responding, then I think
that's a situation where it's veryreasonable to ask to see a specialist.
Yeah.
Agreed.
And we've pretty much sort of gonefrom the top of the head to the end
(23:11):
of the nails, here in this podcast.
So I think it's a good place to finishit and, to people listening, George and I
hope you found it interesting and helpful.
Roger and I do hope you'll join us againin two weeks time when we'll be discussing
another skin-related condition and we'dalso once again like to thank our sponsor
AproDerm® for all their help in puttingthese Skin Deep podcasts together.
(23:33):
We couldn't have done it without them.
So, until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
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