Hello and welcome to this Skin Deep podcast where we look at skin-related issues, conditions and treatments in an interesting and informed way. I'm Dr Roger Henderson. I'm a GP with a long-standing interest in this area of health. And I'm Dr George Moncrieff. I was also a GP although I've now retired from my practice and I was the Chair of the Dermatology Council for England.
Now, today, George and I are going to be talking about the management of psoriasis and discussing the possible options that are available to you if you suffer from psoriasis. This is the second of two podcasts about this very common condition and if you were with us for the first one, where we talked about the basics of psoriasis, I do hope that you found it helpful. But to kick off this week's podcast, let's not dive into medication straight away, George.
Let's chat first about general treatment principles that people should be thinking of. And I think we need to remember we're talking mainly, in our practices, about people that we're seeing with chronic stable plaque psoriasis, scalp psoriasis, and sometimes what we call guttate psoriasis, aren't we? Right, yes. Well, thank you very much. Last time we talked about some of the things that can aggravate and trigger flares of psoriasis.
So, really important to think about those and do what you can to avoid those. I'm thinking here about smoking and alcohol and whether some medication that you're on by mouth might be making things worse, and so on. But I think it's really important, I think doctors don't understand this well enough, but psoriasis is a dry skin condition and dry skin conditions are made worse by detergents.
So, when I see somebody with chronic stable plaque psoriasis, that's psoriasis on the backs of their elbows, predominantly, the fronts of their knees. It's fairly symmetrically, often on their buttocks and all over their body, covering quite large areas sometimes. No one has actually sat down and told them, "tell me, how do you wash?" You mustn't wash with soaps and shower gels and detergents on your skin. They will degrease the skin.
They will make this dry skin condition more dry and they will make things worse. Instead, you should be washing with an emollient soap substitute. For example, the AproDerm® Gel or the AproDerm® Cream will be absolutely ideal for that. They're buffered to the normal pH of the skin, and they are regreasing the skin rather than degreasing it, and they're moisturising the skin. So really, really important message there. And when you use a shampoo, shampoos are potent detergents.
So, if you allow that to wash over your skin, it will dry out the skin significantly. So, ideally wash your hair but don't get the shampoo then rinsing over your body. At the very least, lean right forward in the shower and rinse it off your body, not onto your body. Very important message there. But then coming on to the sort of treatments we can use, they have improved dramatically during my career. When I was a young doctor we didn't have any of the vitamin D analogues.
These are creams and ointments that have a vitamin D-like agent in them. We only had tars and dithranol and things like that, which are messy and stained and smelt. But, vitamin D's transformed the landscape, in the mid 1990s or early 1990s, with Dovonex®, the first one, calcipotriol. Quite irritant. It can certainly make things like eczema worse, but the vitamin D analogues really deal very, very well with the excess scale and the background problems in psoriasis.
And they're clean, they don't smell and they're highly effective, so they're definitely an option. It's an inflammatory skin condition, and so just as in other inflammatory skin conditions, like for example, eczema, topical steroids are highly effective. So sometimes people want to use a vitamin D once in the morning, for example, and a topical steroid at night. It's not a regime I go for to be 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 since the start of this century. And when they first came out, the combination of vitamin D and a potent topical steroid, we suddenly discovered that these have a synergy. They are massively more effective than these two agents used separately, on the same patient. So, almost overnight moved to using combinations. And the one that we had for a long time was called Dovobet® ointment and Dovobet® gel.
A very, very good treatment for chronic stable plaque psoriasis, it works a treat. But about eight years ago, the company who make Dovobet® gel reformulated it into a foam, which is called Enstilar® foam. And I have to say, I don't know about you Roger, but I think that of all the topical treatments that we have developed this century, that is up there as one of my absolute favourites. Yes, me too. I found it really, really helpful.
Obviously, as GPs, we have the luxury of having some choice over what we prefer to prescribe for our patients. We all have our own particular favourites, but with that one, I'm absolutely in accord with you. It's a game changer, absolute game changer. It works very fast because the active ingredients can penetrate 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 on chronic stable plaque psoriasis. It starts working within a week. And, I've seen phenomenal improvement by four weeks. The other nice thing about the foam, the Enstilar® foam, its got a licence for long-term maintenance therapy. So you only need to use it once a day, put it on at bedtime. It's quite, quite greasy stuff.
And you basically, you give the canister a good vigorous shake, and then you spray from about two inches for two seconds, and that gives a little foam ball, which is enough to treat about 1% of your body's surface area, which is the size of one palm. So you can work out roughly how much you need. 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 are that your psoriasis has melted away. You'd be unlucky if it hasn't.
Definitely the vast majority of patients see marked improvement by four weeks. And then you can drop down to maintenance treatment, which is using it just twice a week on two non-consecutive nights. So, for example, Wednesday night and Sunday night and keep the psoriasis completely at bay. One of the things about plaques of 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. And so I'm very eager, when I see someone with psoriasis, to knock back this inflammation, because it's bad for their body, it's bad for their arteries, it's bad for their psychology, 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 at bay, with soap avoidance, emollients, and I love sunlight, non-burning, non-peeling, sensible sunlight.
We use that as a treatment for a lot of skin conditions, but some sensible, natural sunlight therapy will do wonders for psoriasis. We even use it as a treatment. So, a bit of sensible, natural sunlight therapy can help to keep psoriasis at bay. But if all that's not working, we can go back to the tars, which we used to use. They're smelly. You need to use them up 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 used to send all their patients with difficult skin problems my way. So I was seeing a lot of psoriasis. Only then, once a year, was it an option. But if all that fails, then you need to be talking to your doctor about considering seeing a specialist because they've got a number of second-line treatments, which have their drawbacks.
And if those aren't working, we have got the most amazing products, the biologicals now, which have completely changed the experience of patients with psoriasis. Patients with severe psoriasis can have their psoriasis turned off completely and so those are absolutely revolutionary this century, and every year or so, a new one comes out which is even more targeted, even more powerful, even more dramatic, so, fantastic.
They are, it's probably worth mentioning that those are not treatments that GPs have direct access to. They are, from hospital specialists. I think fortunately for you and I, George, facial psoriasis, although it does, does occur, isn't that common, which is fortunate. But an awful lot of what you've just said, general measures do apply, if you do have facial psoriasis, but there 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 using quality emollients, and I think using a quality leave-on emollient, for example, the AproDerm® Colloidal Oat [Cream] would be an excellent leave-on emollient to use on the face. Try and limit the amount of other chemicals and things that are going on there. Bit of natural sunlight therapy helps but often we're into using treatments off-licence here, and you may need to use a potent topical steroid for the face.
I was anxious about using that, partly because you can aggravate some other skin conditions around the face, as well as the 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 a licence, because it's not licensed. But the treatment that works a treat for psoriasis on the face, interestingly, is a treatment for eczema called Protopic®, topical tacrolimus.
And if I had psoriasis on my face, apart from some sensible natural sunlight therapy and emollients and soap avoidance, I would be using Protopic® ointment once a day off-licence. And usually within two or three weeks, you've controlled it. And then you can go back to using the emollients and the soap avoidance. But it's a tricky area and often you need to ask the help of a specialist, a dermatologist.
Talking of tricky areas, and people are often surprised when you mention this, is psoriasis of the nails, it's not just, the big skin patches, we've got to think about, sometimes it's the nails. Now you and I both know these are really tricky things to treat because you've got a dirty great hard nail that doesn't want stuff soaking into it all of the time. Yes, they are, they are notoriously tricky.
Often you need to use treatments by mouth, or, light therapy in the hospital, what's called PUVA, which stands for, you give the patient psoralen which makes their skin sensitive to sunlight and then you expose them to UVA. So, PUVA. Can be effective. But yeah, if you've got a nail that's lifted off from the nail bed. And often has a bit of, quite a lot of scale under there, but if you can trickle things like the Enstilar® Foam under there, that can be effective.
Because the psoriasis is affecting the nail bed, and the nail plate is just getting in the way. Yeah. So, that's an option there, but it is tricky. Remember, if you've got nail disease, that's a marker for psoriatic arthritis. So, it's a situation where if you've got any hint of joint pains, you must alert your doctor to that. Yeah, I think for me, this is one of the messages from the wayside pulpit in this podcast, it's so important for people to take away.
Psoriatic arthritis is not just minor aches and pains. It is a sign of active joint inflammation and unfortunately sometimes joint destruction. So if you do have psoriasis and you do have 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 your doctor takes some action because, unlike psoriasis on the skin, where it can return back to normal skin, and it usually does, not always, but nearly always returns 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 and control it fast, you'll end up with permanently destroyed joints.
So, it demands, even if I was a dermatologist, specialising in psoriasis, if I had a patient, and I suspected psoriatic arthritis, I'd be going around and talking to a rheumatologist there and then. It needs urgent rheumatological joint specialist involvement, and it needs to be controlled definitively. Which they can do normally. So, the sort of drugs and treatments that they have at their disposal, will hopefully keep it controlled. But it's not something to say, 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 more than just a skin deep condition. It is a full body, top to toe potential condition, affecting, so many parts of the body. So if you are listening and do have joint issues, then do let your GP know. The same way the scalp is so commonly affected as well.
My back of an envelope calculation is about, four out of five psoriasis patients I see do have, a degree of scalp psoriasis. 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, unlike you and I, George, you grow a thick, bushy head of hair to hide it. But that can actually make treatment slightly more difficult if we're using it on, on thick, bushy heads of hair.
So, if we're not careful, we've got this Catch-22 going on. So, how do you tend to manage people 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 itchy and very disabling. Therefore it's really important as doctors always to ask about that and to examine for it. Well, the old-fashioned treatments used 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 get them out again the next morning. An important message, none of these treatments work on the hair, they work on the skin. So, you've got to get them down onto that scalp, which often means making a parting and then massaging them down onto the scalp. And in the old days, I used to talk to people 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 helps to descale it, in the hope that then other treatments would get through the scale and down onto the affected area. But I found that Enstilar® works an absolute treat. So this Enstilar® foam, if you massage 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 scalp and then leave it there overnight.
In the morning, you'll need to wash it out with adding shampoo to dry hair. If you wet your hair first, the water will just wash off. So, you need to put shampoo, massage that 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 can get hold of a tar shampoo, my favourite used to be Alphosyl®2in1, 2 in 1, because it's got a conditioner, but I gathered Alphosyl®2in1 is not currently being manufactured and is unavailable, but there's T/Gel® and there's Polytar. So, Enstilar® is absolutely brilliant, in my experience. If that fails, then we're on to, second-line agents, drugs by mouth and the like. Light therapy isn't going to work because the hair gets in the way.
And there's a shampoo that has a potent topical steroid in it, which you massage that onto the scalp, leave it there for a quarter of an hour, and then you wash it out with plenty of soap. But no, the scalp is tricky because of wretched hair. You and I are very lucky, aren't we, that we, don't have that problem. [Inaudible] My mum used to say grass doesn't grow on a busy road. I think she was just being kind. So, guttate psoriasis is something, that we often see in practice.
And again, we might need to look 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's often their first manifestation of their genetic tendency to psoriasis and basically what happens here is they have a really nasty, typically a sore throat, 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 psoriasis looking like psoriasis elsewhere, scaly, red, sharply demarcated. And it can last for even up to six months or longer. But it's usually self-limiting. Though in about a third of patients, it progresses to chronic stable plaque psoriasis. Although it's triggered by a streptococcal infection, usually in the throat, antibiotics don't make any difference at all. So I don't recommend those, unless the patient is remaining critically ill from the streptococcal infection.
Obviously, emollients are really important, and I've been stressing those all the way through. So I think emollients have a very, very important role here, and I won't go into the details of how to use those. Tar lotions are quite good. They help to relieve the mild itch and irritation it can cause, but they smell and they stain. But you can use those up to five or six times 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 and there's no point going to the routine circle for that because you'll be waiting for months and months and months. By the time you get an appointment it's too 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 the hospital and see if they can slip you in.
Because it responds very, very nicely to, light therapy. And with that in mind, I sometimes say to patients, look, if you are prepared to get in the back garden and take your shirt 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 for my patients, and it's not one that most GPs would feel comfortable doing, because it's absolutely not licensed for this, but the Enstilar® foam I've been speaking so highly about does work a treat. And I think that it is a reasonable option to consider. But, your GP will say, "I'm sorry, I'm not that familiar with it perhaps, and I'm certainly not going to be using it off-licence in this situation. It's not in the guidance."
But, in my experience, it does work very nicely indeed, and so, you can save the patient having to be referred on to hospital, but the company who make it are not going to be seeking a licence for this particular use, but it's an option. You can get guttate psoriasis more than once. I've seen one patient who had guttate psoriasis three times, but more usually, once you've had it once, when you next have a streptococcal infection, it just aggravates chronic stable plaque psoriasis.
Yeah, and if someone's listening who's got psoriasis, on their flexures, if I can use that term, again, similar advice, but again, one or two, slightly different possible options that their doctor might think about? Yes. I mean, by flexures, we usually mean under the breasts, in the armpits, in the crack between the buttocks and in the groin, those sort of areas, and also the umbilicus, on the tummy button.
I can't overstress the importance of avoiding soaps and detergents and using quality emollients and emollient soap substitutes. That's such an important part of this. Again, tars work quite well in this area, and less of a problem from the smell because it's more covered up skin. There's a treatment we use normally for fungal infections and thrush called Daktarin™. Miconazole is the active ingredient. Interestingly, that does seem to work quite nicely for flexural psoriasis.
So that's a nice gentle treatment that works there. But occasionally you do need to go in with more powerful things and so I would consider even a moderately potent topical steroid. I'd probably use it as a cream in this area because it's often a bit slippery and wet and moist and an ointment would just slip off. I should have said when I talked about the scalp that often scalp psoriasis is complicated by some dandruff. Doctors call this seborrhoeic dermatitis.
And dandruff seems to like the skin that psoriasis causes, and psoriasis likes damaged skin that seborrhoeic dermatitis causes. So the two commonly go together. So using an anti-dandruff shampoo, like ketoconazole, can be very effective. And often in the flexures, you get some seborrhoeic dermatitis, the same sort of condition, same yeast that causes dandruff, 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 cream, my favourite would be ketoconazole cream, can work really, really well there. Occasionally it's thrush aggravating 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, less dramatic than it is on the face. But that's another option you could consider.
But, if you've got difficult, and troublesome flexural psoriasis, and the diagnosis is correct, it's often misdiagnosed and often missed, but if it is flexural psoriasis, and it's not responding, then I think that's a situation where it's very reasonable to ask to see a specialist. Yeah. Agreed. And we've pretty much sort of gone from the top of the head to the end of the nails, here in this podcast.
So I think it's a good place to finish it and, to people listening, George and I hope you found it interesting and helpful. Roger and I do hope you'll join us again in two weeks time when we'll be discussing another skin-related condition and we'd also once again like to thank our sponsor AproDerm® for all their help in putting these Skin Deep podcasts together. 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.