I have just been diagnosed with psoriasis but I don't know very much about it. What I do know is that there are several treatments available – what do they involve?

Is there anything I can do to stop my psoriasis flaring-up?


My son has psoriasis and has become very depressed about it. What can I do?


What treatments can I use for psoriasis on my scalp?


I have just been diagnosed with psoriasis but I don't know very much about it. What I do know is that there are several treatments available – what do they involve?
While there is no cure for psoriasis, there are a number of treatments which can help to manage the symptoms and enable you to live an independent and happy life. These include creams and pastes that can be applied to the skin (topical therapy) such as:
• Moisturisers (emollients).
• Tar.
• Dithranol.
• Vitamin D.
• Topical steroids.

Depending on the severity of your condition, your medical care will will be provided by your GP or a consultant dermatologist in a hospital clinic. Certain medications such as dithranol, Vitamin D and topical steroids are only available on prescription whereas others are available directly from your pharmacist. Doctors and specialist nurses will provide guidance and advice on how all the various treatments work and on taking care of your skin.

Moisturisers (emollients)
Moisturisers or emollients are substances which help to lubricate and soothe dry, scaly, and inflamed skin. They work by reducing dryness, scaling, cracking, soreness and itching. They also prepare the plaques for active topical therapies, such as tar, thus enabling them to work more effectively. They can be used as a soap replacement and to descale at the same time. It is a good idea to use an emollient on the skin twice a day.

Types of emollients:
Bath oils

There are many types of bath oils available over the counter. They can be added to the bath daily to help soothe the skin, reduce itch and prevent the skin from becoming even drier. If showering, a bath oil or soap substitute can be applied directly to the skin and used as a shower gel.

Soap substitutes
Soap has a drying effect on the skin and strips its natural oils, therefore it is important to use a soap substitute when showering or bathing. This acts as both a soap and a moisturiser, and helps to descale the plaques. It should be applied generally over the entire skin just before getting into the shower or bath and then gently wiped off with a stroking action.

Moisturisers
Moisturisers come in lotion, cream and ointment form. Lotions are water-based and tend to be very easy to apply. They are quite cooling but not very beneficial for moisturising very dry skin. They are useful for maintaining good skin once the psoriasis is under control.

Creams include a mixture of ointment and water. They are thicker and greasier than lotions but are still easy-to-use and are the best option for day-to-day use.

Ointments are very greasy and contain little or no water. They are the best moisturiser but are less pleasant to use because of their consistency. However, if your skin has thick, dry, scaly plaques, they are the best option. Many people find it useful to use a combination of ointments and creams at different times of the day or night.

Moisturisers should be applied daily or even more often if possible. In order to work treatment around your lifestyle it can help to apply a thin film of cream moisturiser in the morning and using a greasier moisturiser at night.

When applying a moisturiser, dot it over the required area and then apply with a downward stroking motion in the direction of hairs. Try not to rub too aggressively, as this will only serve to aggravate the plaques.

The most effective time to apply a moisturiser is straight after a bath or shower, because the skin is warm and absorbs it better. It is important to allow this to happen before applying your active treatment, otherwise your active treatment may become less effective.

Tar
Tar has been used to treat psoriasis for over a hundred years but its exact action is unknown.

A selection of tar products are available, including coal tar solutions containing various amounts of tar; tar creams with topical steroids; bath preparations; and scalp preparations.

Tar products can be difficult to use, as they are messy and certainly not cosmetically appealing. Traditionally they have been associated with a strong odour but newer products tend to have a milder smell.

Many people opt to use them at night when they can wear old clothes and can conceal themselves from other people.

Some concerns have been expressed in recent times about the safety of using tar preparations and the possibility that it could cause cancer. However, the link is not proven and it still remains one of the treatments for psoriasis.


Dithranol
Dithranol is another cream that is used to treat psoriasis. It was first discovered as a treatment for psoriasis in 1877. Now manufactured chemically, it was originally extracted from a special tree bark extract. Its value as a treatment was discovered by accident when a man with both psoriasis and arthritis was given a powder produced from the tree to treat his arthritis. His psoriasis cleared even though the arthritis did not.

Dithranol is used in hospital and applied daily, in tandem with tar baths and UVB (ultra violet light) therapy. It is also available to use at home (known as short contact dithranol treatment). It is available on prescription and comes in five different strengths.

Dithranol is only applied for short periods at a time, usually about half an hour. Treatment is started at the lowest strength and it should be applied to the plaques only, as it can harm normal skin, which should be protected from by coating it with Vaseline. After 30 minutes, the dithranol is then rubbed off with cotton wool, followed by a shower or bath using normal soap. It is important that a doctor or nurse properly instructs you in its use, as it can otherwise be difficult to use.

The strength of dithranol used can be increased every few days until the psoriasis clears up. The treated skin will become stained purple/brown, but this discolouration will gradually fade after treatment.

Micanol cream is an alternative to short contact dithranol. It is available in two strengths (1% and 3%), is used daily and can be increased to 3%. It is applied to affected areas for 30 minutes and washed off using lukewarm water. If precise instructions are followed it causes less erythema (redness of the skin), burning and staining of the skin and clothing.


Vitamin D preparations

Calcipotriol (Dovonex) is a vitamin D analogue for the topical treatment of psoriasis. It acts by promoting normal skin turnover and is available as a cream or scalp application.

It has been licensed since 1991 and can be used once or twice daily, up to 100gms per week, long-term. It will improve psoriasis after two weeks and clearance can be achieved within 12 weeks. It is not a steroid, is non-staining, cosmetically acceptable and easy to apply. Some people can experience some irritation but this usually is fairly mild and only temporary. The psoriasis plaques will clear from the inside to leave a ring that gradually fades.

Calcipotriol (Dovonex) cream is applied twice daily to the psoriasis plaques in a thick smear and rubbed in gently. It is left on until the next application or bath or shower is taken and then re-applied. It is a useful treatment if plaques are thin but active. It is applied daily to the psoriasis areas. With the scalp application, after parting the hair, apply one or two drops to an area the size of a postage stamp and gently rub it in.

Calcipotriol/betamethasone dipropionate (Dovobet) is a vitamin D analogue/steroid combination product. It combines two ingredients that have two different modes of action. The calcipotriol (the same active ingredient as Dovonex) downs the turnover of cells in the skin cells whereas the betamethasone dipropionate is anti-inflammatory. It is indicated for psoriasis amenable to topical therapy and it is available as an ointment in 60 gram and 120 gram tubes.

Dovobet provides relief from the signs and symptoms of psoriasis for example, redness, thickness, and scaling. It is a cosmetically acceptable preparation, and is applied once daily. No more than 100 grams should be used per week and it should not be applied to the face. The hands should be washed after application.



Topical steroids
The use of steroids will need to be carefully monitored by your doctor or nurse, as they can have unwanted, serious side effects. Despite the fact that they may be as effective at clearing psoriasis as other topical treatments, they should never be the mainstay of psoriasis treatments, as the disadvantages far outweigh any need for long-term use.

They are available as an ointment, cream or scalp application and come in a variety of strengths, from mild through to very potent. In their favour, topical steroids are not as messy as other products and do not stain the skin or clothes.

Topical steroids (steroids applied directly to the skin) reduce inflammation and can be used as a short-term treatment for inflamed psoriasis but you may experience a flare-up when you stop using them and your condition may become worse. The general principle is to use the least amount of the weakest steroid that will provide control.

Mild and moderately potent steroids can be used in moderation for certain parts of the body. For example, a mild steroid can be used on the hairline and face, while a moderately potent steroid can be used under the arms, on the groin and on the breasts. Provided that topical steroids are used appropriately, they are an extremely valuable, safe and effective part of psoriasis therapy.


How to apply a steroid
Steroid creams or ointments should be measured using fingertip units. The safest amount of steroid to apply can be estimated by using the space between the tip and last joint of your finger as a measuring guide.

If you are using your steroid cream or ointment on your face, apply a thin layer and rub it in well. It should be used twice daily for a few days and, when improved, it can be reduced to once daily.


Is there anything I can do to stop my psoriasis flaring-up?
It is important that you consult with your doctor or dermatologist to get proper instructions and guidance about your treatment and how to manage your flare-ups.

While exposure to the sun's UV rays usually helps most people with psoriasis, for a very small minority, sunlight can aggravate the condition. If you think that you are one of these people, be sure to strictly limit your skin's exposure. Sunburn also causes the skin to flare up so, for this reason, always take care not to spend too long in the sun without covering up. Your doctor will advise you about this.

Stress is another trigger factor for psoriasis so it important to seek help to cope with your disease. It may help to talk to others with similar worries or problems. Some people like to try complementary medicines such as acupuncture and homeopathy to help them cope with their stress. Relaxation therapies such as yoga can also help. It is important to consult a properly qualified practitioner.

It may also help to talk to friends and work colleagues and reassure them that your psoriasis is not contagious. They may be unfamiliar with the disease and may welcome the fact that you are frank and open with them about it.


My son has psoriasis and has become very depressed about it.
What can I do?

It is important firstly to reassure your son that it is possible to live with psoriasis and that the symptoms can be successfully managed with treatment. Because it is a chronic condition, it can have a devastating effect on a person's self-confidence. The appearance of the plaque, the scaling and the discomfort could all be affecting your son's self esteem and the way he feels about himself.

However, it is important to note that the effects of psoriasis on each individual will vary and that the type and extent of the psoriasis may not seem to equate with the amount of distress experienced. Indeed, a person with a minimal amount of psoriasis could suffer as much psychologically and socially as someone with as much as 50% of their body affected.

People will respond in different ways and psoriasis will have varying impacts on their lives. For this reason, you should encourage your son to see a doctor and to commence treatment if he has not already done so or to seek referral to a dermatologist if his condition warrants it.

Managing psoriasis can often be stressful, as treatment can be time consuming, inconvenient and messy. Therefore, it is important to get the proper detailed instructions on the various treatments and how to apply them. It is also important to help your son to choose a treatment that suits his lifestyle and will, therefore, improve his quality of life.

Ensure that he understands what causes the disease and the importance of a regular skin care regime. This will need to be tailored to his individual needs, particularly to encourage him to develop a life outside of the treatment.

It will help if you encourage the rest of the family to accept the condition and realise that it is not contagious. Reassure your son that he should not feel guilty about the time-consuming nature of treating the disease, especially if you have to help him to apply the creams.

You should try to understand the reasons why your son is depressed. It can be very difficult and embarrassing for someone who is affected by psoriasis in visible areas such as the arms legs and face. Your son may feel self-conscious and resentful if he has to constantly cover up and wear long sleeves and trousers, even in the summertime.

While the disease may restrict your son from choosing careers in areas such as construction and food handling, it is important to point out to him that it by no means rules him out of a broad range of other occupations.

Participation in some sports such as swimming can be severely curtailed due to psoriasis but you should encourage your son to take up alternative sports that do not require special clothing. Participating in a sport can work wonders for your son's self-confidence.

Be on the lookout for signs of bullying or teasing if your son is still at school, such as withdrawal, reluctance to attend or vague complaints of illness. Make sure that his teacher is aware of his psoriasis and understands that the condition is not infectious.

While it may sound very simple, never underestimate the importance of touch. Your willingness to touch your son is crucial so that he does not feel unclean or isolated.

Your son may also have concerns about his appearance, especially to the opposite sex. It is, therefore, important to bolster his confidence by emphasising his positive qualities and achievements, rather than focusing solely on his appearance. People with psoriasis, along with their families, should invest time in learning about their condition and the treatments involved, in order to control the psoriasis rather than allowing it to control them.

Above all, both yourself and your son should try to remain positive about the disease. Research into psoriasis is continuing all the time and, while the actual genes associated with psoriasis may not be identified for some time, an increased understanding of the disease will lead to better treatments.

What treatments can I use for psoriasis on my scalp?
Scalp psoriasis of any severity can be a distressing and socially disabling condition, at least in part due to the fact it is difficult to cover up. Even mild psoriasis can be uncomfortable and itchy and severe cases may cause extreme discomfort. Scaling may cause the scalp to feel tight and, if it forms hard lumps, it can lead to temporary hair thinning.

The treatment used on scalps depends on the extent to which it is affected and the scalp treatments and methods of application are as important. If psoriasis on your scalp is thick and active, the best treatment is a tar-based ointment, eg. tar pomade. This will moisten the plaques and loosen the scale.

Applying the treatment involves parting the hair in sections and rubbing in the ointment to the affected areas, it's best to do this by starting at the front of the scalp and working your way around. It is easier if you can get a friend or a relative to help you, as it can be difficult to manage the top and back of the scalp.

The best time to do this is at night, as the tar makes your hair greasy and has an unpleasant smell. Leave on overnight and fine comb prior to washing it to help loosen the scales, then wash out with shampoo. Tar-based shampoos are best when the scale is lessened and psoriasis is more controlled.

Calcipotriol (Dovonex) scalp application is useful for short-term treatment if the scalp is inflamed or if the scalp remains active even with the use of tar solutions. It is applied daily to the psoriasis areas. After parting the hair, apply one or two drops to an area the size of a postage stamp and gently rub it in.

Written by Breege Fox, SEN, Dip in chiropody, oncology course. Breege previously worked in Hume Street Hospital, Dublin, for 20 years, where she gained a vast experience in dermatology.

She now works for Leo Laboratories, as QualityCareTM Nurse Advisor. QualityCareTM is an international programme which aims to improve the quality of life for those with psoriasis through better self management of the condition. The programme is specifically aimed at practice nurses who are increasingly important in the education of people with psoriasis on how to obtain the best results from their prescribed treatment and thus, the highest possible quality of life.

Currently, Breege is working on developing this programme in order to train and educate practice nurses which will ultimately help improve understanding and self management of psoriasis.

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