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Psoriasis Topical Treatment

   

White soft paraffin

When there are just a few plaques, very little more than the rubbing in of whitesoft paraffin (Vaseline) once or twice a day need be recommended. Other emollients may be tried - in general, the thicker and greasier they are the more effective they are. The least they will do is to improve the appearance and decrease the scaling.

If there are one or two thickly encrusted patches then it is sometimes useful to apply a salicylic acid preparation for a week or two to remove the scale. Two to six percent salicylic acid in white soft paraffin is useful for this purpose.

Tars

If further treatment is required a tar preparation can be prescribed. Tar ointment is the simplest but not the most elegant cosmetically. There are several quite good proprietary preparations, such as Clinitar or Alphosyl.

For psoriasis of the groin, navel and the submammary areas a weak tar cream (e.g. Alphosyl) can be tried although even this is often irritating. For this type of psoriasis topical corticosteroids may be better (see opposite).

Unfortunately some tar preparations tend to be messy and may stain. Patients should be warned of this and told to use only a thin smear, as well as to cover the treated sites with cotton gauze or some other type of light dressing. Tar can also cause redness and soreness on sun exposed areas ('tar smarts') and may also cause an acne type of folliculitis in some patients.

Dithranol

If tars are ineffective then use can be made of the proprietary preparations of dithranol (e.g. Dithrocream, Dithrolan, Exolan, Psora date and Stie-Lasan). At one time dithranol treatment was almost totally restricted to in-patients. This need no longer be the case. Nonetheless the preparations available are not perfect and still produce characteristic staining of the skin, clothes and bedclothes. They also tend to irritate the skin and the patient must be warned of this possibility. Both tar and dithranol preparations need only be applied once daily in most patients. More frequent applications rarely give added benefit. Tar and dithranol applications take at least three weeks to produce improvement but it can be as long as eight weeks before improvement is obvious.


Typical mauvish-brown staining from dithranol treatment.

Calcipotriol

Calcipotriol (Donovex) is an analogue of vitamin D that, when used in a concentration of 50 J.lg/ g, has been found to be very effective for plaque-type psoriasis. It may be expected to clear or considerably improve psoriatic lesions in approximately 65 per cent of patients in an eight to ten week period. Its only major disadvantage is a propensity to irritate the skin - preventing its use by 20 to 25 per cent of subjects. Other vitamin D analogues are being developed and will be available in the near future.

Corlicosteroids

There was a vogue for the use of potent topical corticosteroids in psoriasis. There is little doubt that they can rapidly improve the lesions but unfortunately the disadvantages of their use in this disease outweigh their advantages. It seems that in most psoriatic patients the suppression of the disease that the topical corticosteroids induce is operative only while the preparation is being used. Immediately it is stopped the disease tends to return. What is more, it sometimes seems to return with additional vigor. In addition, these compounds may have unpleasant side-effects both locally and systemically as a result of absorption.

It would be misleading to suggest that there is absolutely no place for the use of topical corticosteroids in psoriasis, but many dermatologists would agree that they have a very limited role to play. Corticosteroid creams or lotions can, however, be very useful for psoriasis of the groin, the navel and the submammary areas. If they are used for this type of psoriasis it is important to make sure that the condition being treated is in fact psoriasis and not ringworm or thrush. They are also sometimes useful in psoriasis of the scalp and flexures of the face.

Shampoos

Psoriasis of the scalp can be difficult to treat. It is best to advise that the patient adopt a short hair style to allow frequent shampooing. When the scalp is quite thickly encrusted it should be shampooed on alternate days at least and preferably every day. A regimen I often recommend is application of an ointment at night and shampooing first thing in the morning. This leaves the scalp free of messy ointments during the day. As far as the actual shampoos and applications are concerned, a tar-based shampoo (e.g. Poly tar liquid) and a tar-and-salicylic acid ointment is quite useful. If this doesn't do the trick then a weak or moderately potent corticosteroid cream can be applied after shampooing.

For psoriasis of the nails

Unfortunately there is no effective topical remedy for psoriasis of the nails. When the nail involvement is not severe, all that needs to be done is to keep the nails short. Injection of corticosteroid suspensions around the nail beds has been tried but is painful and not very effective. If there is severe nail involvement then this will be a factor in persuading the specialist that systemic therapy is indicated.