SKIN CARE
Use of topical treatments in psoriasis management
KEYWORDS:
considered before any topical cal therapy therap is prescribed. In the author’s or’s ’s clinical experience, e patients aree often ofte oft confused confus about ctive topical to t the use of active treatments. They may ay use them regularly but be unaware purpose or the naware of their t ingredients gredients tthey contain. Patients be anxious about the use may also b corticosteroid treatments, for of cor corti example, because of the reported exam sside-effects. It is also easy to confuse si topical treatments, which often have similar names or packaging. Also, when patients have used a range of topical treatments over a long period, they may not always remember which products they have tried, or which were effective.
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Topical therapies are psoriatic oria oriat medications that are applied plied ied to the skin, but can also bee absorbed absorbe through the skin, which means they need to be used d carefully. arefully. Some Som topical treatments ments ents can be obtained o over the counter, most are ounter, ter, although althou altho prescription-only. guidelines ption-o y.. Clinical ption-on Cl provided ded ed by the th National Institute for Health alth and Care Excellence [NICE] (2012) 201 advised that patient preference, the practicalities of application and the product’s cosmetic acceptability should be
Tonia Goman, dermatology specialist nurse, (inflammatory skin conditions) and lead phototherapy nurse, Bristol Dermatology Centre, Bristol Royal Infirmary; joint-chair of British Dermatology Nurse Group (BDNG) phototherapy sub-group; skin camouflage practitioner
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JCN 2017, Vol 31, No 5
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Topical therapy
Specialist referral
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Systemic therapy
Systemic biologic therapy
Figure 1. The psoriasis treatment pathway (adapted from NICE [2016]).
THE SCIENCE — WHAT IS PSORIASIS? Approximately 2–3% of the UK population is affected by the chronic inflammatory skin condition, psoriasis (Dubois Declercq and Pouliot, 2013). There are various forms of psoriasis, but it generally presents as red plaques that can become thick and scaled. It may start as small red lesions that eventually increase and coalesce (join together). Often starting at the knees and elbows, for many it can be limited only to these areas, whereas for others it can affect other parts of the body such as the scalp. Men and women are equally affected, as are children (Van Onselen, 2011).
Credit: Marnanel@ wikicommons
T
his is the third article in a series examining the assessment, diagnosis and management of psoriasis. Previous articles have discussed the different types of psoriasis and the initial treatment strategies as recommended by the National Institute for Health and Care Excellence (NICE) psoriasis treatment pathway (NICE, 2016; Figure 1).
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7KLVWKLUGDUWLFOHLQDVHYHQSDUWVHULHVORRNLQJDWWKHLGHQWLÀFDWLRQDQG treatment of psoriasis, explores the active ingredients and action of the main topical treatments for psoriasis. Community nurses are perfectly placed to help patients take control of their skin condition, particularly LQDGYLVLQJWKHPRQWKHEHQHÀWVRIWRSLFDOWUHDWPHQWVZKLFKDV WKH\FDQEHDSSOLHGGLUHFWO\WRWKHVNLQDOORZWKHDUHDWREHWDUJHWHG ORZHULQJWKHOHYHORIDEVRUSWLRQLQWRWKHEORRGVWUHDPDQGUHGXFLQJ VLGHHͿHFWV 3VRULDVLVDQG3VRULDWLF$UWKULWLV$OOLDQFH 3$3$$D
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SKIN CARE
TYPES OF TOPICAL TREATMENT Vitamin D analogues
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Vitamin D analogues such as calcipotriol (Dovonex®; LEO Laboratories), tacalcitol acalcitol alcit (Curatoderm®; Almirall) mirall) and calcitriol cal (Silkis®; Galderma) ma) can be a very effective form m of treatment treatmen for psoriasis. They in a Th y are produced prod pro varietyy of formats, creams, form s,, including in ments ents and sscalp applications, ointments ste and aree not steroid-based. For this reason, vitamin D analogues have ta
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Practice point
Topical treatments play a vital role in reducing excess skin cell production and inflammation in the dry skin that characterises psoriasis, which can range from mild dryness through to severely dry and heavily scaled skin.
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JCN 2017, Vol 31, No 5
used on the face but Curatoderm or Silkis can be used on the face and other sensitive areas.
Vitamin A derivatives and topical retinoids
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Topical retinoids such as tazarotene (Zorac®; Allergan) are available as a gel and aim to reduce skin cell reproduction and the inflammatory process (McClelland, 1997). Although not fully understood, it is believed belie they normalise cell differentiation, ifferentiatio fferentiatio suppress the growth wth of skin cells cel and restrain inflammatory by atory responses respon the body (Saurat, aurat, 1999). 99). Originally O developed d in 1997 for ffo mild-tomoderate retinoids ate psoriasis, topical to are manufactured nufacture in two strengths, 0.05% .05% 5% and 0.1%, 0.1 and are available as prescription-only (Psoriasis prescription prescriptio Association, 2014b). Patients should Associat Association be advised advis to begin with the lower ad strength streng and only apply a thin layer. Topical retinoids are designed as a Top once-daily treatment, for up to 12 weeks, before any improvements may be seen.
Pe op le
‘Patients often confuse e emollients with topical ical treatments. Thus,, when a topical treatment ment ent has been bee prescribed, the he e nurse should s discuss the he e product p oduct with the patient, its atient, nt, highlighting hig appearance, of action, pearance, arance, mode m side-effects.’ and side-eff side-ef
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This article provides a brief outline of a range of topical treatments, which will enable community nurses to better guide patients through the complexities of the different products available.
the advantage of being a safer option for long-term regular use. They also do not stain and thus can be more cosmetically acceptable to patients. Vitamin D analogues work by slowing cell turnover in the skin, normalising keratinocyte hyperproliferation and inhibiting the production of specific cells responsible for the development of psoriasis, (interleukin-2 [IL-2] and IL-6) (Kim, 2010; Stein Gold, 2016), as well as having an antiinflammatory effect by reducing the production of psoriatic cells (Kim, 2010; Stein Gold, 2016). It can take up to four to six weeks before any improvement in the patient’s psoriasis symptoms is noted, although it can be cleared within three months (van Onselen, 2011; Psoriasis Association, 2014a).
C ar e
As with emollients, topical treatments may be used in conjunction with other therapies, such as phototherapy, systemic and biologic treatments, to reduce the effects of a psoriasis ‘flare’, for example, or while other treatments begin to take effect. Patients often confuse emollients with topical treatments. Thus, when a topical treatment has been prescribed, the nurse should discuss the product with the patient, highlighting its appearance, mode of action, and sideeffects, and provide a written plan to guide the patient in using the product correctly. An audit by Peters et al (2008) highlighted the benefits of involving patients in any discussions about their care and providing comprehensive education around any treatments prescribed, enabling the patient to participate fully in their treatment. Figure 2 highlights some of the basic guidelines that community nurses should follow when caring for a patient who has been prescribed a course of topical treatment.
Side-effects SSi Hypercalcaemia (raised calcium levels) can be a side-effect of vitamin D analogues and this treatment should be avoided if the patient has a history of calcium metabolism disorders. It is also advised to use vitamin D analogues with caution in patients with generalised pustular or erythrodermic exfoliative psoriasis (British Medical Association [BMA], 2017a). The most common side-effect reported by patients using vitamin D analogues is skin irritation, including a burning or stinging sensation. Lesser reported side-effects include skin peeling, rash or worsening psoriasis. Not all vitamin D analogues are suitable for the skin on the face and flexures and the manufacturer’s instructions should be consulted, for example, Dovonex should not be
The main advantage of topical retinoids is that they are non-staining and odourless. They can only be used on the body (as they are too strong to be applied to the face), providing the psoriasis is stable and covers less than 10% of the body’s surface area. If the skin is particularly dry, emollients should be applied before using topical retinoids. Side-effects Topical retinoids are not regularly used due to the side-effects, which include skin irritation, pruritis (itching) and a burning sensation; initially, they can also cause psoriasis to become redder in colour. However, persistently applying topical retinoids will enable the skin to build up a tolerance to any sensitivity (PubMed Health, 2017). Community nurses should advise the patient to apply a thin layer of gel to the centre of the psoriasis plaque, using a gentle circular motion and working outwards avoiding non-affected skin. If the initial irritation persists, the nurse should advise the patient to reduce the amount applied until the reaction settles (Psoriasis and Psoriatic Arthritis Alliance [PAPAA], 2017a).
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Prescribe Adex Gel and see the results Adex Gel Presentation: White opaque gel. Uses: Highly moisturising and protective emollient with an ancillary anti-inflammatory medicinal substance for the treatment and routine management of dry and/or inflamed skin conditions such as mild to moderate atopic dermatitis, various forms of eczema, contact dermatitis and psoriasis. Directions: Adults, the elderly and children from 1 year of age. For generalised all-over application to the skin. Apply three times daily or as often as needed. Adex Gel can be used for as long as necessary either occasionally, such as during flares, or continuously if the added anti-inflammatory action is beneficial. Seek medical advice if there is no improvement within 2-4 weeks. Contra-indications, warnings, side effects etc: Do not use if sensitive to any of the ingredients. Keep away from the eyes, inside the nostrils and mouth. Temporary tingling, itching or stinging may
occur with emollients when applied to damaged skin. Such symptoms usually subside after a few days of treatment, however, if they are troublesome or persist, stop using and seek medical advice. Rarely skin irritation (mild rashes) or allergic skin reactions can occur on extremely sensitive skin, these tend to occur during or soon after the first few uses and if this occurs stop treatment. As safety trials have not been conducted during pregnancy and breast-feeding, seek medical advice before using this product. Care should be taken as emollients which soak into clothing, pyjamas, bedlinen etc. can increase the flammability of these items. Patients should avoid these materials coming into contact with naked flames or lit cigarettes etc. As a precaution, dressings and clothing, etc., should be changed frequently and laundered thoroughly. Ingredients: Carbomer, glycerol, isopropyl myristate, liquid paraffin, nicotinamide, phenoxyethanol, sorbitan laurate, trolamine, purified water.
Pack sizes and NHS prices: 100g tube £2.69, 500g pump pack £5.99. Legal category: Class III medical device with an ancillary medicinal substance. Further information is available from the manufacturer: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. Date of preparation: August 2017. ‘Adex’ is a trademark. Adverse events should be reported to Dermal.
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SKIN CARE
Coal tar
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Coal tar is a renowned topical treatment used for medical purposes since the 1800s, although originally discovered as far back as 1665. It comes in a variety of formats ts, gels ge and g including creams, ointments, shampoos. It is mainly found ound und as a a coal c tar solution for products uctss available availabl over the counter. It is cost-effective cost-effect cost-ef
Retinoids etinoids noids
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Red Flag g
Retinoids potent treatments, noids oids are p which shoul should not be applied to non-affected skin. They are far too strong to be applied to flexures (where skin-on-skin areas double the potency) and facial psoriasis. They will aggravate eczema or open wounds (Psoriasis Association, 2014c). They should be used under caution for patients with a history of skin cancer (including lentigo maligna), as they may make this condition worse (PubMed Health, 2017).
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Follow instructions Pregnancy/ breastfeeding: seek advice
Unless directed, apply thinly
Only apply to psoriasis
Do NOT occlude unlesss directed d
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ADVICE
Pe op le
Do NOT overuse
If using several creams, use at times advised by clinicians
JCN 2017, Vol 31, No 5
Consistent ons nsis nsis i t use takes time to be effective
NOT use Doo N OT u s to sensitive sens nsiitt e aareas, ns nsit eaas refer too iinstructions
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Figure 2. General advice for patients undergoing dergoing topical ica treatment. he treatment reatmen and safe to use in the of psoriasis.
Various formulations for lations of coal tar form include crude de coal coa tar (manufactured by thee distillation istillation of o bituminous coal at high medicated gh temperatures), tempera tempe shampoos, ampoos, such su as Polytar® (GlaxoSmithKline), and a variety (GlaxoSm of sca scalp treatments including Cocois® (Focus Pharmaceuticals), Coco Exorex® (Forest Laboratories) and E Psoriderm® (Dermal Laboratories). Coal tar possesses anti-inflammatory properties and works as a keratolytic to reduce the proliferation of skin cells that produce the thick scaling associated with psoriasis. Coal tar is effective against thick-scaled psoriatic plaques, in turn relieving the associated pruritis (Ngan, 2005).
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Topical retinoids are contraindicated during pregnancy and while breastfeeding. Contraception is also recommended while using this topical therapy, as absorption can harm a foetus. The ‘mini pill’ is not advised, due to it not being the most reliable contraceptive method (Allen, 2015). If pregnancy is reported, the treatment should be immediately discontinued. Patients should also be advised that vitamin A and herbal products should be treated with caution while undergoing treatment with topical retinoids such as benzoyl peroxide, as should antibiotics, diuretics, phenothiazine drugs (antipsychotic medications), sulphonamides (antibacterial medications). Natural sunshine, sunbeds and cold weather should be avoided due to the photosensitive nature of topical retinoids and patients should be advised to apply sun factor 30 or above each day when undergoing treatment. Nurses should also advise patients that topical retinoids must not be used on inflamed, pustular, flexural or facial psoriasis (van Onselen, 2011; Psoriasis Association, 2014b; PubMed Health, 2017).
Crude coal tar is effective and can clear psoriasis within a 3–6week period (Griffiths et al, 2004). Crude coal tar can be produced in a concentration of 1–20% in a soft paraffin base (PAPAA, 2017c). In a controlled trial back in 1997, it was found that 6% crude coal tar was more effective than salicylic acid and petroleum (both overnight, under occlusion) (Kumar et al, 1997). One significant advantage of coal tar is that it is non-steroidal, which means
that it does not have the side-effect profile that many patients are wary of (DermNet, 2005). For decades coal tar was regarded as an effective, daily treatment for patients with severe psoriasis admitted to hospital. Outpatient departments took this on where the patient attended the department daily (Mondays to Fridays) and no longer required the use of a hospital admission. The combination of artificial ultraviolet B (UVB) spectrum phototherapy and coal tar, known as the Goeckerman regimen, was introduced in 1925 and some hospitals are still using this system (van Onselen, 2011). However, availability of coal tar is limited in many departments, as well as practical considerations, such as finding the staff available to apply the coal tar and hospital departments equipped with the shower facilities required to remove it, have often limited the use of the Goeckerman regimen. There are cleaner forms of coal tar available that can also be applied to the body, such as Exorex and Psoriderm and many of the coal tar products now available come in shampoo format (scalp psoriasis will
SKIN CARE
be discussed in the next article in this series). However, while these forms of coal tar are not as effective as crude coal tar, they still have a place in treating psoriasis (PAPAA, 2017c).
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Side-effects Although effective, coal tar is not always popular with patients due to the time it takes to apply, the mess and odour involved, and the fact that it can stain clothes, bedding and furniture. Coal tar should be patch tested at each percentage increase due to its side-effect profile (National Psoriasis Foundation, 2017).
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Coal tar is also a photosensitiser and community nurses should warn rn patients to avoid natural sunshine, ine, cover exposed skin and apply ply sun su protection (National Psoriasis oriasis iasis Foundation, 2017). There here re have been bee b concerns about coal carcinogenic al tar’s carc carcino effect, which is thought to be related to higher gher her doses, although aalt the few studies u ess carried out have been inconclusive (Pion et al, 1995; nconclu vee (P nconclus Paghdal Schwartz, 2009). dal al and Sc Sch
Dithranol ol
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Dithranol, available as Dithrocream (Dermal Laboratories) and Psorin® (LPC Pharmaceuticals), suppresses the cell production. It can irritate skin that has not been affected by psoriasis, therefore community nurses should ensure that it is only applied within the border of the psoriasis plaques themselves. Often called a ‘short contact therapy’, dithranol should only be applied to the skin for a limited period of time (20–30
Lt d
While some dermatology outpatient departments offer a dithranol service, as with coal tar treatments, resources are often limited and the treatment is not widely available (Pugsley, 2009). Prescribed treatment courses, such as Dithrocream, that can be applied at home, are available in varying strengths. Community nurses should advise patients to apply these creams thinly and within the plaque border. When applying the cream, patients ts should be told to leave it in place for the correct length of time, to o carefully carefu avoid normal skin and to wash h the cream off after treatment ent using lukewarm water. Patients tients nts should shoul also be advised to immediately mediately wash was away wa any cream that comes omes into contact with skin unaffected This unaffe naf ted by psoriasis. p regimen will ll need to be b continued over several everal eral weeks. weeks If irritation does occur, cream can cur,, a lower strength st be used; the cream can be applied frequently; or the length of time less freque cream is left on can be reduced the cr crea (MayoClinic, 2017). (May
(pimecrolimus), and work by blocking a chemical called calcineurin, which is responsible for activating symptoms of inflammation, redness and itching (British Association of Dermatologists [BAD], 2016). At the time of writing, topical calcineurin inhibitors were not licensed for the treatment of psoriasis. However, they are regularly used off-license for psoriasis. They are effectively used and licensed for howing wing the eczema, with studies showing m tacrolimus. tacrolimu efficacy resulting from ntinue ue with the th t Further studies continue ll transfer to the hope that this will psori is also (Malecic treatment off psoriasis and Young, g, 2016).
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The combination of artificial ultraviolet B (UVB) spectrum phototherapy and coal tar, known as the Goeckerman regime, was introduced in 1925. In summary, patients are exposed to a Quartz light following a 24-hour regimen of having plaques covered in ‘White’s crude coal tar ointment’ (Orseth and Cropley, 2013). Nowadays, this regimen is known as a crude coal tar and a form of phototherapy, which generally is Narrowband UVB.
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minutes) on a daily basis (Stein Gold, 2016). Dithranol is available in a range of strengths, starting with the lowest dose (0.1%) and graduating to the more potent doses (up to 2%) as the skin becomes more tolerant. Test doses are recommended at the beginning of treatment and as the doses increase.
Did you know...
As dithranol contains yellow soft paraffin, which is highly inflammable, it should not be used near any heat sources such as electric heaters or lit cigarettes. It should also not be applied to children, pustular psoriasis, on flexures, the face or genitals, or to inflamed, broken, ‘weepy’ or blistered skin (National Patient Safety Agency, 2007).
Topical calcineurin inhibitors These topical therapies, which include tacrolimus (Protopic® 0.03% and Protopic® 0.1%; Leo Laboratories) and pimecrolimus (Elidel®; Meda Pharmaceuticals), are classed as immunomodulating agents and act on the immune system by weakening the skin’s defence and reducing inflammation to the skin. They are available as ointments (tacrolimus) and creams
Tacrolimus in two rolimus is available ava strengths; strength, trengths; ngths; the weaker we 0.03%, for use in children 3%, is licensed licen lice aged 2–16 The weaker 2–1 years. y preparation is also suitable for prepa preparat application to the face (DermNet applic NZ, NZ 2017). Tacrolimus is not a steroid treatment, but is often prescribed to be used ideally in the evening or before bedtime. Often, protopic treatment is used on the face and other active areas to the body may be treated with a corticosteroid or other treatments (Furue et al, 2004). Primarily used for eczema flares, tacrolimus is also prescribed for use on psoriasis. One study concluded that as it does not cause skin atrophy (thinning of the skin), the most appropriate sites to apply tacrolimus are on the face, flexures and genitalia (Wang and Lin, 2014). Studies have also proven that picrolimus has its benefits, mainly reduced side-effects, although it is considered far less effective than tacrolimus (Wang and Lin, 2014).
W
Remember...
Although some topical corticosteroids are available in pump dispensers enabling measured amounts to be applied, a finger tip unit (FTU) helps to ensure accuracy. This should be about 500mg and be enough to treat an area of skin which is double the size of the flat of the hand with fingers together.
JCN 2017, Vol 31, No 5
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SKIN CARE
Keratolytics
Moderate
Potent
Very potent
Hydrocortisone 0.5%
Eumovate® (GlaxoSmithKline) Clobetasone butyrate
Betnovate® (GlaxoSmithKline) Betamethasone valerate
Dermovate® (GlaxoSmithKline) Clobetasol proprionate
Betnovate RD® (GlaxoSmithKline) Betamethasone valerate
Dovobet® (Leo Laboratories) Calcipitriol + betamethasone as dipropionate
Nerisone Forte® (Meadow) ortolon olon valerate Diflucortolone
Haelan flucloxycortide 0.0125%
Cutivate® (Pharmaderm) ropionate Fluticasonee propionate
Pe op le
Hydrocortisone 1%
Synalar 1:4 dilution Flucinolone acetonide
Side-effects Continual use of keratolytics can result in striae (stretchmarks), superficial dilation (blood vessels or capillaries noticeable on the skin), or localised skin atrophy (PAPPA, 2017b). Keratolytics should not be applied to more than 20% of the body’s surface as this could induce salicylism, a toxic 64
JCN 2017, Vol 31, No 5
sone® Diprosone (Merck Merckk Sharp & Dohme) me Betamethaso Betamethasone as dipro dipropiona dipropionate
Elocon® Mometasone furorate Mom (M (Merck Sharp & Dohme)
With antimicrobial agents Daktacort® (Janssen Cilag) Hydrocortisonee rate Miconazole nitrate
Trimovate® (GlaxoSm laxoSm (GlaxoSmithKline) Clob Clobe Clobetasone butyrate O Oxytetracycline, nystatin
cidin H® Fucidin (Leoo Laboratories Laboratories) Laborator Hydrocortiso Hydrocortison Hydrocortisone acetate Fusidic ac acid
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Keratolytic agents such as Diprosalic® (Merck Sharp & Dohme) come in ointment form and are effective at removing the scale associated with psoriasis, creating a more receptive base for the application of other topical pic pical treatments. The main ingredient ngredient gredie to keralytic treatments ts is salicylic salicyli acid. Diprosalic also so contains betamethasone,, a steroid that tha helps to reduce thee symptoms of o psoriasis. In adults, keratolytics ke atolytics can c be applied once-to-twice o-twice daily aily ily over a two-week period, d,, although althoug children should be limited ited ted to a five-day course. The maximum dose per week is no more md than 60g (British National Formulary [BNF], 2017).
Lt d
Mild
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Manufacturers for these topical calcineurin inhibitors (National Eczema Society, 2016) and the British Association of Dermatologists (BAD, 2016) advise that topical treatments should not be used within two hours of application of tacrolimus. One study showed that the use of an emollient on the skin before the protopic was applied resulted in a reduced inflammatory response. Topical calcineurin inhibitors also act as photosensitisers and precautions against exposure to natural ultraviolet light should be taken, i.e. avoiding natural sunshine between the hours of 10.00am–4.00pm, or using a broad spectrum sunscreen that covers UVA/ UVB with a minimum SPF of 30 (Skin Cancer Foundation, 2017).
Table 1: Potency profile of topical corticosteroids (adapted from Oakley, 2009; National Psoriais Foundation, 2017)
C ar e
Side-effects The main side-effect of topical calcineurin inhibitors is localised skin irritation, often described as an intense tingling, burning or itching sensation. Patients will often experience this within the first week of treatment, but should be advised to persevere as this side-effect is usually temporary (BAD, 2016).
Betnovate-N® (GlaxoSmithKline) Betamethasone -as valerate 0.1%, Neomycin sulphate Betnovate-C® (GlaxoSmithKline) Betamethasone, as valerate, 0.1%, Clioquinol Synalar C Fluocinolone acetonide 0.025%, Clioquinol 3% Synalar-N Flucinilone acetonide 0.025%, Neomycin sulphate 0.5% With salicylic acid Diprosalic® (Merck Sharp & Dohme) Betamethasone, as Dipropionate, salicylic acid
Topical corticosteroids
inflammatory reaction in the skin (BAD, 2015). They are easy to apply, provide fast relief and, when used correctly, present a minimal risk of side-effects.
Topical corticosteroids are effective against psoriasis where their primary action is to suppress the
Topical corticosteroids are available in four strengths, ranging
effect that results in tinnitus, nausea and vomiting (Federman et al, 1999; Menter et al, 2009).
SKIN CARE
Adult
Children — number of fingertip units (FTUs) 2.5 FTU Face and neck 7 FTU Trunk front Trunk back
6 FTU one leg
Face and neck Child’s age
from mild, moderate, potent to very potent (Table 1).
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©
Occlusion sio with clingfilm or hydrocolloid dressings can increase the effectiveness of topical steroids, but can also intensify the side-effects (National Psoriasis Foundation, 2016). Side-effects When a patient is prescribed topical corticosteroid treatment, the potency as well as specific instructions for use should be explained. Side-effects from these treatments can result in (Condoo et al, 2014):
Front Fron
Back including buttocks
1–2 years
11/2
3–5 years
11/2
6–10 years
2
1
11/2
1
11/2
11/2
2
2
3
2
3
3
31/2
21/2
41/2
31/2
5
` Irreversible skin kin atrophy and a striae, which h can cause cau the skin to be more m re prone pron to psoriasis iasiss flaring flarin ` Bruising ruising sing ` Enlarged nlarged blo blood b vessels (telangiectasia) (telangie (telangiec ` Loss o of skin pigment ` Foll Folliculitis (infection of the Fo hair follicles) h ` Loss of hair growth at the treatment site.
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As topical corticosteroids are absorbed at different rates depending on the thickness of the skin, the following applications are recommended (Sharma et al, 2017): ` Mild topical corticosteroids such h as hydrocortisone or eumovate atee can be applied to the face ` Moderate-strength topical ica ical corticosteroids, alongside gside side antifungals, can be used to treat trea tr flexural psoriasis sis ` Potent and/or or very potent poten topical po steroid treatments eatments atments can be used on the palms and soles alm of the hands ha h of the areas have he feet, ass these the th additional of skin. dditional ditional layers lay l
1
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Figure 3. Measuring fingertip units (FTUs).
Leg and foot
Number of FTUss needed
3–6 months
2 FTU one foot
Arm and hand
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1 FTU one hand
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3 FTU one arm
There is evidence that systemic side-effects can develop when topical corticosteroids are applied to extensive psoriasis (over 10% of the body). Patients can also experience an exacerbation of their psoriasis when topical corticosteroid treatments are stopped suddenly; similarly, the withdrawal of very potent corticosteroids can precipitate the development of severe pustular psoriasis (NICE, 2015; BMA, 2017b). Ideally, the patient should be advised to gradually reduce the potency of topical corticosteroid treatment, which can be achieved either by reducing the frequency of application or moving to a weaker strength preparation. NICE (2012) advised that very
potent corticosteroids should not be used continuously at any site for longer than four weeks at a time, and that the potency and formulation should be appropriate to the current status of the patient’s psoriasis. When using potent or very potent topical corticosteroids, a four-week break should be considered with the topical corticosteroid being replaced with vitamin D analogues or coal tar for the duration. NICE (2012) also suggested that a potent topical steroid can be applied once a day in conjunction with a vitamin D analogue at the other end of the day.
Figure 4. One fingertip unit. JCN 2017, Vol 31, No 5
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SKIN CARE
CONCLUSION
British Association of Dermatologists (2015) Topical corticosteroids. Patient information leaflet. Available online: www.bad.org.uk/shared/get-file. ashx?id=183&itemtype=document (accessed 25 June, 2017)
British Association of Dermatologists (2016) ologists gists (201 (2016 Calcineurin inhibitors. Patient information ient informatio leaflet. BAD, London.. Available online: ailable on onlin www.bad.org.uk/shared/get-file. shared/get-file. ashx?id=155&itemtype=document emtype=docu mtype=docu (accessed 30 May, 2017) 0M Ma British Medical Association (2017a) al Assoc Associ British Formulary. Vitamin itish h National Fo analogues. Available online: D and nd analogu www.evidence.nhs.uk/formulary/bnf/ www.evide current/13-skin/135-preparations-forcurrent/ eczema-and-psoriasis/1352-preparationsecze for-psoriasis/topical-preparations-forfo psoriasis/vitamin-d-and-analogues (accessed 30 May, 2017)
W ou nd
As these treatments enable patients to manage their condition at home, community nurses will regularly be asked questions about their implications and use during routine visits for other complaints.
Allen H (2015) Tazarotene for psoriasis (Zorac). Patient, 29th September. Available online: https://patient.info/medicine/ tazarotene-for-psoriasis-zorac (accessed 18 June, 2017)
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20 17
Community nurses are ideally placed to manage patients coping ng with the symptoms of psoriasis, but it is crucial that they have ave a comprehensive understanding anding nding of the treatments available blee so that they the t can provide up-to-date -date management manage mana and advice. Many ny topical therapies the are provided at the beginning of beginn begin treatmentt for fo psoriasis, psoriasis when patients are stilll coming to with their o terms te ‘unsightly’ skin ghtly’ htly’ and uncomfortable u condition. While GPs commonly on. Wh Whi prescribe topical therapies, limitations to on their time mean that patients are not always provided with enough information about these medications. While patients may be referred to dermatology specialty nurses, who are well-placed to evaluate them in detail, including discussing the practicalities of topical therapies such as application quantities and how various preparations may affect patients’ daily lives, unfortunately 66
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Dubois Declercq S, Pouliot R (2013) Promising new treatments for psoriasis. Scientific World Journal. Available online: www.hindawi.com (accessed 6 January, 2017) Federman DG, Froelich CW, Kirsner RS (1999) Topical psoriasis therapy. Am Fam Physician 59(4): 957–62 Furue M1, Terao H, Moroi Y, ett al (2004) Dosage and adverse effects topical ects of top tacrolimus and steroids ids in daily management of atopic dermatitis. J topic dermati dermatitis Dermatol 31(4):: 277–83 –83
Lt d
Dose of cream in a fingertip unit varies with age: ` Adult male: one fingertip unit provides 0.5g ` Adult female: one fingertip unit provides 0.4g ` Children of four years — approximately 1/3 of adult amount ` Infants six months to one year — approximately 1/4 of adult amount.
REFERENCES
tacrolimus/ (accessed 21 June, 2017)
Griffiths CEM, RDR, Barker JNWN EM, Camp R (2004) Psoriasis. Burns T, Breatnach S, oriasis. In: Bur Coxx N, Griffiths CEM CEM, eds. Rook’s textbook 2. 7th edn. Blackwell of dermatology.Vol dermatology Oxford Science, cience, Oxfor Oxfo
Pe op le
Due to the varying rates of absorption into the skin, it is important that community nurses assist patients in understanding the correct amount of topical therapy to be applied. For this reason, doses are often referred to as fingertip units (FTU). One adult fingertip unit is the amount of cream or ointment taken from an average 5mm diameter nozzle, applied from fingertip to first crease of the index finger (Figures 3 and 4).
the numbers of dermatology nurses across the UK is limited. This is precisely why it is crucial that community nurses have an understanding of psoriasis and its treatments, which will allow them to provide best practice themselves or refer on to specialist services if necessary. JCN
C ar e
FINGERTIP UNIT
British Medical Association (2017b) British National Formulary. Topical corticosteroids. www.evidence.nhs.uk/formulary/ bnf/current/13-skin/134-topicalcorticosteroids (accessed 30 May, 2017) British National Formulary (2017) Betamethasone with Salicylic acid. Available online: www.medicinescomplete.com/mc/ bnf/64/PHP88041-betamethasone-withsalicylic-acid.htm (accessed 25 June, 2017) Coondoo A, Phiske M, Verma S, Lahiri K (2014) Side-effects of topical steroids: A long overdue revisit. Ind Dermatol Online J, 5(4): 416–25 DermNet NZ (2005) Coal Tar Treatment. Available online: www.dermnetnz.org/ topics/coal-tar (accessed 18 June, 2017) DermNetNZ (2017) Tacrolimus. Available online: www.dermnetnz.org/topics/
(2010) The rationale behind topical Kim G GK (20 vitamin D analogs in the treatment of vita vitami psoriasis: where does topical calcitriol fit pso in? J Clin Aesthet Dermatol 3(8): 46–53 Kumar B, Kumar R, Kaur I (1997) Coal tar therapy in palmoplantar psoriasis: old wine in an old bottle? Int J Dermatol 36(4): 309–12 Malecic N, Young H (2016) Tacrolimus for the management of psoriasis: clinical utility and place in therapy. Psoriasis: Targets and Therapy 6: 153–63 MayoClinic (2017) Anthralin (topical route), drugs and supplements. Available online: www.mayoclinic.org/drugs-supplements/ anthralin-topical-route/proper-use/drg20061896 [accessed 21/6/17] McClelland PB (1997) New treatment options for psoriasis. Dermatol Nurs 9(5): 295–306 Menter A, Korman N, Elmets C, et al (2009) Guidelines of care for the management of psoriasis and psoriatic arthritis, section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol 60(4): 643–59 National Eczema Society (2016) Factsheet: Topical Calcineurin Inhibitors (TCIs). Available online: ///C:/Users/Me/ Downloads/Topical%20Calcineurin%20 Inhibitors%20September%202016.pdf (accessed 21 June, 2017) National Institute for Health and Care Excellence (2012) Psoriasis: assessment and management. Clinical Guideline [CG153]. NICE, London. Available online: www.
SKIN CARE
Ngan V (2005) Coal tar treatment. DermNet New Zealand. Available online: www. dermnetnz.org/topics/coal-tar/ (accessed 30 May, 2017) National Institute for Health and Care Excellence (2015) Corticosteroids — topical (skin), nose and eyes. NICE, London. Available online: https://cks.nice.org. uk/corticosteroids-topical-skin-noseand-eyes#!scenariorecommendation:7 (accessed 30 May, 2017)
National Psoriasis Foundation (2017) Over-the-Counter Products, June. Available online: www.psoriasis.org/sites/default/
Revalidation n Alert
Having read ad this article, art UHÁHFWRQ Your our understanding u rstan of psoriasis ps soriasis and how and when treatments to use tr If you are familiar with the guidelines set out by NICE Your knowledge of the different products available and how they work.
D Then, upload the article to the new, free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation
therapies are psoriatic medications that are applied to the skin, but can be absorbed through the skin, which means that they need to be used carefully.
Orseth ML, Cropley TG (2013) What’s in a name? Goeckerman Therapy. JAMA Dermatol 149(12): 1409
Patients are often confused about the use of active topical treatments.
Paghdal KV, Schwartz RA (2009) Topical tar: back to the future. J Am Acad Dermatol 61(2): 294–302
Peters J, Sterling A, Robertson S (2008) Knowledge and application of topical emollients: an audit. Dermatol Nurs 7(2): 30–5
This
Pion IA, Koenig KL, Lim HW (1995) Is dermatologic usage of coal tar carcinogenic? A review of the literature. Dermatol Surg 21(3): 227–31 Psoriasis Association (2014a) Vitamin D. Available online: www. psoriasis-association.org.uk/media/ dia/ InformationSheets/Vitamin_D.pdf D.pdf df (accessed 30 May, 2017)
Psoriasis Association (2014b) Tazarotene 2014b) b) Tazaroten Tazarote (Zorac). Available online: www. psoriasis-association.org.uk/media/ ation.org.uk/m ion.org.u InformationSheets/Tazarotene.pdf nSh nShe /Tazaro (accessed ed 30 0 May, 22017)
W ou nd
National Institute for Health and Care Excellence (2016) Psoriasis overview. NICE, London. Available online: https:// pathways.nice.org.uk/pathways/psoriasis (accessed 30 May, 2017)
Topical
Lt d
National Psoriasis Foundation (2016) Topical treatments for psoriasis. Available online: www.psoriasis.org/sites/default/files/ topicals_booklet.pdf (accessed 30 May, 2017)
Oakley A (2009) Topical corticosteroid treatment for skin conditions. BP J 23: 8–13
KEY POINTS
article provides des a brief outline of topical pical treatments, treatm which will enable ble community com nurses to bette better guide ui patients through complexities of the gh the com different products available. rent produ
Pe op le
National Patient Safety Agency (2007) Examples of products containing paraffin. Pharmaceutical Services Negotiating Committee (PSNC). Available online:///C:/Users/Me/Downloads/NRLS1028F-products-conta--paraffin-200711-V1.pdf (accessed 21 June, 2017)
files/otc_product_fact_sheet_0.pdf (accessed 18 June, 2017)
C ar e
nice.org.uk/guidance/cg153/chapter/1Guidance#topical-therapy (accessed 18 June, 2017]
Psoriasis asiss Association (2014c) Tazarotene (Zorac). (Zorac) rac).. Available Availab online: www. Availa psoriasis-association.org.uk/media/ psoriasis-a psoriasis-as InformationSheets/Tazarotene.pdf Informa (accessed 18 June, 2017) (acc (acce Psoriasis and Psoriatic Arthritis Alliance P Ps (2017a) Retinoids and psoriasis. Available online: www.papaa.org/furtherinformation/retinoids-and-psoriasis (accessed 30 May, 2017)
Psoriasis and Psoriatic Arthritis Alliance (2017b) Diprosalic. Available online: www.papaa.org/combination-therapies/ diprosalic (accessed 30 May, 2017) Psoriasis and Psoriatic Arthritis Alliance (2017c) Coal tar. Available online: www. papaa.org/psoriasis-treatments/coal-tar (accessed 18 June, 2017) PubMed Health (2017) Tazarotene (on the skin). Available online: www. ncbi.nlm.nih.gov/pubmedhealth/ PMHT0012296/?report=details (accessed 30 May, 2017) Pugsley H (2009) Psoriasis management: a primary care perspective. Dermatol Nurs 8(3): 20–4 Saurat JH (1999) Retinoids and psoriasis:
Due to th the varying rates of absorption into the skin, it is absorptio important that community imp nurses assist patients in n understanding the correct amount of topical therapy to be applied.
Community
nurses are ideally placed to manage patients coping with the symptoms of psoriasis.
Novel issues in retinoid pharmacology and implications for psoriasis treatment. J Am Acad Dermatol 41: S2–6 Sharma R, Abrol S, Wani M (2017) Misuse of topical corticosteroids on facial skin. A study of 200 patients. J Dermatol Case Rep 11(1): 5–8 Skin Cancer Foundation (2017) Prevention Guidelines. Available online: www. skincancer.org/prevention/sun-protection/ prevention-guidelines (accessed 25 June, 217) Stein Gold LF (2016) Topical Therapies for Psoriasis: Improving Management Strategies and Patient Adherence. Seminars in Cutaneous Medicine and Surgery, supplement 35(2): S39. Available online: www.globalacademycme.com/ fileadmin/images/supplement_image/ psoriasis/SCMS_Psoriasis0316.pdf (accessed 18 June, 2017) Wang C, Lin A (2014) Efficacy of topical calcineurin inhibitors in psoriasis. J Cutan Med Surg 18(1): 8–14 Van Onselen J (2011) Psoriasis Dermatology Nursing: A Practical Guide. Churchill Livingstone, London
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