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NICE guidelines 2012

''Management of chronic plaque psoriasis''
    regular emollients - reduce scale and pruritus
    1st - potent corticosteroid od plus vitamin D analogue od (separately, one in morning, other in evening) for up to 4/52
    2nd - vit D analogue bd for another 4/52
    3rd - potent corticosteroid bd or coal tar od-bd
    short-acting dithranol can also be used

''topical steroids in psoriasis''
    may lead to skin atrophy, striae and rebound symptoms
    systemic side-effects may be seen if used on large areas (> 10%BSA)
    4 week break before starting another course 
    only use potent corticosteroids for 8/52 or very potent ones for 4/52 without 4/52 break initially
    maintenance - 1-2/52 / month
    use for flexural or facial mild steroid for od or bd  for 2/52)

''vitamin D analogues''
    calcipotriol (Dovonex), calcitriol and tacalcitol
    reducing cell division and differentiation
    adverse effects are uncommon
    may be used long-term (unlike steroids)
    do not smell or stain (unlike coal tar or dithranol)
    reduce scale and thickness of plaques but not erythema
    avoid in pregnancy
    maximum weekly amount for adults is 100g

''Scalp psoriasis''
    potent topical corticosteroids od 4/52 
    then try different formulation (shampoo/mousse) or topical agent to remove scale (salicylic acid, emollients and oils) before steroid

''Secondary care management''

''Phototherapy''
    narrow band ultraviolet B light is treatment of choice. (3 times a week)
    photochemotherapy is also used - psoralen + ultraviolet A light (PUVA)
    adverse effects: skin ageing, squamous cell cancer (not melanoma)

''Systemic therapy''
    1st - oral methotrexate - esp good if also joint disease
    ciclosporin
    systemic retinoids
    biological agents: infliximab, etanercept and adalimumab
    ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials

''Mechanism of action of commonly used drugs''
    coal tar: probably inhibit DNA synthesis
    calcipotriol: vitamin D analogue which reduces epidermal proliferation and restores a normal horny layer
    dithranol: inhibits DNA synthesis, wash off after 30 mins, SE: burning, staining