Treatment Psoriasis

This section is about what over the counter treatments are available (not all treatments may be available in that country) and how they help.

Please check all ingredients if one are allergic or sensitive to them
Treatments are not allowed on mouth, lips, eyes/ears, genitals and/or anus
For external use only
All treatment takes time to work, so please be compliant.
Emollient products/creams/oils can be highly flammable, keep away from naked flames.
Do not share products with others
Products can be mixed and matched (not steroids)

Aim:

To control the psoriasis and bring the skin back to its original state and not have it affect ones daily routine.

Treatment available

There are a wide range of treatments available over the counter.

The medication will generally help to soothe the skin rather than stop psoriasis since it is of an unknown cause.

Please be patient with the treatment, they do take time to control psoriasis (most treatments at least a month). Normally scales will disappear first and the psoriasis may appear red, with continuous treatment the red pink areas will slowly fade back to normal skin colour.
Psoriasis can have a big impact on one’s lives, if you need to talk to and need advice; see your pharmacist or medical doctor.

Emollient moisturisers

They help by softening the hard skin and red lesions.
They may help to reduce scaling.
It decreases itchiness and soothes irritated skin and has anti-cleaning properties so soaps are not needed.
It also decreases the penetration of allergens and irritants (hence used in allergies).
They are useful in mild psoriasis and a wide range of choice is available and can be used in addition to other treatments.
They help to make other creams/ointments to be more effective.
First use the emollient then 10-15 minutes in Luke warm water. (spending more than 20 minutes in the bath can irritate and worsen the dry skin), later one can apply creams/coal tar preparation (approx. 30 minutes later, so both treatments are effective).
One should use emollients in the same direction as the hair grows and do not rub in a circular motion onto skin (it will block pores and make the skin condition worse).
Be aware emollients can make the skin, bath and showers very slippery and extra care is needed especially with children and elderly, a bath mat may help.
Always once finished clean the bath or shower thoroughly after use.
Always ‘pat dry’ with a clean dry towel, do not rub the skin.
A big advantage with emollients is that it can be used to cover large areas and should be used regularly (every day) even if one has no flare-ups.

Further tips on emollients in psoriasis management:

Find an emollient or range of emollient products for washing and moisturising that you like and suit you, and use them each day;
Moisturise your entire body (including psoriasis areas) each day using long, smooth, soothing strokes (in the direction of hair growth);
Carry a small amount of moisturiser with you and apply to dry and itchy plaques during the day;
Avoid scratching and picking;
Leave around 20–30 minutes between emollient and psoriasis topical treatments, to aid the effectiveness of each;
Persevere with topical psoriasis treatments for at least one month — most take around four weeks to begin to work;
Be aware that the scale will disappear first and the psoriasis may appear red — this is normal and continuing with treatment will result in pink areas, which will gradually fade to normal skin colour;
If you have scalp psoriasis, de-scale your scalp before applying topical treatments. Remember to part the hair and treat the scalp;
Work out a good individual routine — emollients should be used daily and psoriasis treatments only when condition is flaring;
Once the skin becomes flat, active treatments can be stopped, although you should continue with emollients.

Clinical Pharmacist, CP, March 2018, Vol 10, No 3;10(3):DOI:10.1211/PJ.2018.20204451

Soap Substitutes/Skin Cleansers

Soaps, bubble baths, moisturising soaps can dry out your skin and leave the skin very irritated. An alternative to soaps are soap substitutes. They leave your skin moist and less irritated; one should wash with those instead.
Most soap substitutes come in a dispenser to prevent bacterial contamination. However, we do advise if more than one member uses a product, they should have their own. If one does not have a dispenser one should scoop cream on a clean pate, instead of dipping their hands into a pot.
Soap substitutes do not lather like soap but they do cleanse the skin.
Refrain from use of inappropriate solvents (i.e. gasoline) or abrasives (i.e. pumice stone) to cleanse hands.

Creams

Creams hydrate the skin like emollients and prevent water evaporating from the skin.
Some creams are also used as ‘soap substitutes’.
They should be used liberally and regularly (four to six times daily). It is not unusual to use 250g-600g of cream each week. Most people believe that is too much, but it is not.
One should take a tub to school/work and it can be used all the body if required and not just on patches. Again it should be used even if one has no flare-ups.
A good tip is to warm cream with hands to make it easier to apply.
It should be used especially after one has had a bath or shower to lock water in the skin, since it is then one loses a lot of water from ones skin when drying oneself (ideally within three minutes of bathing and showering to ‘trap’ moisture).
Rub the cream softly in a downward fashion in direction of hairline.
Do not rub vigorously.
If itching is a particular problem, creams can be kept cooled in a fridge before applying them.
Ideal for summer use.

Ointments

Are like creams and lock in even more moisture, but are harder to apply, it can take up to an hour to soak in and can stain clothing.
Have less additives hence good for very sensitive skin.
Thick and greasy, hence good for very dry and thickened skin.
Ideal for night time (sleeping hours ) use.
It is ideal to use at night or if one has extremely dry skin. If itching is a problem, they can be cooled in the fridge before applying them.
It is best not to use on hairy areas as they can block hair follicles which can lead to further swelling and infection.
Ideal for cold weather and/or winter use.

Salicylic Acid

Salicylic acid belongs to a group of drugs called keratolytics. It works by bringing moisture to the top layer of the skin and works by softening keratin, a protein which is found in the skin structure. It removes the outer dead layer of the skin and tends to loosen and lift scales of psoriasis.
It helps other medicinal treatments to penetrate more into the skin making them more effective, hence it is used in many products as a combination.
It should not be used by anyone who is sensitive to salicylates.

Coal Tar Preparations

Used for many years and is thought to reduce the turnover of the skin, though it is not clear how they work.
They also seem to have anti-scaling properties and reduce inflammation.
They are not to be used in direct sunlight or if pregnant or breastfeeding.
Beware it can stain clothes, hair, skin and bedding, so wear old clothes and protect bed linens with old towels when using such treatments.
Use the correct dose as it can burn the skin.
The products does have a strong odour which some patients may dis-like.
They are usually applied two or three times daily and can take up to 4- 8 weeks to take effect.

Dithranol

Used for many years and is a well established product for psoriasis.
They reduce inflammation and silvery scales.
One needs to be careful as it can irritate good skin, so one must wash hands after use or wear protective gloves or cover the surrounding skin with white soft paraffin.
It can also stain clothing, bedding, baths, hair and skin, so wear old clothes and protect bed linens with old towels when using such treatments.
It is available in a combination form with coal tar and salicylic acid.
treatment is normally applied for between 30- 60 minutes then washed off.
Skin improvement can take up to six weeks though many notice a difference between 2- 3 weeks.
It can be left on overnight if required.

Steroid creams

These products should be discussed with your medical doctor before use as one may need high strength formulations.
Talk to your pharmacist if a mild steroid is considered:
These creams are only used sparingly when one has a flare-up on unbroken skin.
- It can only be used up to seven days and restrictions do apply.
  - Do not apply on:
    - The face
    - Genitals
    - Any orifice i.e. inside mouth, earholes, anus without medical advice.
    - Under sweaty skins/skin folds i.e. armpits, under breasts, big belly folds, without medical advice.
    - Between toes
    - Under bandages or dressings.
    - Any suspected viral infection i.e. cold sores, shingles, genital herpes, chicken pox.
If one wants to use it outside the restricted rules then one must see a medical doctor for a prescription, because the medical doctor must asses if it is suitable to use.
They help to reduce redness and inflammation
Do not use creams/lotions at the same time with steroidal products as this makes the steroid less effective.
Ointments tend to be used at night or in more severe ‘flare ups’.
Creams are generally used in mild ‘flare ups’ and are easier to apply.

Witch Hazel

It contains tannins which has:

Antioxidant properties
Anti-inflammatory activity
non anti-inflammatory activity that fights against bacteria
Can act as an astringent by drying out the skin
Always use a high quality forms (many cosmetics contain perfumed products and other additives which may not agree with your skin)- preferably non alcohol and/or contain aloe vera (has antiseptic properties and good for sunburns as well as moisturising properties) and/or hyaluronic acid (act as a good moisturiser)
It does not help to get rid of itchiness
It is not be advisable for certain skin conditions, such as rosacea and/or extreme dryness as it can be very drying, which could cause your skin to overproduce oil and worsen blemishes.
If one have any open skin areas, the product also cause the skin to burn when applied and/or one may want to use with caution if you have sensitive skin. If one finds condition is getting worst after using witch hazel then stop using it.
If you’re trying out witch hazel for the first time, it’s a good idea to test it out in a small area of skin away from your face, such as the inside of your arm. If you don’t see any redness, rash, or dryness after a couple of days, then you can try it out on your face.
Do not apply under the skin directly to help bags under the eye (mix with other creams and/or lotions).
If using this product and have signs of an allergic/anaphylaxis reaction, such as problems breathing, hives, facial swelling, or swelling of your lips, tongue, or throat, call for an ambulance and seek emergency medical attention.

Tazarotene

These products should be discussed with your medical doctor before use.

Vitamin D analogues

Used for many years and is thought to reduce the turnover and inflammation of the skin, though it is not clear how they work.
Used mainly on the trunk and limbs , not usually on the face as it can cause skin irritation.
apply a thin layer once or twice day to affected areas for up to eight weeks.
One should notice a difference with in one or two weeks.

Antihistamines

These drugs work by blocking the chemical histamine which is released during an allergic reaction and itching.
It helps to calm down the inflammation (hot, red and swelling) of the skin.

Older anti-histamines(can make one drowsy)	Time to Work	Duration of Action
Chlorpheniramine	15 20 mins	4-6 hrs
New anti-histamines (can rarely make one drowsy)	Time to Work	Duration of Action
Cetirizine	1 hr	24 hrs
Loratadine	1 hr	24 hrs
Acrivistine	15 – 20 minutes	8 hrs

Please note never to exceed the stated dose and are available in liquids and/or tablets and side effects of anti-histamines are more noticeable in older patients.

Vitamins

Multivitamins are not intended to prevent long term conditions, reduce infection and is not proven (or data is weak) to help with cancer.

These are essential nutrients that the body requires in small amounts to function properly.

Herbal

Vitamins - If depressed