13. MANAGING DIFFERENT KINDS OF PSORIASIS

3.1. Psoriasis of the scalp

• First line of treatment, Daivonex® or Apsor emulsion lotion.
• Second line of treatment: topical corticotherapy. It is sometimes necessary to carry out scalp disinfection with a ten-day antibiotic treatment (with Josamycin®, for example) combined with a cleansing using silver sulfadiazine (Flammazine®), renewed every 8 hours, for one weekend. Practically always well tolerated on the scalp, the use of topical corticotherapy is simple: Dermoval® cream (the gel may irritate at the start of treatment but will be quite comfortable thereafter), 1/2 tube every evening for one month, one evening out of two for two months, two evenings a week for three months and one evening a week for one year. Dermoval® may be left on all night or for just two hours. A mild shampoo or anti-dandruff product will be needed to remove it. Every morning, the scalp will be given a quick massage with a few drops of vitamin D3 derivatives or corticosteroid in lotion form. This is to be done every day without increasing ever the interval and to be continued after the Dermoval® is stopped. This strategy yields good results in 95 to 98% of cases. It is the most effective strategy designed for severe and resistant psoriasis of the scalp. The patient can only follow this treatment if he puts up a calendar in his bathroom, ticking off the treatment days in advance. It is indeed possible to remember a daily treatment, difficult not to forget a treatment prescribed every other day, impossible to remember a treatment prescribed twice a week and possible again to remember a treatment prescribed once a week. Of course, strategies can be varied to match the severity of the psoriasis but, in this site, long-term treatment continued long after the disappearance of the lesions will always be necessary. The special difficulty of treating psoriasis of the scalp in women also needs to be stressed, especially if they have thick hair. The treatment becomes very soon more constraining than the psoriasis itself. Clobetasol based shampoo, when available, seems to be both convenient and efficacious. It is also necessary to emphasize the special problem posed by the lichenified plaques on the nape. It all starts with a scratching tic, with permanent Köebner’s phenomenon.. In this situation, apart from the explanation given to the patient (5 minutes of scratching = two weeks of psoriasis), the lichenification must be treated by cauterizing the intra-epidermal nerve endings with 33% trichloracetic acid or Anthralin followed by Dermovat. Dermoval® alone is ineffective. An alternative strategy is more and more used: after the clearing phase obtained by Dermovat, the maintenance treatment is Daivonex during the week and Dermoval the weekend.
• Third line of treatment: all general treatments, when necessary.
• Finally, it should be noted that mechlorethamine (Caryolysine®, made by Synthelabo Labs), diluted at a rate of one vial to 50 ml water, is highly effective in psoriasis of the scalp, provided that any run-off onto the face and into the eyes is strictly avoided; this product is highly irritant, allergenic, mutagenic and carcinogenic. Psoriasis of the scalp resistant to all treatments is undoubtedly the last indication for Caryolisine® in psoriasis. This product has actually been abandoned long since, as it caused 25% of contact eczemas and after a few years of treatment provoked spinocellular carcinomas. Moreover, its use before or after PUVA therapy is completely unreasonable.
  
  

  “ I disagree. We use steroids as a first line of scalp psoriasis therapy. Salicylic acid is used for desquamation. Topical antiseptis or antibiotics are very rarely used.

  Olle Larkö

  Olle Larkö

Photo 96. The refractory areas: the scalp.

3.2. The skin folds

A secondary mycotic infection can always be associated with psoriasis and aggravate it. It is therefore important to check for its absence or treat it where it does exist. Topical treatments are difficult to use on these sites due to their occlusive nature and to maceration, which biases the efficacy/toxicity ratio in favour of toxicity. Drying in very hot air and using corticosteroids in lotion form to avoid any maceration generally enables these difficult sites to be kept under control, unfortunately often at the cost of skin atrophy and stretch marks. Calcipotriol in cream or ointment form is an irritant. The lotion would be interesting to assess. Calcitriol seems particularly effective and well tolerated in these delicate zones, where it is most useful. Anthralin® is contraindicated or difficult to manage. Tacrolimus would be interesting to assess.

3.3. The genital area

Topical corticotherapy is remarkably efficacious in general and well tolerated around the genitalia, in the form of a cream for women, but preferably in lotion form for men, avoiding overly irritating alcoholic lotions. Tacrolimus (Protopic) is of major interest because effective and not atrophogenic.

3.4. The tongue

Topical corticotherapy, in the form of suckable tablets, is rather ineffective. Applying topical retinoids in lotion form can sometimes yield good results in this hard-to-treat location.

3.5. The nails (photo 97)

In my experience, topical treatments completely lack efficacy since the matrix is too deep. Microtraumas need to be investigated and their source avoided, the nails cut short and a battle waged against subjects scratching their nails. Of the general treatments, retinoids act very slowly and can only be used at very weak doses, since at high doses they are able to induce ungual dystrophy that can cause ungual psoriasis by Köebner’s phenomenon. Methotrexate may be effective, but retards nail growth and its action is therefore slow.

Photo 97. Incapacitating attack on the nails.

3.6. The face

Facial psoriasis invariably has a serious effect on the quality of life.

• The first line of treatment is based on skin hydration and imidazoles or Lithioderm.
• The second line of treatment is based on vitamin D derivatives, particularly Calcitriol. They have still to be assessed in this indication.
• Tacrolimus®, in third line, is very effective.
• In fourth position, UVB phototherapy may be of help.

3.7. The external auditory canals

This site, which is particularly embarrassing because of the frequently associated pruritus, is a good indication for topical corticotherapy used in lotion form. Tacrolimus® would be just as interesting to assess when there is resistance to topical corticotherapy. At this location there is often an associated secondary infection that may require oral antibiotics for several days, coupled with topical corticotherapy, or the regular use of 0.5% silver nitrate 3 times a week.

3.8. Palmoplantar psoriasis (photos 98 and 99)

• The first line of treatment is hydration of the skin every hour. Moisturizing every hour with cream from a tube is not practicable. Patients must learn to use a lipstick, if possible containing shea butter. One should apply as little as possible in order to avoid the feeling of greasy hands and thus follow the treatment regularly without embarrassment. Keratolytics in the evenings and mornings may be very useful; it is their only indication in psoriasis. The effectiveness of topical steroids, even under occlusive, is not long lasting because they inhibit the repair of the barrier function. A possible strategy is to clear skin with Dermovat under occlusive and to maintain the result via Protopic; however, this remains to be evaluated.
• The second line of treatment is possibly the combination of topical retinoids/topical corticosteroids. This combination still needs to be assessed in this site.
• The third line of treatment can be Anthralin at 0.1% in Diprosone ointment + 2% of salycilic acid.
• The fourth line of treatment is systemic retinoids in small doses, bearing in mind that Soriatane displays particularly substantial tropism for the cornified epithelia of the palms and soles.
• Only in the event of Soriatane failing would methotrexate or cyclosporine be contemplated in some cases.
• If necessary biologicals can be discussed.

Photo 98. The effect on the hands is disabling.

Photo 99. The effect on the feet is highly painful and prevents walking.

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