Case histories

CASE 1

A boy of seven has plaque psoriasis limited to his scalp, elbows and knees with just a few scattered plaques all over.

He would be treated with moisturisers, topical vitamin D analogues, such as calcipotriol applied in cream or ointment form twice a day, or short-contact dithranol cream. His scalp could be treated with calcipotriol scalp solution or, if severe, a salicylic acid and tar product to reduce the scaling before the calcipotriol scalp solution is applied. The treatment will need to be supervised by his parents.

CASE 2

A girl of seven has very widespread psoriasis covering most of her body.

She should be referred to a hospital dermatology department for consideration of dithranol treatment in the Ingram regimen or possibly the vitamin D analogue calcipotriol with or without UVB phototherapy.

CASE 3

A girl or young woman has guttate psoriasis 10 to 14 days after a nasty bout of tonsillitis.

This type of psoriasis often settles after six to eight weeks of using moisturisers and calcipotriol. Short-contact dithranol is another possibility if her symptoms are severe. A short course of UVB phototherapy is often very effective, but this will require referral of the patient to a dermatology department.

CASE 4

A man has plaque psoriasis limited to a few areas of his body.

Moisturisers will help to reduce scaling, and he may not want to bother with other treatments. If, however, he wants to be treated, a topical vitamin D product, such as calcipotriol, is the best to begin with, in cream or ointment form and applied twice a day. Dovobet ointment, used daily for a maxi­mum of four weeks, could be tried.
An alternative treatment would be short-contact dithranol.

CASE 5

A woman has widespread plaque psoriasis covering most of her body.

It is worth trying vitamin D analogues first – for example, calcipotriol used topically twice a day – but only if less than 100 grams a week is required. If this is ineffective or if more than 100 grams a week is required, she should be referred to a der­matology department for dithranol in the Ingram regimen with UVB phototherapy or calcipotriol with UVB phototherapy. PUVA or sys­temic drugs should be considered if her psoriasis is really severe, fails to respond to other treat­ments or, having responded, flares up quickly.

CASE 6

A man has severe plaque psoriasis or pustular psoriasis on his palms and soles that interferes with his work and leisure activities.

A short course of a very potent topical corticosteroid is justi­fiable, but it is likely that his condition will flare up again once the treatment is discontinued. He should be referred to a hospital dermatology department for con­sideration of PUVA or another systemic treatment. A topical steroid could be used while he is waiting for an appointment.

CASE 7

An elderly woman has very itchy psoriasis – especially on her legs.

Elderly people often suffer from eczema. Their skin is often very dry and cracked and psoriasis and eczema can often coexist, so it is important to check that psoriasis is the cause of the itching. She may find that using moisturisers in the bath or shower and on her skin brings some relief, especially when used with mild or moderately potent topical corticosteroid oint­ments. It is important to be very careful with dithranol, even in its short-contact form, because irrita­tion may result. This may also apply to vitamin D analogues.

CASE 8

An obese woman has psoriasis in her creases, for example, in her armpits, under her breasts or in her groin.

It may help if she loses some weight to prevent the skin in the creases rubbing together. She should use moisturisers and mild topical corticosteroid products (such as hydrocortisone) or a moderately potent steroid such as clobetasone butyrate. The vitamin D analogue calcipotriol can be used with care, but it may sting, so she should use it only daily at first and build up to twice a day if it is tolerated.

CASE 9

A woman has severe nail psoriasis.

There is no topical treatment that has consistently been shown to benefit patients with psoriasis of the nails. If she also has severe plaque psoriasis sufficient to warrant systemic treat­ment, then her nails may improve. She may also find that her nails improve spontaneously at any time.