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How to manage the impatient patient
SlO4
Satellite
svntposiunt
ST8 Psoriasis
with have shown that eyelid phototherapy is a safe and effective treatment in selected patients. A topical application of glucocorticosteroids may be avoided by usage of calcipotriol cream. ST8-2
Treatment Calcipotriol
of overweight psoriatic in skin folds
J.-H. Saurat. Dept of Dermarolagy Geneva-Lnusatme,
Geneva
patients:
and DHURDV
Switzerland
Intertriginous psoriasis is often a therapeutic challenge. Local intrinsic factors such as maceration and bacterial as well as mycotic superinfection cause chronicity and irritation. Topical steroids are not ideal in these areas for perpetuating infection and causing atrophy. The use of calcipotriol has been considered with some concern because of the risk of irritation. In fact many dermatologists have used the drug in intertriginous psoriasis, with much benefit to the patients. An open study in twelve patients treated for 6 weeks with calcipotriol ointment twice daily (Brit. J. Derm. 1996: 135. 647-650) has confirmed this practice; there was good response in ten, and slight lesionnal and perilesionnal irritation in five. We have treated our patients with intertriginous psoriasis with calcipotriol cream, which appears more convenient for these areas than the ointment. We prefer using one application per day. Some (about 15%) patients respond rapidly and completely to this regimen. When no or insufficient response is obtained after one week we add mometasone furoate cream once every other day. Adjonctive therapy includes washing body folds with ketoconazole shampoo three times a week and Tannosynt@. We consider calcipotriol as a first line therapy intertriginous psoriasis; irritation is not a major problem in most of the patients and, possibly due to lesser scaling and better absorption in these areas, a response to once daily application can be expected. ST8-3
Psoriasis
Hammersmith
Hospital,
Imperial London, UK
solutions
College
of Medicine,
Psoriasis affects the scalp in over 50% of patients and may be the only site of involvement in 25%. It can be one of the most difficult sites to treat, partly due to the poor cosmetic acceptability of the preparations used and thus poor patient compliance. The advent of calcipotriol scalp solution has marked a major advance in our treatment of this condition. Case 1: A 40-yearold man had had scalp psoriasis for 4 years, unsuccessfully treated with topical steroids. Thin plaque psoriasis covered 40% of the scalp. Treatment with calcipotriol scalp solution twice daily gave a rapid response with total clearance of the scalp in 8 weeks. Case 2: A 17-year-old woman presented with severe pruritus of the scalp for 6 months failing to respond to ketaconazole shampoo and topical steroids. Pruritus was so severe that she shaved her hair off. Examination showed 95% scalp involvement with 5-7 mm thick plaque psoriasis. Tteatment was started with 20% urea in aqueous cream applied at night, washed out next morning and calcipotriol scalp solution applied to the dry hair in the morning. After 4 weeks the scaling had subsided and the urea was stopped and after a further 8 weeks of calcipotriol scalp solution twice daily the scalp was clear.
to dificult
patients
To optimise treatment result, educate the patient in how to use treatment properly and use a descaling agent if thick scale is present Calcipotriol scalp solution should be considered the first line treatment of choice. ST8-4
How to manage
K. Kragballe. Dept. University
of Aarhus,
the impatient
Dertnatology, Marselisborg Aarhus, Detttttark
patient Hospital,
The impatient patient may not have severe psoriasis in a strict sense. Rather it is typically a person with urgent business and/or travel plans that requires fast improvement of her/his skin condition. In this situation the dermatologist is expected to prescribe a fast acting, reliable and easy to administer anti-psoriatic treatment. This may create a dilemma, because many treatments act rather slowly, and potent therapies often require monitoring that may be difficult to implement if the patient travels abroad. Thus, methotrexate acts slowly and requires monitoring of bone marrow and liver functions. In contrast, systemic steroids induce fast relief, but may destabilise the disease and even precipitate pustular psoriasis or otherwise exacerbate the disease when the dose is tapered off. There are additional considerations in patients travelling to places where prophylaxis against malaria is recommended. Thus, the chloroquines may in some patients cause a severe exacerbation of their psoriasis. There is no general solution to the question how to treat the impatient psoriatic patient. It is necessary to individualise. As an example, your past experience with the patient is important. Thus, a patient known to tolerate methotrexate and/or cyclosporin A can readily be put on this treatment without close work up of the laboratory tests. ST8-5
Mentally ill patients aspects of psoriasis
J. Koo. University Medical Center
of the scalp
T. Chu. Unit of Dermatology,
- Practical
of California USA
and the psychological San Francisco
(UCSF)
Psoriasis patients who are mentally compromised, such as those with schizophrenia, mental retardation or dementia, or character disorder leading to questionable compliance, are frequently at greater risk for suffering long-term side effects from excessive use of topical steroids. In dealing with these types of patients, the clinicians frequently feel uneasy about using systemic agents such as methotrexate, or cyclosporin, or phototherapy due to their concerns about the patients’ capacity to understand the proper use of these treatment modalities, or because of their concerns about compliance. Consequently, topical steroids are often used exclusively, and frequently excessively, because they are considered the “safer alternative”. Since psoriasis is a chronic disease that requires long-term therapy, strategies for minimizing steroid dependence, excessive steroid use, and steroid side effects in these patients will be discussed. In addition, there will be a discussion regarding an approach to psoriasis patients who report that psychological stress exacerbate their psoriasis (which is approximately half of the psoriatic population). These issues will be illustrated with actual cases.
Satellite
svntposiunt
ST8 Psoriasis
with have shown that eyelid phototherapy is a safe and effective treatment in selected patients. A topical application of glucocorticosteroids may be avoided by usage of calcipotriol cream. ST8-2
Treatment Calcipotriol
of overweight psoriatic in skin folds
J.-H. Saurat. Dept of Dermarolagy Geneva-Lnusatme,
Geneva
patients:
and DHURDV
Switzerland
Intertriginous psoriasis is often a therapeutic challenge. Local intrinsic factors such as maceration and bacterial as well as mycotic superinfection cause chronicity and irritation. Topical steroids are not ideal in these areas for perpetuating infection and causing atrophy. The use of calcipotriol has been considered with some concern because of the risk of irritation. In fact many dermatologists have used the drug in intertriginous psoriasis, with much benefit to the patients. An open study in twelve patients treated for 6 weeks with calcipotriol ointment twice daily (Brit. J. Derm. 1996: 135. 647-650) has confirmed this practice; there was good response in ten, and slight lesionnal and perilesionnal irritation in five. We have treated our patients with intertriginous psoriasis with calcipotriol cream, which appears more convenient for these areas than the ointment. We prefer using one application per day. Some (about 15%) patients respond rapidly and completely to this regimen. When no or insufficient response is obtained after one week we add mometasone furoate cream once every other day. Adjonctive therapy includes washing body folds with ketoconazole shampoo three times a week and Tannosynt@. We consider calcipotriol as a first line therapy intertriginous psoriasis; irritation is not a major problem in most of the patients and, possibly due to lesser scaling and better absorption in these areas, a response to once daily application can be expected. ST8-3
Psoriasis
Hammersmith
Hospital,
Imperial London, UK
solutions
College
of Medicine,
Psoriasis affects the scalp in over 50% of patients and may be the only site of involvement in 25%. It can be one of the most difficult sites to treat, partly due to the poor cosmetic acceptability of the preparations used and thus poor patient compliance. The advent of calcipotriol scalp solution has marked a major advance in our treatment of this condition. Case 1: A 40-yearold man had had scalp psoriasis for 4 years, unsuccessfully treated with topical steroids. Thin plaque psoriasis covered 40% of the scalp. Treatment with calcipotriol scalp solution twice daily gave a rapid response with total clearance of the scalp in 8 weeks. Case 2: A 17-year-old woman presented with severe pruritus of the scalp for 6 months failing to respond to ketaconazole shampoo and topical steroids. Pruritus was so severe that she shaved her hair off. Examination showed 95% scalp involvement with 5-7 mm thick plaque psoriasis. Tteatment was started with 20% urea in aqueous cream applied at night, washed out next morning and calcipotriol scalp solution applied to the dry hair in the morning. After 4 weeks the scaling had subsided and the urea was stopped and after a further 8 weeks of calcipotriol scalp solution twice daily the scalp was clear.
to dificult
patients
To optimise treatment result, educate the patient in how to use treatment properly and use a descaling agent if thick scale is present Calcipotriol scalp solution should be considered the first line treatment of choice. ST8-4
How to manage
K. Kragballe. Dept. University
of Aarhus,
the impatient
Dertnatology, Marselisborg Aarhus, Detttttark
patient Hospital,
The impatient patient may not have severe psoriasis in a strict sense. Rather it is typically a person with urgent business and/or travel plans that requires fast improvement of her/his skin condition. In this situation the dermatologist is expected to prescribe a fast acting, reliable and easy to administer anti-psoriatic treatment. This may create a dilemma, because many treatments act rather slowly, and potent therapies often require monitoring that may be difficult to implement if the patient travels abroad. Thus, methotrexate acts slowly and requires monitoring of bone marrow and liver functions. In contrast, systemic steroids induce fast relief, but may destabilise the disease and even precipitate pustular psoriasis or otherwise exacerbate the disease when the dose is tapered off. There are additional considerations in patients travelling to places where prophylaxis against malaria is recommended. Thus, the chloroquines may in some patients cause a severe exacerbation of their psoriasis. There is no general solution to the question how to treat the impatient psoriatic patient. It is necessary to individualise. As an example, your past experience with the patient is important. Thus, a patient known to tolerate methotrexate and/or cyclosporin A can readily be put on this treatment without close work up of the laboratory tests. ST8-5
Mentally ill patients aspects of psoriasis
J. Koo. University Medical Center
of the scalp
T. Chu. Unit of Dermatology,
- Practical
of California USA
and the psychological San Francisco
(UCSF)
Psoriasis patients who are mentally compromised, such as those with schizophrenia, mental retardation or dementia, or character disorder leading to questionable compliance, are frequently at greater risk for suffering long-term side effects from excessive use of topical steroids. In dealing with these types of patients, the clinicians frequently feel uneasy about using systemic agents such as methotrexate, or cyclosporin, or phototherapy due to their concerns about the patients’ capacity to understand the proper use of these treatment modalities, or because of their concerns about compliance. Consequently, topical steroids are often used exclusively, and frequently excessively, because they are considered the “safer alternative”. Since psoriasis is a chronic disease that requires long-term therapy, strategies for minimizing steroid dependence, excessive steroid use, and steroid side effects in these patients will be discussed. In addition, there will be a discussion regarding an approach to psoriasis patients who report that psychological stress exacerbate their psoriasis (which is approximately half of the psoriatic population). These issues will be illustrated with actual cases.