Other systemic drugs for psoriasis

There are a number of other drugs which may occasionally be used for the treatment of psoriasis particularly when the alternatives explored above are not suitable. In a systematic review (Griffiths et al., 2000), the evidence for the use of these four alternatives was reviewed. In summary their findings were as follows:

Hydroxyurea: One study fulfilled the inclusion criteria and it suggested that hydroxyurea does improve psoriasis in some patients. It was suggested that it may be a helpful drug for individuals who could not take ciclosporin or methotrexate.
Fumaric acid esters (fumarates): These were the drugs for which there was most evidence; they are widely used in German speaking countries. Although initial side effects of gastric upset (up to 66%) and flushing (up to 33%) were reported, these rarely stopped people continuing with the drugs and other more serious side effects were rare. It was concluded that fumarates are helpful in treating moderate to severe psoriasis.
Azathioprine: There were no recent studies relating to this drug and it is rarely used. Sulphasalazine: One randomised controlled trial showed it was effective, although 25% had side effects bad enough to make them stop taking the drug.

Service provision for those who need treatment for psoriasis
The general rule is that those with mild to moderate disease should be cared for in primary care, whilst those with moderate to severe disease should be referred for specialist care within a hospital environment. The National Institute for Health and Clinical Excellence (NICE) clarified what specialist services should provide (see Box 8.6); at the same time they published referral advice which classified the level of urgency with which someone should be referred (see Box 8.7) (National Institute for Clinical Excellence, 2001).

Box 8.6 What specialist services should be able to provide for patients with psoriasis Specialist services are in a position to: Confirm or establish the diagnosis; Provide in-patient and day-care services; Provide, in conjunction with other health care professionals, advice on the condition and its treatment, together with social and psychological support; Assess and supervise the use of phototherapy and PUVA, as well as oral retinoids, cytotoxic therapy and immunosuppressive therapy; Treat psoriasis that is unresponsive to therapies tried in primary care, or to resolve problems where the patient cannot tolerate such treatment; Offer acute treatment in patients with severe conditions such as EP or GPP; Provide and support specialist nursing services working in primary and secondary care; Provide assessment and advice for patients with painful psoriatic arthropathy.

Box 8.7 Referral criteria to specialist services Referral to specialist services, which may be prompted by features such as sleep disturbance, social exclusion, reduced quality of life or reduced self-esteem is advised if: **** The patient has generalised pustular or erythrodermis psoriasis. *** The patient’s psoriasis is acutely unstable. *** The patient has widespread GP (so that he/she can benefit from early phototherapy). ** The condition is causing severe social or psychological problems. ** The rash is sufficiently extensive to make self-management unpractical. ** The rash is in a sensitive area (such as face, hands, feet, genitalia) and the symptoms particularly troublesome. ** The rash is leading to time off work or school which is interfering with employment or education. ** The patient requires assessment for the management of associated arthropathy. * The rash fails to respond to management in general practice. Failure is probably best based on the subjective assessment of the patient. Sometimes failure occurs when patients are unable to apply the treatment themselves. **** should be seen immediately (within 1 day) *** should be seen urgently (it is recommended that this is within 2 weeks) ** should be seen soon (no specific recommendation as to timelines) * should be seen as a routine patient (no specific recommendation as to timelines)

As well as specialist services within hospitals, there is an ever increasing number of specialist practitioners working in community settings.

These may be nurse specialists who provide a range of services across primary care and between hospitals and primary care trusts or General Practitioners with a specialist interest in dermatology. The most commonly seen nursing roles include:

• Clinical nurse specialists in dermatology will see patients in their own homes or in clinics and generally help with chronic disease management for adults and children. Often they will work in such a way as to improve liaison between dermatological care provided in a hospital and that received in the community. This feature of the role may be emphasised as some are called dermatology liaison nurses. They may or may not be nurse prescribers.
• Nurse practitioner will do some of the above, but is also likely to have a significant diagnostic role. They are likely to be a nurse prescriber.