Psoriasis -advice before GP appointment

[artishard]

Hi,

I've suffered with minor patches of psoriasis for the last ten years or so. Following breaking my arm and the subsequent surgery in November, I am now covered in psoriasis patches and plaques (also affecting my scalp to a considerable degree).

I've overhauled my diet, use emolient cream daily but it's just got worse and worse. I have a doctor's appointment this week. Can anyone advise what I should be advocating for to my GP? Would it be reasonable to push for a dermatologist referral? Would this be classed as a severe case of psoriasis, or is it relatively mild?

Pics attached for reference. The one of my arm follows the line of the surgical scar.

sorry, further pics attached

That's absolutely something worth asking for a dermatology referral for, rather than just having a prescription for steroid cream and emollient. For a start, there are so many systemic treatments these days that can stop a flare in its tracks and ensure there are nowhere near so many flares in future.

Still take the steroid prescription, but ask for the referral too.

Hi, OP - I've had psoriasis for a long time. It's a hard slog, I won't lie.

I'd say that was moderate plaque psoriasis that's treatable with Enstilar foam in the here and now, while you wait on a Dermatology referral. The reason I think you should ask for (and insist on) a referral is because of the involvement of psoriasis around damaged tissue (your arm scar) which is known as Koebner Phenomenon. I have this and it can become unstable very rapidly unfortunately. (I'm now on biologics.)

There are lots of good treatments available now. Most of the really good ones such as UV light therapy are available through a Dermatology Department only, however. The exception to that is Enstilar foam which GPs can prescribe. I use Enstilar for outbreaks and it's excellent - I wish it'd been around when I was younger.

Best of luck

Oddly i have read that having ones tonsils removed can alleviate some psoriasis flares.

exGP here, with a postgrad diploma in dermatology. However I've been retired a while so I'm not going to recommend specific creams etc as I'll probably be out of date.

The waiting list for dermatology all over the country is humungous, so for that reason I would probably refer you simply to get you on the list. Also for that reason, if you have the money I'd strongly suggest you investigate whether private referral might possible in your area. (Dermatology is a very understaffed speciality and almost non-existent in some parts of England).

Steroid cream is good at damping down psoriasis but runs the risk of "tachyphylaxis" - ie if you stop using it, the psoriasis can quickly flare worse than ever. It's best to combine steroid with something more specific for psoriasis, such as the creams based on vitamin A, or the immunosuppressive options. Your GP should know which ones are currently available. Lots and lots of emollient in the meantime won't stop the plaques developing but might limit the scale and stop the skin cracking.

Do you use enough emollients? Many people don't, and many GPs don't prescribe enough at a time. Do you know about finger tip units, (FTUs) to measure the amount you should use? Google it if necessary. I'd recommend anything up to 500ml of moisturiser per fortnight if you're using it all over an adult human body. There's no point getting 50ml to last a month!! Obviously this doesn't apply to psoriasis creams which you only apply to the plaques themselves.

Guttate psoriasis (hundreds of tiny spots) is sometimes linked to streptococcal infection, which can also cause tonsillitis.

Oh, I should have said, Enstilar is a mix of steroid + vitamin A derivative cream so that's the sort of thing I had in mind in my first response.

Thanks for the advice everyone! Sadly I don't think my GP will be able to whip my tonsils out during my 15 minute consultation, but worth a shot 😝. Enstilar sounds like a promising first option, with a view to potentially seeing a dermatologist. Money is a bit tight, but if necessary I think I could scrape together enough for a private consultation if it looks unlikely to happen anytime soon via the NHS!

And most definitely what @mauvish wisely advises - in the words of my lovely consultant dermatologist: moisturise, moisturise, moisturise.

And that means all over your body. I have psoriatic arthritis as well so it can be very tricky on the dexterity front, but I made the effort because it really does help to prevent and dampen down flare-ups, and to keep my skin in better condition.

I'm lucky to be prescribed large quantities of Epimax emollient whenever I need and ask for it, and a bath lotion.

@mauvish my former GP had your qualifications and was excellent. Sadly for me (though not for him!) he retired just before the first lockdown. He deserves it, in spades.

I agree that's probably what classified as moderate. I'd want a referral but be prepared to wait 2 year or so to be seen. To be honest, a private referral wouldn't probably be massively different to a GP appt at least in terms of first steps. There are various systemic treatments you can try as well as things like IV therapy but they come with their own risks so creams (which a GP can do) will usually be the first step.

Low dose naltrexone helps with psoriasis, also.

Also, @artishard, do look after yourself psychologically if you can. I think the emotional impacts of having psoriasis can be massively underestimated.

A referral to rheumatology is also a possibility as this is an autoimmune disease.

Just wanted to firstly to offer sympathy. I know just how miserable it can be. Hope you can get it sorted.

secondly, not to be a pessimist, but editing lists for dermatology are years and years long. Apparently it’s the worst discipline for waiting times. In terms of private appointments, you are still looking at a 3 month wait. I hope I’m wrong though and you can get seen sooner.

If you can manage a referral to rheumatology, that's definitely better in terms of waiting lists. In my experience, they only get involved when there's also Psoriatic arthritis present and are, generally, somewhat disinterested in the skin alone.

Proof of this?

Is the psoriasis all over your body or just on the injured arm? If all over, then that's moderate to serious, I'd say.

I had UV light therapy for my psoriasis, and it worked a treat. I'd ask to be referred to Dermatology.

Mine was similar: dermatology and then PUVA treatment.
If you can afford to see the consultant privately they’ll refer you back to NHS for treatment as PUVA not available privately (from what I understand) and usually has a short waiting time. The consultant could be months/years as they obviously have to prioritise suspected cancer.

Unless there is also evidence of psoriatic arthritis, this referral will get bounced. Rheumatologists don't treat psoriasis if it only affects the skin. In fact, I doubt they would know how; they'd defer to their dermatology colleagues

Id be grateful for any advice on the severity of my case too as im struggling to even get an appointment and im miserable! Left sided joint pain is incredible too so i suspect psoriatic arthritis. Its like this on both sides of my neck, forehead, face, back, chest. Ive tried doublebase cream all day every day as well as steroid cream i still had at home.

Poor you, it must be miserable.

I've no great ideas other than what's already been suggested in the thread above.

But just one thing - I think the last picture is your forehead, isn't it? It may well just be a trick of the camera but that looks a bit more flaky than scaly in the picture. So I wondered if you've maybe got a bit of seborrhoeic dermatitis superimposed on your psoriasis on your face? Is it flaky in your eyebrows, and in the creases around the nose? If so, it won't hurt to stick a bit of antifungal cream on those bits as a trial. It won't help the rest of your psoriasis but if it helps your face even a bit, it's worth trying.

(Once again, I'm obliged by law to say that I'm retired, I'm no longer registered as a doc and can't give specific medical advice!)

Ooh I get flare ups of psoriasis and it's horrendous, I will be covered head to toe and it is so hard to get back under control. My last flare up lasted a year 😭😭 I can't get the treatment I want, they just give me steroid creams which I heard damages your skin over time, but for years it's all they will do for me.

If you get a good GP and can access a referral there is a UV treatment, I think you have sessions under a lamp of some sort but everyone who said they have gone through it have never had a flare up again! I'm desperate for it so if you can get that push for it!!!

That's moderate to severe and you need a dermatologist. GP definitely needs to refer you on.

One tip that's helped me though is vitamin D at a very high dosage.

My DH has suffered for the last 30+ years. He's used a variety of creams/lotions and had the light treatment that I can't remember the name off.

He now takes Salmon Oil capsules and moisturises with doublebase cream.

Might be coincidence but since starting salmon oil his skin has been significantly better.