# Psoriasis (Mild-to-Moderate & Referral) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: BAD Guidelines for Biological Therapies for Psoriasis 2020 · Egyptian National Drug Formulary - Endocrine System 2024 (betamethasone monograph) · Salicylic Acid Ointment BP 2% SmPC sections 4.2 and 4.4 (eMC product 4961) · Coal Tar (Exorex) Lotion SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 10069) · ZITHRANOL-RR (anthralin) 1.2% cream US prescribing information, Indications and Dosage and Administration (DailyMed SetID 45bad116-0351-442f-8e49-f11089a955fd) · Remsima 100 mg powder for concentrate for solution for infusion (infliximab) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 3709) · Psoriasis - disease-level clinical article (psoriasis-referral-full.txt) - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Endocrine System 2024 (betamethasone monograph) - Salicylic Acid Ointment BP 2% SmPC sections 4.2 and 4.4 (eMC product 4961) - Psoriasis - disease-level clinical article (psoriasis-referral-clinical.txt) - Psoriasis (Mild-to-Moderate & Referral) - disease-level clinical article (psoriasis-referral-full.txt) - Coal Tar (Exorex) Lotion SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 10069) - ZITHRANOL-RR (anthralin) 1.2% cream US prescribing information, Indications and Dosage and Administration (DailyMed SetID 45bad116-0351-442f-8e49-f11089a955fd) - Remsima 100 mg powder for concentrate for solution for infusion (infliximab) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 3709) - Psoriasis - disease-level clinical article (psoriasis-referral-full.txt) ## Treatment metadata - Betamethasone — topical - Referral & safety-netting (no drug therapy) - Coal tar — topical - Dithranol — topical - Infliximab — injection - Salicylic acid — topical ## Complete treatment card ```text PSORIASIS (MILD-TO-MODERATE & REFERRAL) Sources: BAD Guidelines for Biological Therapies for Psoriasis 2020 · Egyptian National Drug Formulary - Endocrine System 2024 (betamethasone monograph) · Salicylic Acid Ointment BP 2% SmPC sections 4.2 and 4.4 (eMC product 4961) · Coal Tar (Exorex) Lotion SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 10069) · ZITHRANOL-RR (anthralin) 1.2% cream US prescribing information, Indications and Dosage and Administration (DailyMed SetID 45bad116-0351-442f-8e49-f11089a955fd) · Remsima 100 mg powder for concentrate for solution for infusion (infliximab) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 3709) · Psoriasis - disease-level clinical article (psoriasis-referral-full.txt) Review status: REVIEWED against Egyptian National Drug Formulary - Endocrine System 2024 (betamethasone monograph), Salicylic Acid Ointment BP 2% SmPC sections 4.2 and 4.4 (eMC product 4961), Psoriasis - disease-level clinical article (psoriasis-referral-clinical.txt), Psoriasis (Mild- to-Moderate & Referral) - disease-level clinical article (psoriasis- referral-full.txt), Coal Tar (Exorex) Lotion SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 10069), ZITHRANOL-RR (anthralin) 1.2% cream US prescribing information, Indications and Dosage and Administration (DailyMed SetID 45bad116-0351-442f-8e49-f11089a955fd), Remsima 100 mg powder for concentrate for solution for infusion (infliximab) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 3709), Psoriasis - disease-level clinical article (psoriasis-referral-full.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (2) - The erythrodermic form brings severe itching, swelling, and pain along with the skin changes [itching] - Skin folds affected by the inverse form can be malodorous and itchy [itching] SIGNS - what you find (11) - Well-demarcated red plaques covered by silvery scale classically appear on the scalp and extensor surfaces such as the knees, elbows, and low back [redness] - New lesions can appear at sites of mechanical, chemical, or radiation skin injury, called the Koebner phenomenon, and this marks active disease [skin lesions] - Scraping off the scale produces pinpoint bleeding, the Auspitz sign, which clinically confirms the diagnosis [bleeding] - The guttate form produces raindrop-shaped scaly lesions on the trunk and back, typically in children after a streptococcal throat infection [scaling] - Generalized pustular disease shows sterile pustules on red skin over the whole body and is linked to low blood calcium [pustules · redness] - The erythrodermic form covers more than 90% of the body with erythema and skin shedding, often following abrupt withdrawal of systemic steroids [redness] - Nail involvement shows pitting, oil spots, thickening under the nail plate, dystrophy, and fusion of the nail - A fissured tongue is the most common oral finding, seen in roughly 6.5% to 20% of patients with skin disease - The inverse form appears as smooth, sharply demarcated red patches in body folds such as the groin, armpits, and under the breasts, sometimes moist or fissured [redness] - Psoriatic arthritis causes painful joint swelling, especially sausage-like swollen fingers or toes called dactylitis [joint pain] - Eye involvement can affect the lid, conjunctiva, and cornea, most often as blepharitis that can progress to scarring lid changes and lash loss [scarring] TESTS (3) - Diagnosis usually rests on the clinical look and distribution of lesions; biopsy is rarely needed unless another skin disease must be excluded - Biopsy shows parakeratosis, an absent granular layer, evenly elongated rete ridges, microabscesses, and Kogoj spongiform pustules with dilated tortuous dermal capillaries - Baseline labs can include a CBC, renal and liver panel, rheumatoid factor, ESR, uric acid, fungal scrapings if only hands or feet are affected, a pregnancy test, hepatitis serology, and a PPD IF NOT THIS - what else fits (1) - Eczema, seborrheic dermatitis, pityriasis rosea, mycosis fungoides, and secondary syphilis are on the differential Source StatPearls "Psoriasis" - disease-level clinical article Status traced to the source above Rx: Main treatment | Initial topical option alongside a corticosteroid | Initial topical option, applied short-contact and washed off | Biologic reserved for severe disease when other biologics cannot be used - dermatology-initiated MAIN TREATMENT - choose one, plus any add-on marked below 1. BETAMETHASONE [1st line] Adult Once to twice daily. (for adults and children). Peds For adults and children over 1 year: Source Egyptian National Drug Formulary - Endocrine System 2024 (betamethasone monograph) Why Betamethasone is a potent topical corticosteroid that reduces the inflammation and scaling of psoriatic plaques; it is first-line topical therapy for mild-to-moderate psoriasis, used in short courses to limit skin atrophy. Caution Avoid prolonged continuous use to prevent skin atrophy and striae. Do not use on face or flexures without specialist advice. Refer severe (>10% body surface area) or erythrodermic psoriasis urgently. The Egyptian formulary limits a course to 5 days when this is used on the face or in a child - 0.1% betamethasone is potent and the face thins fastest. Egypt CRONOMESONE 0.1% CREAM 15 GM PHAROPHARMA 4.00 EGP CRONOMESONE 0.1% OINT. 15 GM PHAROPHARMA 4.00 EGP BETNOVATE 0.1% TOP. OINT. 15 GM SMITHKLINE BE... 6.90 EGP BETAMETHASONE DIPROPIONATE 0.05% CREAM 20 GM AMRIYA 11.50 EGP BETAVAL 0.1% OINT. 15 GM ARAB DRUG COM... 15.00 EGP BETADERM 0.1% TOPICAL OINT. 15 GM EIPICO 18.00 EGP BETNOVATE 0.1% TOPICAL CREAM 15 GM SMITHKLINE BEECHAM > GLAXO SMITHKLINE 21.00 EGP BETADERM 0.1% CREAM 30 GM EIPICO 23.00 EGP 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Psoriasis - disease-level clinical article (psoriasis-referral-clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Pustular and erythrodermic psoriasis can be life-threatening. RED FLAG - Extensive disease, or involvement of nails and psoriatic arthritis, is a threshold for systemic (specialist) therapy. RED FLAG - The explicit severity thresholds for referral are >10% BSA, or involvement of face, nails, scalp, genitals, flexures, or soles. 3. SALICYLIC ACID [add-on - not a substitute] Adult Adults, children and the elderly: apply twice daily to the affected area. Peds Avoid application over large surface areas in young children Source Salicylic Acid Ointment BP 2% SmPC sections 4.2 and 4.4 (eMC product 4961) Why Salicylic acid is a keratolytic that breaks down the intercellular matrix holding thick psoriatic scale together; it is used as an adjunct to strip scale from hyperkeratotic plaques so topical corticosteroids can penetrate more effectively, not as treatment on its own. Caution Salicylic acid is a keratolytic agent used to remove scale prior to topical steroid application. Avoid contact with eyes, mucous membranes, or inflamed skin. Salicylate can be absorbed through skin: over large areas, for long stretches, or on a neonate it causes real poisoning. Tinnitus, dizziness or deafness means stop. Fabric (clothing, bedding, dressings etc.) that has been in contact with this product burns more easily and is a serious fire hazard. Egypt SALICYLIC ACID COLLODION 12% PAINT B.P.2001 UNIPHARMA CO. > UNIPHARMA 3.00 EGP -> ? different route - not topical SALICYLIC ACID SOAP (WEISER) 45 GM WEISER 15.00 EGP -> ? different route - not topical INITIAL TOPICAL OPTION ALONGSIDE A CORTICOSTEROID 4. COAL TAR [1st line] Adult Applied to clean skin. SmPC verbatim: "Ensure that the lesions are clean. Apply a thin layer of Exorex two to three times per day to the affected areas. Massage gently and leave to dry." - Continued while it helps and stopped if the skin becomes irritated. SmPC verbatim: "Coal tar may cause skin irritation. If irritation occurs, the treatment should be reviewed and discontinued if necessary." Peds Licensed from 12 years at full strength, diluted below that. SmPC verbatim: "Adults and children over 12 years of age" apply it at full strength; "For young children under 12 years of age and the elderly" - "The emulsion may be diluted by mixing with a few drops of freshly boiled and cooled water in the palm of the hand." Source Coal Tar (Exorex) Lotion SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 10069) Why The disease article names it among the topicals used first, verbatim: "Topical agents used are coal tar, dithranol, corticosteroids, vitamin D analog, and retinoids are used initially." The SmPC's indication line names the disease and nothing else, verbatim: "Exorex is for the treatment of psoriasis of the skin and scalp." Egypt registers no plain coal tar preparation licensed for psoriasis - the six coal-tar products on the register are combination hair-care shampoos and lotions - so the row may show no therapeutic brand, which is the truth about what is on the shelf rather than a gap in the source. Caution Not on broken or inflamed skin. SmPC verbatim: "Exorex should not be applied to inflamed or broken skin (open exuding wounds or infection of the skin)." Contraindicated with folliculitis or acne. SmPC verbatim: "Presence of folliculitis and acne vulgaris." It makes the skin burn more easily in sun. SmPC verbatim: "Coal tar enhances photosensitivity of the skin, and exposure to direct sunlight after application of Exorex should be avoided." That is a daily consideration in Cairo. Avoid in photosensitive disease. SmPC verbatim: "Exorex should not be used on patients who have disease characterised by photosensitivity such as lupus erythematosus or allergy to sunlight." It stains skin, clothing and bedding, and it smells - warn the patient before the first tube rather than after. Egypt no Egyptian brand matched - prescribe by generic name INITIAL TOPICAL OPTION, APPLIED SHORT-CONTACT AND WASHED OFF 5. DITHRANOL [1st line] Adult Once daily, contact time built up rather than started long. US label verbatim: "Generally, it is recommended that Zithranol-RR cream be applied once a day." Where the patient's response to it is not yet known, the label directs a short contact time of 5 to 15 minutes for at least one week, then verbatim: "When a short contact time is used initially, it can be increased stepwise to thirty minutes before removing the cream by washing or showering." Application verbatim: "Apply sparingly to the psoriatic lesions avoiding normal skin and rub gently and carefully into the skin." Wash it off with cool water - "At the end of each period of treatment, rinse the skin thoroughly with cool to lukewarm water before washing with soap." - Contact time is titrated to the individual. US label verbatim: "The optimal period of contact will vary according to the patient's response to treatment." Peds No separate paediatric dose is stated in the label used here. The short-contact method, staining and irritation make it a poor fit for a small child; a corticosteroid or tar preparation is the usual first move, and refractory childhood psoriasis belongs with dermatology. Source ZITHRANOL-RR (anthralin) 1.2% cream US prescribing information, Indications and Dosage and Administration (DailyMed SetID 45bad116-0351-442f-8e49-f11089a955fd) Why The disease article lists it among the topicals used first-line, alongside coal tar, corticosteroids, a vitamin D analogue and the retinoids. The US label's indication covers topical treatment of stable plaque psoriasis. The label calls the molecule anthralin, the article calls it dithranol - they are the same drug, and Egypt registers it under both names: ANTHRAMASH and ANTHRAWEST 1% cream at 18 EGP as anthralin, PSORANOL 1% cream at 4 EGP as dithranol. Either name finds the same drug. Caution Not on acute or inflamed psoriasis. US label verbatim: "Zithranol-RR is contraindicated for patients with acute or actively inflamed psoriatic eruptions or a history of hypersensitivity to any of the ingredients." Keep it off normal skin, the face and the flexures. US label verbatim: "Avoid contact with the eyes or mucous membranes. Exercise care when applying Zithranol-RR cream to the face or intertriginous skin areas." Stop it if the skin reacts. US label verbatim: "Discontinue use if a sensitivity reaction occurs or if excessive irritation develops." It stains. US label verbatim: "To prevent the possibility of staining clothing or bed linen, it may be advisable to use protective dressings." and "Contact with fabrics, plastics and other materials may cause staining and should be avoided. Always wash hands thoroughly after use." Rinse the bath immediately - "always rinse the tub/shower with lukewarm water immediately after washing/showering". Purple-brown staining of treated skin is expected and fades. Egypt PSORANOL 100MG/100GM CREAM 20 GM ALFACURE PHAR... 4.00 EGP ANTHRAMASH 1% CREAM 20 GM DEBEIKY > MAS... 18.00 EGP ANTHRAWEST 1% CREAM 20 GM WESTERN PHARM... 18.00 EGP BIOLOGIC RESERVED FOR SEVERE DISEASE WHEN OTHER BIOLOGICS CANNOT BE USED - DERMATOLOGY-INITIATED 6. INFLIXIMAB [3rd line] Adult Intravenous infusion, dosed by body weight. SmPC verbatim: "5 mg/kg given as an intravenous infusion followed by additional 5 mg/kg infusion doses at 2 and 6 weeks after the first infusion, then every 8 weeks thereafter." - Stopped at 14 weeks if four doses have not worked. SmPC verbatim: "If a patient shows no response after 14 weeks (i.e. after 4 doses), no additional treatment with infliximab should be given." Peds Not a paediatric prescription in this disease. SmPC verbatim: "The safety and efficacy of infliximab in children and adolescents younger than 18 years for the indication of psoriasis have not been established." Source Remsima 100 mg powder for concentrate for solution for infusion (infliximab) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 3709) Why The disease article names it first among the biologics, verbatim: "Biologicals are manufactured proteins that interrupt the immune process in psoriasis which are infliximab, adalimumab, etanercept, and interleukin antagonists." and places it precisely, verbatim: "Infliximab is reserved for patients with severe disease in whom other biological agents cannot be used". The SmPC's indication section names the disease, verbatim: "Remsima is indicated for treatment of moderate to severe plaque psoriasis in adult patients who failed to respond to, or who have a contraindication to, or are intolerant to other systemic therapy including ciclosporin, methotrexate or psoralen ultra-violet A (PUVA)." Egypt registers one infliximab product, REMICADE 100 mg powder for intravenous infusion at roughly 5,900 EGP a vial, and a course is several vials per infusion at adult body weights. Caution RED FLAG - tuberculosis is excluded before the first infusion, not after it. SmPC verbatim: "Before starting treatment with infliximab, all patients must be evaluated for both active and inactive ('latent') tuberculosis." and "Appropriate screening tests, (e.g. tuberculin skin test, chest X-ray, and/or Interferon Gamma Release Assay), should be performed in all patients". The SmPC also warns that "in the majority of these reports tuberculosis was extrapulmonary". Latent tuberculosis is common in Egypt, so this is a real gate rather than a formality. Hepatitis is screened for alongside tuberculosis - the disease article asks for both to be worked up before any biological agent is started. Infection risk runs for months after the last infusion. SmPC verbatim: "Patients must be monitored closely for infections including tuberculosis before, during and after treatment with infliximab. Because the elimination of infliximab may take up to six months, monitoring should be continued throughout this period. Further treatment with infliximab must not be given if a patient develops a serious infection or sepsis." A blunted fever is part of the hazard - "suppression of TNF may mask symptoms of infection such as fever". Contraindicated outright in some patients. SmPC verbatim: "Patients with tuberculosis or other severe infections such as sepsis, abscesses, and opportunistic infections" and "Patients with moderate or severe heart failure (NYHA class III/IV)". An intravenous hospital drug, not a prescription pad drug. SmPC verbatim: "Remsima infusions should be administered by qualified healthcare professionals trained to detect any infusion-related issues." and "Infliximab has been associated with acute infusion- related reactions, including anaphylactic shock, and delayed hypersensitivity reactions". Egypt REMICADE 100 MG PD. VIAL FOR I.V. INF. 10 ML JANSSEN CILAG > SOFICOPHARM 5936.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)