Gudielines
Management
General Approach:
- Step 1: topical therapy in primary care
- Step 2: phototherapy in secondary care
- Step 3: systemic therapy in secondary care
Although with slight variations depending on the site affected
Referral Criteria
Refer to dermatology if:
- There is uncertainty about the diagnosis
- Extensive psoriasis (>10% of body surface area)
- Moderately severe or above psoriasis, as measured by the Physician’s Global Assessment
- Psoriasis is resistant to topical therapy in primary care
- There is a significant impact on the person’s physical, psychological, or social well-being
If psoriatic arthritis is suspected → urgent referral to rheumatology.
Topical Therapy (Primary Care)
All patients:
- Offer regular topical emollient (to reduce scale & itch) PLUS
- Further topical therapy (depending on site affected as shown below)
Trunk & Limbs
| Step | Topical Therapy | Description |
|---|---|---|
| 1st line | Potent corticosteroid + vitamin D once daily for 4 weeks
Administered at different times: 1 in the morning and 1 in the evening. |
Good response: continue topical treatment Advise the person not to apply potent topical steroids for more than eight weeks at any one site in the trunks/limbs. Courses can be used as needed to maintain control, with a four-week "treatment break" between corticosteroid courses (during which topical vitamin D preparations may continue). until skin is clear/nearly clear
If not effective after 4-week course of steroid → attempt another 4-week course
If poor response after 8 weeks → step up to 2nd line |
| 2nd line | Vitamin D twice daily
(Stop the corticosteroid) |
If poor response after 8-12 weeks → step up to 3rd line |
| 3rd line | Stop the vitamin D and offer:
|
|
| 4th line | Consider combined preparation containing potent corticosteroid and vitamin D once daily for 4 weeks | |
| 5th line | Consider short-contact dithranol | Also:
|
Note that topical vitamin D preparations should be avoided in:
- Use on face
- Pregnancy
- Breastfeeding
Scalp
1st line: topical potent corticosteroid once daily for 4 weeks
If no improvement after 4 weeks:
- Try different formulation of topical potent corticosteroid, and/or
- Apply topical agents to remove adherent scale before application of topical steroid
Face / Flexural / Genital
1st line: topical mild / moderate potent corticosteroid once / twice daily for 2 weeks
Phototherapy
1st line: narrow-band UVB light therapy
Other options:
- Broad-band UVB light therapy
- Psoralen plus UVA (PUVA) phototherapy
Frequency and doses:
- 2-3 times a week
- Dose is based on the person’s ‘minimal erythema dose’ and sun-reactive skin type
Systemic Therapy
First offer conventional systemic therapy:
- 1st line: methotrexate
- 2nd line: ciclosporin, should be offered instead of methotrexate as first line if any of the following:
- Rapid / short-term disease control needed (e.g. psoriasis flare)
- Patient is considering conception
- Palmoplantar pustulosis
- 3rd line: acitretin
If conventional systemic therapy failed → consider targeted immunomodulatory therapy (initiated and supervised only by consultant dermatologists)
- TNF-alpha inhibitors (e.g. adalimumab, etanercept, infliximab)
- IL-12/23 inhibitor (ustekinumab)
- IL-17 inhibitor (brodalumab)
- IL-23 inhibitor (e.g. guselkumab)
Summary of Topical Corticosteroid Use in Psoriasis
Examples
The potency of a topical corticosteroid preparation is determined solely by the corticosteroid molecule/component itself, regardless of the formulation or concentration used
The following examples were derived from the BNF: [Ref]
| Potency Class | Examples of Topical Corticosteroids |
|---|---|
| Mild |
|
| Moderate |
|
| Potent |
|
| Very Potent |
|
Summary of Topical Corticosteroid Use in Psoriasis (By Site)
TCS = Topical Corticosteroid
|
Site of Psoriasis
|
First-Line Steroid Potency
|
Maximum Duration / Recommended Use Schedule
|
Key Restriction
|
|---|---|---|---|
|
Trunk, Limbs
|
(often used initially in combination with a topical Vitamin D preparation)
|
|
Very potent preparations should not normally be used in primary care
|
|
Scalp Psoriasis
|
|
||
|
Facial, Flexural, and Genital Psoriasis
|
|
|
Do NOT prescribe potent/very potent TCS to these areas due to the greater risk of adverse effects like skin atrophy
|
References
NICE Psoriasis: assessment and management
NICE CKS Psoriasis