Psoriasis management

The information below is based on NICE Clinical Guideline CG153 Psoriasis: assessment and management (October 2012 [updated September 2017]). Further information on psoriasis and useful website links can be found in the 'Resources' slider below.

Psoriasis is a systemic, immune-mediated inflammatory skin condition that typically has a chronic relapsing and remitting course. It occurs equally in men and women and can appear at any age.

Psoriasis typically causes red patches of skin that are covered with silver scales. In some cases, the patches can be itchy or sore, and the condition can also affect the nails and the joints.

Different forms of psoriasis exist:

  • Plaque psoriasis is the most common form, affecting 80-90% of people with psoriasis. It usually affects extensor surfaces, but also frequently on sacral, umbilical, and scalp sites
  • Scalp psoriasis affects 75-90% of people with psoriasis at some point
  • Flexural psoriasis, (also known as inverse psoriasis) affects around 5% of people with psoriasis. It presents in the flexures with erythematous plaques with absence of scale.
  • Pustular psoriasis can be localised (usually palms and soles, with large sterile pustules ranging from yellow to brown) or generalised. The latter is a rare but unstable form which may necessitate urgent hospital admission.
  • Guttate psoriasis is characterised by rapid onset small plaque psoriasis that is predominantly truncal and may be triggered by infections.
  • Nail psoriasis affects about 50% of all people with psoriasis at diagnosis and may affect the nail plat and/or the nail bed.
  • Psoriatic arthritis causes swelling and stiffness around joints and may lead to permanent joint damage unless treated early. Suspicion of psoriatic arthritis should prompt referral to a rheumatologist

Treatment of psoriasis depends upon individual circumstances. Examination and assessment of clinical features and the impact of any type of psoriasis on physical, psychological, and social wellbeing, will help with appropriate treatment therapies.

Emollients are essential in the management of psoriasis, and their regular use can alleviate symptoms and reduce flare-ups. They are generally recommended as adjunctive treatment to topical or systemic therapies and are rarely enough as monotherapy. See section 13.2.1 Emollients

Topical treatments (such as corticosteroids, vitamin D analogues (especially in combination), and tar preparations) are first line therapy options in primary care (refer to guidance below).

Topical treatments are often used in intermittent bouts so whilst the patients do not often need continuous treatment when there has been good response, they may restart treatment when their condition flares.

For people with more extensive or difficult to treat psoriasis, specialist treatments such as phototherapy (broad- or narrow-band ultraviolet B Light and psoralen plus UVA Light [PUVA]), systemic non-biological agents such as ciclosporin, methotrexate and acitretin, or systemic biological therapies may be required under the supervision of a consultant dermatologist.

Psoriasis, particularly moderate to severe psoriasis, is associated with an increased risk of anxiety, depression and harmful use of alcohol. Moderate to severe psoriasis increases the risk of heart disease and stroke and treatment of psoriasis may reduce this risk. Psoriasis can also be associated with diabetes, obesity, venous thromboembolism, high cholesterol and high blood pressure. Psoriasis is also associated with inflammatory bowel disease and there is a small increased risk of skin cancer.

Plaque psoriasis

Topical treatment of psoriasis affecting the trunk and limbs

Initial treatment

Initial treatment for adults with trunk or limb psoriasis is with potent corticosteroid plus vitamin D analogue once daily.

Treatments should be applied separately; one in the morning and the other in the evening, for up to 4 weeks

Potent steroid:

Betamethasone valerate 0.1% (cream or ointment) once daily, or

Mometasone furoate 0.1% (cream or ointment) once daily

PLUS

Vitamin D analogue:

Calcipotriol (ointment) once daily, or

Calcitriol (ointment) once daily

See section 13.4 Topical corticosteroids, 13.5.2 Preparations for psoriasis

Review the patient after 4 weeks

If good response to initial treatment

Continue topical treatment until the skin is clear or nearly clear

  • Maximum of 8 weeks of treatment with topical corticosteroids; if necessary, steroid treatment may be restarted after a four-week 'treatment break'
  • Topical vitamin D analogue may be continued throughout

If poor response to initial treatment

Check adherence to treatment, and ask about any issues with application, cosmetic acceptability, or tolerability of topical treatments

  • Consider continuing initial treatment for another four weeks (then review), or
  • Consider alternative treatment options below

Alternative treatment

After a maximum of 8 weeks of initial treatment, if response is still poor:

  • Stop the steroid and
  • Increase Calcipotriol or Calcitriol to twice daily, for 4 weeks

Review the patient after 4 weeks

If this does not result in clearance, near clearance or satisfactory control after 8–12 weeks (total treatment duration), consider further treatment options below

Further treatment

After 4 weeks of alternative treatment, if response is still poor:

  • Stop vitamin D analogue and
  • Offer either potent corticosteroid twice daily or coal tar preparation once or twice daily for up to 4 weeks
Potent steroid:

Betamethasone valerate 0.1% (cream or ointment) twice daily, or

Mometasone furoate 0.1% (cream or ointment) twice daily

OR

Coal tar preparation:

Psoriderm (cream) once or twice daily, or

Exorex (lotion) two or three times daily

If a twice-daily potent corticosteroid or coal tar preparation cannot be used, or a once-daily preparation would improve adherence offer:

Calcipotriol monohydrate / Betamethasone dipropionate 0.05% (gel or ointment or foam) once daily for up to 4 weeks

See section 13.4 Topical corticosteroids, 13.5.2 Preparations for psoriasis

Review the patient after 4 weeks

Consider a referral to a specialist for additional support with topical applications and/or advice on other treatment options.

Patients do not often need continuous treatment when there has been good response or clearance, they may restart treatment when their condition flares.

Scalp psoriasis

Topical treatment of psoriasis affecting the scalp

Initial treatment

Initial treatment for people with scalp psoriasis is with a potent corticosteroid once daily for up to 4 weeks

Potent steroid:

Betamethasone valerate 0.1% (scalp application) once daily, or

Mometasone furoate 0.1% (scalp lotion) once daily

See section 13.4 Topical corticosteroids

If the patient cannot use steroids, refer to alternative treatment options below

Review the patient after 4 weeks

If good response to initial treatment

Continue topical treatment until the skin is clear or nearly clear

  • Maximum of 8 weeks of treatment with topical corticosteroids; if necessary, steroid treatment may be restarted after a four-week 'treatment break'

If poor response to initial treatment

Check adherence to treatment, and ask about any issues with application, cosmetic acceptability, or tolerability of topical treatments

  • Consider a different formulation of the potent corticosteroid for up to 4 weeks (then review), or
  • Addition of topical agents to remove adherent scale before application of the potent corticosteroid for a further 4 weeks of treatment (then review), or
  • Consider alternative treatment options below
Topical agents to remove thick scale:

Capasal (shampoo) (coal tar / coconut oil / salicylic acid), or

Psoriderm (scalp lotion) (coal tar), or

Emollients, or

olive oil (non-formulary)

See section 13.2.1 Emollients, 13.5.2 Preparations for psoriasis, 13.9 Shampoos and other preparations for scalp and hair conditions

Review the patient after 4 weeks

If this does not result in clearance, near clearance or satisfactory control after 8 weeks (total treatment duration), consider alternative treatment options below

Alternative treatment

If there is poor response after a maximum of 8 weeks of initial treatment, consider a combined topical preparation containing a potent corticosteroid and vitamin D:

Calcipotriol monohydrate / Betamethasone dipropionate 0.05% (gel or foam) once daily for up to 4 weeks

OR, for patients with mild to moderate scalp psoriasis, who cannot use steroids:

Calcipotriol (scalp solution) once daily for up to 8 weeks

See section 13.5.2 Preparations for psoriasis

Review the patient after 4 weeks

If this does not result in clearance, near clearance or satisfactory control after 8–12 weeks (total treatment duration), consider further treatment options below

Further treatment

Consider a very potent corticosteroid applied twice daily for 2 weeks or a coal tar preparation applied once or twice daily for up to 4 weeks:

Very potent steroid:

Dermovate 0.05% (scalp application) twice daily or,

Etrivex 0.05% (shampoo) twice daily (unlicensed dose)

See section 13.4 Topical corticosteroids

Review the patient after 2 weeks

OR

Coal tar preparation:

Sebco (scalp ointment) once or twice daily or,

Cocois (scalp ointment) once or twice daily

See section 13.5.2 Preparations for psoriasis

Review the patient after 4 weeks

Consider a referral to a specialist for additional support with topical applications and/or advice on other treatment options.

Patients do not often need continuous treatment when there has been good response or clearance, they may restart treatment when their condition flares.

Flexural, genital, and facial psoriasis

Topical treatment of psoriasis affecting flexures, genitals, and the face

Initial treatment

Initial treatment for people with psoriasis affecting flexures, genitals, and the face is with a mild or moderate corticosteroid applied once or twice daily for up to two weeks:

Mild steroid:

Hydrocortisone 1% (cream or ointment) once or twice daily

OR

Moderate steroid:

Eumovate 0.05% (cream or ointment) once or twice daily, or

Betnovate RD 0.025% (cream or ointment) once or twice daily

See section 13.4 Topical corticosteroids

Review the patient after 2 weeks

If good response to initial treatment

Repeated short courses of topical corticosteroids may be used to maintain disease control, however:

  • A treatment break of four weeks between corticosteroid courses is required
  • Topical corticosteroids should only be used for 1–2 weeks each month.

If poor response to initial treatment

Check adherence to treatment, and ask about any issues with application, cosmetic acceptability, or tolerability of topical treatments.

Consider a referral to a specialist for additional support with topical applications and/or advice on other treatment options.

Do not use potent or very potent corticosteroids on the face, flexures or genitals.

When prescribing topical agents at facial, flexural and genital sites take into account that they may cause irritation; inform patients of these risks and how to minimise them.

The face, flexures and genitals are particularly vulnerable to steroid atrophy and corticosteroids should only be used for short-term treatment of psoriasis (1–2 weeks or daily use or 2 days per week as maintenance).

Patients do not often need continuous treatment when there has been good response or clearance, they may restart treatment when their condition flares.

Pustular psoriasis

Palmo-plantar pustular psoriasis is stubborn to treat and usually requires a greasy ointment type emollient and a very potent topical steroid such as:

Emollient:

Zeroderm (ointment) or,

Hydromol (ointment) or,

Cetraben (ointment)

AND

Very potent steroid:

Dermovate 0.05% (cream or ointment) once daily for at least 3-4 weeks.

See section 13.2.1 Emollients, 13.4 Topical corticosteroids

Review the patient after 3-4 weeks

Generalised pustular psoriasis is very rare, but patients are generally red all over with tiny white pustules. They are often systemically unwell and require hospital admission for urgent systemic treatment.

Guttate psoriasis

Due to the very widespread nature of this condition, topical treatments can be impractical. It usually responds rapidly to phototherapy so if not resolving, patients should be referred to a dermatologist.

Consider a trial of a topical combined product or coal tar lotion whilst awaiting secondary care review.

Calcipotriol monohydrate / Betamethasone dipropionate 0.05% (gel or ointment or foam) once daily for up to 4 weeks

OR

Exorex (lotion) (coal tar) two or three times daily

See section 13.5.2 Preparations for psoriasis

Nail psoriasis

Nail psoriasis can be debilitating and responds poorly to topical treatment, although a combined product containing Calcipotriol monohydrate / Betamethasone dipropionate 0.05% applied to the free edge of the nail and allowed to melt under the nail plate can sometimes be helpful for nail bed disease.

See section 13.5.2 Preparations for psoriasis

Psoriasis in children and young people

For children and young people under 18 years of age, consider referral to secondary care for confirmation of diagnosis and management plan.

Whilst awaiting secondary care review, consider the options for each psoriasis presentation below. Mild cases of psoriasis may be suitably managed without referral.

Arrange a review appointment 2 weeks after starting a new topical treatment in children and young people.

Presentation of pustular psoriasis requires an urgent referral to secondary care.

Topical treatment of plaque psoriasis

Vitamin D analogue:

Calcipotriol (ointment) once daily, (only for those over 6 years of age)

NB: There is limited experience with the use of calcipotriol ointment in children and young people. Whilst the efficacy and long-term safety have not been established in children and adolescents, its unlicensed use in this patient group is supported by BNFC, NICE CG153, and local specialists.

OR

Potent steroid:

Betamethasone valerate 0.1% (cream or ointment) once daily (only for those over 1 year of age)

See section 13.4 Topical corticosteroids, 13.5.2 Preparations for psoriasis

Review the patient after 2 weeks or as per specialist management plan

Topical treatment of psoriasis affecting the scalp

Consider potent corticosteroid (use topical agents to remove adherent scale before application of the potent corticosteroid if necessary), or a coal tar preparation as sole treatment:

Potent steroid:

Betamethasone valerate 0.1% (scalp application) once daily (only for those over 1 year of age)

See section 13.4 Topical corticosteroids

Topical agents to remove thick scale:

Capasal (shampoo) (coal tar / coconut oil / salicylic acid), or

Psoriderm (scalp lotion), (coal tar), or

Emollients, or

olive oil (non-formulary)

OR

Coal tar preparation:

Sebco (scalp ointment) once a week or,

Cocois (scalp ointment) once a week

Apply coal tar preparation to patches on scalp overnight and wash off in the morning (it is recommended to wear a shower cap).

See section 13.2.1 Emollients, 13.5.2 Preparations for psoriasis, 13.9 Shampoos and other preparations for scalp and hair conditions

Review the patient after 2 weeks or as per specialist management plan

Topical treatment of psoriasis affecting flexures, genitals, and the face

Mild steroid:

Hydrocortisone 1% (cream or ointment) once daily

OR

Moderate steroid:

Eumovate 0.05% (cream or ointment) once daily

See section 13.4 Topical corticosteroids

Review the patient after 2 weeks or as per specialist management plan

Topical treatment of guttate psoriasis

Due to the very widespread nature of this condition, topical treatments can be impractical. It usually responds rapidly to phototherapy so if not resolving, patients should be referred to a dermatologist.

Whilst awaiting secondary care review consider:

Vitamin D analogue:

Calcipotriol (ointment) once daily, (only for those over 6 years of age)

NB: There is limited experience with the use of calcipotriol ointment in children and young people. Whilst the efficacy and long-term safety have not been established in children and adolescents, its unlicensed use in this patient group is supported by BNFC, NICE CG153, and local specialists.

OR

Potent steroid:

Betamethasone valerate 0.1% (cream or ointment) once daily (only for those over 1 year of age)

See section 13.4 Topical corticosteroids, 13.5.2 Preparations for psoriasis

Review the patient after 2 weeks or as per specialist management plan

Referral to secondary care

Following assessment in primary care, refer people for dermatology specialist advice if:

  • there is diagnostic uncertainty or
  • any type of psoriasis is severe or extensive, for example more than 10% of the body surface area is affected or
  • any type of psoriasis cannot be controlled with topical therapy

Local specialists suggest that Calcipotriol monohydrate / Betamethasone dipropionate foam 0.05% is tried once daily for four weeks before referral to secondary care, as it may be more efficacious in some adult patients and its use may reduce the need for referral.

NB: This recommendation does not apply to pustular psoriasis; calcipotriol monohydrate / betamethasone dipropionate foam is contraindicated in generalised pustular psoriasis.

Refer people to a rheumatologist for assessment and advice about care plans if psoriatic arthritis is suspected

Please see local referral guidelines for Psoriasis

Resources

NICE Clinical Guideline CG153 – Psoriasis: assessment and management

NICE Clinical Knowledge Summary – Psoriasis

NHS.UK – Psoriasis

Dermnet NZ - Psoriasis

British Association of Dermatologists (BAD) – Psoriasis Patient Information Leaflet

Psoriasis association – UK charity for people affected by psoriasis

For suitable quantities of prescribing topical medications, see Management of skin conditions

Last updated: 08-10-2019

 

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