Diagnosis

• Patient with any type of psoriasis assess:
  • Severity at initial presentation to help evaluate efficacy of treatment:
    • Physician’s Global Assessment: clear, nearly clear, mild, mod, severe or very severe
    • Patient’s Global Assessment: clear, nearly clear, mild, mod, severe or very severe
    • Body surface affected
    • Nail, scalp, palms, sole involvement
    • Systemic upset: malaise, fever common in unstable condition
  • Impact on physical, psychological and social wellbeing: use Dermatology Life Quality Index
  • Whether they have psoriatic arthritis: Psoriasis Epidemiological Screening Tool annually
  • Presence of comorbidities especially CVD see other NICE guidance, note psoriasis risk factor for VTE
• Refer to specialist: if diagnostic uncertainty; severe i.e. > 10% body surface; cannot be controlled; acute guttate psoriasis

Investigation

• n/a

Management

First Line: Topical Therapy

• Account for patient preference: cream, lotion, ointment and review at 4 wks for tolerability
• Stress importance of continuation if effective and likelihood of relapse
• Before escalating treatment discuss difficulties with application
• Educate: continued potent steroid use leads to skin atrophy, striae and instability in psoriasis
• Aim for 4 week application very potent, 8 week potent and break of 4 weeks between applications

Trunk and Limbs

• Potent steroid + Vitamin D analogue OD, separately for up to 4 weeks
• If Ineffective Vitamin D analogue only BD
• If ineffective: potent steroid BD for 4 wks OR coal tar preparation OD or BD
• Very potent in specialist setting only for max 4 weeks

Scalp

• Potent corticosteroid OD for up to 4 weeks
• If ineffective: different formulation or topical treatment to remove scale
• If ineffective: combined Calcipotriol + Betamethasone OD for 4 weeks OR vitamin D analogue if cannot tolerate steroids
• If ineffective: very potent steroid BD for 2 weeks for adults only OR coal tar OD or BD

Face, Flexors, Genitalia

• Mild or Moderate potency steroid OD or BD for 2 weeks, particularly vulnerable to skin atrophy
• In ineffective: Calcineurin inhibitor (Tacrolimus) BD for up to 4 weeks

Second Line: Phototherapy

• Not to be used for maintenance
• Narrowband ultraviolet B 3 x week if extensive > 10% body surface or moderate Physician’s assessment or topical therapy ineffective
• Ultraviolet A (PUVA) irradiation, but council that increased risk of squamous cell carcinoma
• Psoralen (oral or topical) with local ultraviolet A (PUVA) irradiation to treat palmoplantar pustulosis
• If poor response, relapse or poorly tolerated then consider systemic therapy

Third Line: Systemic Therapy

• Offer systemic non-biological therapy if:
• cannot be controlled with topical therapy
• and has a significant impact on physical and extensive (> 10 % body surface)
• First Line: Methotrexate. Be aware that hepatotoxic, rise in AST, hence avoid in fibrosis/cirrhosis
• Second Line: Ciclosporin: Rapid disease control; have palmoplantar pustulosis; considering conception. Consider changing from methotrexate to ciclosporin (or vice-versa) if first-line inadequate
• Third line: Systemic biological therapy: if disease severe and not responded to standard treatment and anti-TNF being considered e.g. Adalimumab; Etancerpt; Infliximab; Ustekinumab

NICE Source: CG153 Psoriasis: assessment and management. Summary compiled by Dr D P Sheppard MBBS.