Management of Psoriasis

Assessment

  • Usually symmetrical erythematous plaques with a silvery surface scale
  • Typically occurs on extensor surfaces and can be generalised or erythrodermic (erythroderma means around 90% of the body surface area is bright red)
  • Koebner phenomenon
    • Occurs at sites of trauma
  • It is associated with nail changes and inflammatory arthritis
    • Nail pitting, onycholysis, hyperkeratosis

See figure 1 for images of psoriasis.

Treatment options

Below is a stepped approach for newly diagnosed psoriasis. Patients with pre-existing psoriasis should be treated according to their symptoms.

Important points for prescribing topical treatments:

  • In general, ointments are preferred for dry skin but are poorly tolerated.
  • Creams are used on less dry skin and better tolerated.

Prescribe regular emollients up to four times a day. Examples include: Hydromol® ointment, Zerobase® cream, QV® cream, white soft paraffin 50% / liquid paraffin 50% ointment (avoid aqueous cream).

Topical treatments

  • Face / flexures: hydrocortisone 1% or if severe, clobetasone butyrate 0.05% (Eumovate®) once a day for 7 days.
  • Trunk and limbs: Calcipotriol 50 microgram per 1 gram and betamethasone 500 micrograms per 1 gram ointment applied once a day. Usual duration 4 weeks but longer at reduced frequency if required. Prescribe appropriate quantities e.g. 120 gram.
  • Large, thin plaques: coal tar preparations. Examples include: Exorex® lotion, Psoriderm® cream, Sebco® scalp ointment. Refer to individual product’s Summary of Product Characteristics for prescribing information.

Consider referral to dermatology team

  • In patients with severe psoriasis who are not responding to treatment.
  • Suspected erythrodermic or pustular psoriasis.
  • Where there is diagnostic uncertainty.

General measures

  • Referral to GP surgery for skin monitoring post-discharge.
  • Provide patient information leaflet from the British Association of Dermatologists website.
  • Raise awareness of patient support groups.
  • Assess patients for related comorbidities e.g. cardiovascular disease, psoriatic arthritis.
  • Consider referral to Dermatology Specialist Nurse.

 

Guideline reviewed October 2023
Page updated November 2023



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