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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 image 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.

Prescribe regular emollients four times a day. Examples include: Zerobase® and liquid and white soft paraffin. See GGC Adult Medicines Formulary for preferred choice. Important prescribing points:

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

Topical treatments

  • Calcipotriol 50 microgram per 1 gram ointment (or in combination with betamethasone 500 micrograms per 1 gram) once a day.
  • Usual duration 4 weeks but longer if required.
  • Prescribe appropriate quantities e.g. 120 gram.
  • Large, thin plaques: coal tar preparations. See GGC Adult Medicines Formulary.
  • Thin skin: calcitriol 3 microgram per 1 gram ointment or clobetasone butyrate 0.05% (Eumovate®) once a day.
  • Dithranol remains the most effective topical treatment, especially for solitary plaques but can stain the skin, hair and fabrics. Discuss application with dermatology.

Descaling treatments

  • For lesions with thick scale, it may be necessary to use descaling agents e.g. salicylic acid in yellow soft paraffin 5%. See GGC Adult Medicines Formulary.
  • Consider tubular bandages for limbs.

Consider referral to local 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: August 2023

Page last updated: November 2023