Psoriasis: the assessment and management of psoriasis continued

Assessment and referral

Assessment tools for disease severity and impact and when to refer for specialist care

• For people with any type of psoriasis assess:
  • disease severity
  • the impact of disease on physical, psychological, and social wellbeing
  • whether they have psoriatic arthritis
  • the presence of comorbidities
• Assess the severity and impact of any type of psoriasis:
  • at first presentation
  • before referral for specialist advice and at each referral point in the treatment pathway
  • to evaluate the efficacy of interventions
• When assessing the disease severity in any healthcare setting, record:
  • the results of a static Physician’s Global Assessment (classified as clear, nearly clear, mild, moderate, severe, or very severe)
  • the patient’s assessment of current disease severity, for example, using the static Patient’s Global Assessment (classified as clear, nearly clear, mild, moderate, severe, or very severe)
  • the body surface area affected
  • any involvement of nails, high-impact and difficult-to-treat sites (for example, the face, scalp, palms, soles, flexures, and genitals)
  • any systemic upset, such as fever and malaise, which are common in unstable forms of psoriasis such as erythroderma or generalised pustular psoriasis
• Assess the impact of any type of psoriasis on physical, psychological, and social wellbeing by asking:
  • what aspects of their daily living are affected by the person’s psoriasis
  • how the person is coping with their skin condition and any treatments they are using
  • if they need further advice or support
  • if their psoriasis has an impact on their mood
  • if their psoriasis causes them distress (be aware the patient may have levels of distress and not be clinically depressed)
  • if their condition has any impact on their family or carers
• Ask children and young people age-appropriate questions
• When using an assessment tool for a person with any type of psoriasis:
  • take account of their age, any disabilities (such as physical, visual, or cognitive impairment), and any language or other communication difficulties, and provide help and support if needed
  • ensure that the chosen assessment tool continues to be a sufficiently accurate measure
• Following assessment in a non-specialist setting, 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 or
  • acute guttate psoriasis requires phototherapy or
  • nail disease has a major functional or cosmetic impact or
  • any type of psoriasis is having a major impact on a person’s physical, psychological, or social wellbeing
• People with generalised pustular psoriasis or erythroderma should be referred immediately for same-day specialist assessment and treatment
• Refer children and young people with any type of psoriasis to a specialist at presentation

Assessment and referral for psoriatic arthritis

• Offer annual assessment for psoriatic arthritis to people with any type of psoriasis. Assessment is especially important within the first 10 years of onset of psoriasis
• Use a validated tool to assess adults for psoriatic arthritis in primary care and specialist settings, for example the Psoriasis Epidemiological Screening Tool (PEST). Be aware that the PEST does not detect axial arthritis or inflammatory back pain
• As soon as psoriatic arthritis is suspected, refer the person to a rheumatologist for assessment and advice about planning their care

Psoriasis: the assessment and management of psoriasis continued

Identification of comorbidities

• Offer adults with severe psoriasis of any type a cardiovascular risk assessment at presentation using a validated risk estimation tool. Offer further assessment of cardiovascular risk every 5 years, or more frequently if indicated following assessment. For further information see ‘Lipid modification’ (NICE CG67)
• For people with multiple comorbidities and/or multimorbidities and any type of psoriasis needing second- or third-line therapy, ensure multidisciplinary working and communication between specialties and, if needed, interdisciplinary team working (for example when both skin and joints are significantly affected)
• Be aware that psoriasis of any type, especially if severe, is a risk factor for venous thromboembolism in adults, and:
  • explain this risk to adults with any type of psoriasis
  • offer advice on how to minimise the risk (for example, during hospital admission, surgery, or periods of immobility)
  • manage the risk in line with ‘Venous thromboembolism: reducing the risk’ (NICE CG92)
• Assess whether people with any type of psoriasis are depressed when assessing disease severity and impact, and when escalating therapy. If appropriate offer information, advice and support in line with ‘Depression in adults with a chronic physical health problem’ (NICE CG91) and ‘Depression in children and young people’ (NICE CG28)

Topical therapy

The treatment pathway in this guideline begins with active topical therapies. The GDG acknowledged that the use of emollients in psoriasis was already widespread and hence the evidence review was limited to active topical therapies for psoriasis. Please refer to the BNF and cBNF for guidance on use of emollients

General recommendations

• Offer people with psoriasis topical therapy as first-line treatment
• Offer second- or third-line treatment options (phototherapy or systemic therapy) at the same time when topical therapy alone is unlikely to adequately control psoriasis, such as:
  • extensive disease (for example more than 10% of body surface area affected) or
  • at least ‘moderate’ on the static Physician’s Global Assessment or
  • where topical therapy is ineffective, such as nail disease
• Offer practical support and advice about the use and application of topical treatments. Advice should be provided by healthcare professionals who are trained and competent in the use of topical therapies. Support people to adhere to treatment in line with ‘Medicines adherence’ (NICE CG76)
• When offering topical agents:
  • take into account patient preference, cosmetic acceptability, practical aspects of application, and the site(s) and extent of psoriasis to be treated
  • discuss the variety of formulations available and, depending on the person’s preference, use:
    • cream, lotion, or gel for widespread psoriasis
    • lotion, solution, or gel for the scalp or hair-bearing areas
    • ointment to treat areas with thick adherent scale
  • be aware that topical treatment alone may not provide satisfactory disease control, especially in people with psoriasis that is extensive (for example more than 10% of body surface area affected) or at least ‘moderate’ on the static Physician’s Global Assessment
• If a person of any age with psoriasis requiring topical therapy has a physical disability, or cognitive or visual impairment, offer advice and practical support that take into account the person’s individual needs
• Arrange a review appointment 4 weeks after starting a new topical treatment in adults, and 2 weeks after starting a new topical treatment in children, to:
  • evaluate tolerability, toxicity, and initial response to treatment (including measures of severity and impact described in Principles of care)
  • reinforce the importance of adherence when appropriate
  • reinforce the importance of a 4 week break between courses of potent/very potent corticosteroids (see below)
• If there is little or no improvement at this review, discuss the next treatment option with the person
• Discuss with people whose psoriasis is responding to topical treatment (and their families or carers where appropriate):
  • the importance of continuing treatment until a satisfactory outcome is achieved (for example clear or nearly clear) or up to the recommended maximum treatment period for corticosteroids
  • that relapse occurs in most people after treatment is stopped
  • that after the initial treatment period topical treatments can be used when needed to maintain satisfactory disease control
• Offer people with psoriasis a supply of their topical treatment to keep at home for the self-management of their condition
• In people whose psoriasis has not responded satisfactorily to a topical treatment strategy, before changing to an alternative treatment:
  • discuss with the person whether they have any difficulties with application, cosmetic acceptability or tolerability, and where, relevant offer an alternative formulation
  • consider other possible reasons for non-adherence in line with ‘Medicines adherence’ (NICE CG76)

Psoriasis: the assessment and management of psoriasis continued

How to use corticosteroids safely

• Be aware that continuous use of potent or very potent corticosteroids may cause:
  • irreversible skin atrophy and striae
  • psoriasis to become unstable
  • systemic side-effects when applied continuously to extensive psoriasis (for example more than 10% of body surface area affected)
• Explain the risks of these side-effects to people undergoing treatment (and their families or carers where appropriate) and discuss how to avoid them
• Aim for a break of 4 weeks between courses of treatment with potent or very potent corticosteroids. Consider topical treatments that are not steroid-based (such as vitamin D or vitamin D analogues or coal tar) as needed to maintain psoriasis disease control during this period
• When offering a corticosteroid for topical treatment select the potency and formulation based on the person’s need
• Do not use very potent corticosteroids continuously at any site for longer than 4 weeks
• Do not use potent corticosteroids continuously at any site for longer than 8 weeks
• Do not use very potent corticosteroids in children and young people
• Offer a review at least annually to adults with psoriasis who are using intermittent or short-term courses of a potent or very potent corticosteroid (either as monotherapy or in combined preparations) to assess for the presence of steroid atrophy and other adverse effects
• Offer a review at least annually to children and young people with psoriasis who are using corticosteroids of any potency (either as monotherapy or in combined preparations) to assess for the presence of steroid atrophy and other adverse effects

Topical treatment of psoriasis affecting the trunk and limbs

• Offer a potent corticosteroid applied once daily plus vitamin D or a vitamin D analogue applied once daily (applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment for adults with trunk or limb psoriasis
• If once-daily application of a potent corticosteroid plus once-daily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance, or satisfactory control of trunk or limb psoriasis in adults after a maximum of 8 weeks, offer vitamin D or a vitamin D analogue alone applied twice daily
• If twice-daily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance, or satisfactory control of trunk or limb psoriasis in adults after 8–12 weeks, offer either:
  • a potent corticosteroid applied twice daily for up to 4 weeks or
  • a coal tar preparation applied once or twice daily
• If a twice-daily potent corticosteroid or coal tar preparation cannot be used or a once-daily preparation would improve adherence in adults offer a combined product containing calcipotriol monohydrate and betamethasone dipropionate applied once daily for up to 4 weeks
• Offer treatment with very potent corticosteroids in adults with trunk or limb psoriasis only:
  • in specialist settings under careful supervision
  • when other topical treatment strategies have failed
  • for a maximum period of 4 weeks
• Consider short-contact dithranol for treatment-resistant psoriasis of the trunk or limbs and either:
  • give educational support for self-use or
  • ensure treatment is given in a specialist setting
• For children and young people with trunk or limb psoriasis consider* either:
  • calcipotriol applied once daily (only for those over 6 years of age) or
  • a potent corticosteroid applied once daily (only for those over 1 year of age)

*  Please refer to the BNF for children for information on appropriate dosing and duration of treatment

Psoriasis: the assessment and management of psoriasis continued

Topical treatment of psoriasis affecting the scalp

• Offer a potent corticosteroid^† applied once daily for up to 4 weeks^‡ as initial treatment for people with scalp psoriasis
• Show people with scalp psoriasis (and their families or carers where appropriate) how to safely apply corticosteroid topical treatment
• If treatment with a potent corticosteroid^† does not result in clearance, near clearance, or satisfactory control of scalp psoriasis after 4 weeks^‡ consider:
  • a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or
  • topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients, and oils) before application of the potent corticosteroid
• If the response to treatment with a potent corticosteroid for scalp psoriasis remains unsatisfactory after a further 4 weeks of treatment^‡ offer:
  • a combined product containing calcipotriol monohydrate and betamethasone dipropionate^§ applied once daily for up to 4 weeks or
  • vitamin D or a vitamin D analogue^| applied once daily (only in those who cannot use steroids and with mild to moderate scalp psoriasis)
• If continuous treatment with either a combined product containing calcipotriol monohydrate and betamethasone dipropionate^§ applied once daily or vitamin D or a vitamin D analogue applied once daily for up to 8 weeks^‡ does not result in clearance, near clearance, or satisfactory control of scalp psoriasis offer:
  • a very potent corticosteroid applied up to twice daily for 2 weeks for adults only or
  • coal tar applied once or twice daily or
  • referral to a specialist for additional support with topical applications and/or advice on other treatment options
• Consider topical vitamin D or a vitamin D analogue*^,| alone for the treatment of scalp psoriasis only in people who:
  • are intolerant of or cannot use topical corticosteroids at this site or
  • have mild to moderate scalp psoriasis
• Do not offer coal tar-based shampoos alone for the treatment of severe scalp psoriasis

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

• Offer a short-term mild or moderate potency corticosteroid^¶ applied once or twice daily (for a maximum of 2 weeks‡) to people with psoriasis of the face, flexures, or genitals
• Be aware that the face, flexures, and genitals are particularly vulnerable to steroid atrophy and that corticosteroids should only be used for short-term treatment of psoriasis (1–2 weeks per month). Explain the risks to people undergoing this treatment (and their families or carers where appropriate) and how to minimise them
• For adults with psoriasis of the face, flexures, or genitals if the response to short-term moderate potency corticosteroids is unsatisfactory, or they require continuous treatment to maintain control, and there is serious risk of local corticosteroid-induced side-effects, offer a calcineurin inhibitor applied twice daily for up to 4 weeks. Calcineurin inhibitors^¶ should be initiated by healthcare professionals with expertise in treating psoriasis
• 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 and inform people undergoing treatment (and their families and carers where appropriate) of these risks and how to minimise them

†  Only use potent corticosteroids according to UK marketing authorisation, which was limited to those over 1 year of age at the time of publication (October 2012)

‡  In children and young people the specified duration of therapy may not be appropriate. Please refer to the BNF for children for information on appropriate dosing and duration of treatment

§  At the time of publication (October 2012), the combined product containing calcipotriol monohydrate and betamethasone dipropionate did not have UK marketing authorisation for this indication in children and young people.The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines—guidance for doctors for further information

|  In children, when offering an agent in the vitamin D or vitamin D analogue class choose calcipotriol, because at the time of publication (October 2012) calcitriol and tacalcitol did not have UK marketing authorisation for this group

¶  At the time of publication (October 2012), moderate potency corticosteroids, and calcineurin inhibitors did not have UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines—guidance for doctors for further information

Psoriasis: the assessment and management of psoriasis continued

Systemic therapy

General recommendations

• Responsibility for use of systemic therapy should be in specialist settings only. Certain aspects of supervision and monitoring may be delegated to other healthcare professionals and completed in non-specialist settings, in which case, such arrangements should be formalised
• When offering systemic therapy, tailor the choice of agent and dosing schedule to the needs of the individual and include consideration of:
  • the person’s age
  • disease phenotype, pattern of activity, and previous treatment history
  • disease severity and impact
  • the presence of psoriatic arthritis (in consultation with a rheumatologist)
  • conception plans
  • comorbidities
  • the person’s views
• Offer systemic non-biological therapy to people with any type of psoriasis if:
  • it cannot be controlled with topical therapy and
  • it has a significant impact on physical, psychological, or social wellbeing and
  • one or more of the following apply:
    • psoriasis is extensive (for example, more than 10% of body surface area affected or a Psoriasis Area and Severity Index (PASI) score of more than 10) or
    • psoriasis is localised and associated with significant functional impairment and/or high levels of distress (for example severe nail disease or involvement at high-impact sites) or
    • phototherapy has been ineffective, cannot be used, or has resulted in rapid relapse (rapid relapse is defined as greater than 50% of baseline disease severity within 3 months)

Methotrexate and risk of hepatotoxicity

• When considering the risks and benefits of treating any type of psoriasis with methotrexate, be aware that methotrexate can cause a clinically significant rise in transaminases and that long-term therapy may be associated with liver fibrosis (see below)

Methotrexate and monitoring for hepatotoxicity

• Before and during methotrexate treatment, offer the person with any type of psoriasis an evaluation for potential risk of hepatotoxicity. Use standard liver function tests and serial serum procollagen III levels to monitor for abnormalities during treatment with methotrexate, taking into account pre-existing risk factors (for example obesity, diabetes and alcohol use), baseline results, and trends over time
• When using serum procollagen III levels to exclude liver fibrosis or cirrhosis, be aware that the:
  • test cannot be used in children and young people
  • results may be unreliable in people with psoriatic arthritis
  • estimated positive predictive value is 23–95% and the estimated negative predictive value is 89–100%
• Provide advice on modifiable risk factors for liver disease prior to and during therapy, including alcohol intake and weight reduction if appropriate in line with ‘Alcohol-use disorders: preventing harmful drinking’ (NICE public health guidance 24), and ‘Obesity’ (NICE CG43). For further advice on how to support attitude and behavioural change see ‘Behaviour change’ (NICE public health guidance 6)
• Seek timely specialist advice and consider referral to a clinician with expertise in liver disease if the results of liver tests are abnormal

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
guidance.nice.uk/CG153

National Institute for Health and Care Excellence. Psoriasis: the assessment and management of psoriasis. October 2012

First included: Oct 05.