Guidance

Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

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.

  • 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 (see recommendation 1.4.1.1) 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.

Assessment and referral for psoriatic arthritis

  • As soon as psoriatic arthritis is suspected, refer the person to a rheumatologist for assessment and advice about planning their care.

Identification of comorbidities

Topical therapy: general recommendations

Topical therapy: 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, 1 in the morning and the other in the evening) for up to 4 weeks as initial treatment for adults with trunk or limb psoriasis.

Phototherapy (broad- or narrowband ultraviolet B light)

  • Offer narrowband ultraviolet B (UVB) phototherapy to people with plaque or guttate-pattern psoriasis that cannot be controlled with topical treatments alone. Treatment with narrowband UVB phototherapy can be given 3 or 2 times a week depending on patient preference. Tell people receiving narrowband UVB that a response may be achieved more quickly with treatment 3 times a week.

Systemic non-biological therapy

  • 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

    • 1 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).

Choice of drugs (systemic non-biological therapy)

  • Offer methotrexate as the first choice of systemic agent for people with psoriasis who fulfil the criteria for systemic therapy (see previous recommendation 1.5.2.1) except in the circumstances described in recommendations 1.5.2.4 and 1.5.2.12.

    In October 2012, methotrexate did not have a UK marketing authorisation for this indication in children and young people. See NICE's information on prescribing medicines.

Changing to an alternative biological drug (systemic biological therapy)

  • Consider changing to an alternative biological drug in adults if: