Previous changes

September 2023 — minor update. Information that aqueous cream can be used as a soap substitute has been removed from this topic in line with updated advice from the National Eczema Society and withdrawal of the SPS article Using aqueous cream as a soap substitute for skin washing.

September 2022 — reviewed. A literature search was conducted in August 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic has undergone minor restructuring. The recommendations on the diagnosis and management of psoriasis have been amended in line with current evidence.

May 2021 — minor update. Information that severe or atypical psoriasis is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

December 2020 — minor update. A typographical error has been corrected.

April 2020 — minor update. New management scenario created to provide information regarding COVID-19. 

March 2018 — minor update. New product availability, Ilumya™ has been approved for the treatment of moderate-to-severe plaque psoriasis. 

October to November 2017 — reviewed. A literature search was conducted in October 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic has undergone minor restructuring. The recommendations on the diagnosis and management of psoriasis have been amended in line with current evidence. An additional node has been added to the Management section on Specialist investigations and treatment. The section on Topical corticosteroids has been removed from the Prescribing information section, and replaced with links to the CKS topic on Corticosteroids - topical (skin), nose, and eyes.

July 2017 — minor update. Text added to the section on contraindications for topical vitamin D preparations, to reflect changes to the manufacturer's Summary of Product Characteristics.

December 2016 — minor update. The product availability section has been updated, as a foam preparation containing calcipotriol and betamethasone is now available. Information that any of the systemic adverse effects associated with oral corticosteroids could also occur with topical corticosteroids has been added to this topic.

September 2014 — minor update to the prescribing information to reflect the discontinuation of Carbo-Dome^® topical cream preparation.

May 2013 — minor update to the text to reflect advice issued by the Medicines and Healthcare products Regulatory Agency (MHRA) regarding aqueous cream.

December 2012 — reviewed. A literature search was conducted in November 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. There are several changes to the recommendations, following the publication of guidance from the National Institute for Health and Clinical Excellence Assessment and management of psoriasis.

March 2011 — update to the text to reflect recommendations from a guideline published by the Scottish Intercollegiate Guidelines Network (SIGN) Diagnosis and management of psoriasis and psoriatic arthritis in adults. Issued in June 2011.

August 2010 — minor update. The usage instructions for calcipotriol combined with betamethasone products have been clarified. Issued in September 2010.

February to May 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 August 2022.

HTAs (Health Technology Assessments)

• NICE (2025) Spesolimab for treating generalised pustular psoriasis flares. National Institute for Health and Care Excellence. [Free Full-text]

Economic appraisals

No new economic appraisals relevant to England since 1 August 2022.

Systematic reviews and meta-analyses

• Feng, Y., Zhou, B., Wang, Z., et al. (2022) Risk of Candida Infection and Serious Infections in Patients with Moderate-to-Severe Psoriasis Receiving Biologics: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. International Journal of Clinical Practice. [Free Full-text]
• Sbidian, E., Chaimani, A., Guelimi, R., et al. (2023) Systemic pharmacological treatments for chronic plaque psoriasis: a network meta‐analysis. Cochrane Library https://www.cochranelibrary.com [Free Full-text]

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 August 2022.

New policies

No new national policies or guidelines since 1 August 2022.

New safety alerts

• MHRA (2023) Janus kinase (JAK) inhibitors: new measures to reduce risks of major cardiovascular events, malignancy, venous thromboembolism, serious infections and increased mortality. Medicines and Healthcare products Regulatory Agency. www.gov.uk [Free Full-text]

Changes in product availability

• New product deucravacitinib is indicated for treating moderate to severe plaque psoriasis. See more here. 
• Deucravacitinib selectively inhibits the TYK2 enzyme, a member of the JAK family. It is licensed for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy. See more here. 
• New product Uzpruvo 45 mg solution 
• New product Amgevita HCF (adalimumab) 40 mg solution for injection in pre-filled pen and 20mg and 40mg in pre-filled syringe. Biosimilar licensed for treatment of rheumatoid arthritis, juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, ankylosing spondylitis, psoriatic arthritis, hidradenitis suppurativa, psoriasis, Crohn's disease, ulcerative colitis, and uveitis. See more here.
• New product Imraldi 40 mg solution for injection is indicated for the treatment of moderate to severe chronic plaque psoriasis in adult patients who are candidates for systemic therapy. See more here.
• New product Steqeyma (ustekinumab) 45 mg solution for injection in pre-filled syringe. This biosimilar is licenced for the treatment of plaque psoriasis, paediatric plaque psoriasis, psoriatic arthritis and Crohn’s disease. Unlike the originator product, Stelara, it is not licensed for the treatment of ulcerative colitis. See more here.
• New product metosyn is suitable for treating a wide variety of inflammatory, pruritic and allergic disorders of the skin. See more here.
• New product Otulfi (ustekinumab) 45 mg and 90 mg solution for injection in pre-filled syringe. This biosimilar to the reference product Stelara, is licensed for treatment of plaque psoriasis, paediatric plaque psoriasis, psoriatic arthritis, Crohn's disease, ulcerative colitis. See more here.
• New product WEZENLA is indicated for the treatment of moderate to severe plaque psoriasis in adults who failed to respond to, or who have a contraindication to, or are intolerant to other systemic therapies including ciclosporin, methotrexate (MTX) or PUVA (psoralen and ultraviolet A). See more here.
• New product Ovixan cream is indicated for the treatment of inflammatory and pruritic manifestations of psoriasis (excluding widespread plaque psoriasis) in adults, elderly patients, and children. See more here.
• SPC for Otezla (apremilast) Film-coated Tablets updated with new indication of moderate-severe plaque psoriasis in patients aged over 6 years and weighing at least 20 kg. See more here.
• New product Tremfya (guselkumab) 100 mg PushPen solution for injection in pre-filled pen, is licensed for the treatment of psoriatic arthritis. See more here.
• New product Spevigo (spesolimab) 450 mg concentrate for solution for infusion is indicated for the treatment of generalised pustular psoriasis flares in adults and adolescents from 12 years of age as monotherapy. See more here.
• New product Otulfi (ustekinumab) 45 mg Solution for injection is a new presentation of Otulfi in a vial, licensed for subcutaneous administration, to treat adult and paediatric plaque psoriasis. See more here.
• New product Remsima (infliximab) 40mg/1ml concentrate for Solution for infusion vial. This new formulation is licensed for the treatment of rheumatoid arthritis, Crohn’s disease, ulcerative colitis, ankylosing spondylitis, psoriasis and psoriatic arthritis. It contains sorbitol and is contra-indicated in patients with hereditary fructose intolerance. See more here.

Basis for recommendation

The recommendations on assessment are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Psoriasis: assessment and management [NICE, 2017], the Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline Diagnosis and management of psoriasis and psoriatic arthritis in adults [SIGN, 2010a], a guideline from the Primary Care Dermatology Society (PCDS) Psoriasis: an overview and chronic plaque psoriasis [PCDS, 2022],a concise guideline on psoriasis convened by NICE in association with the Royal College of Physicians [Samarasekera, 2014], a systematic review on topical therapies for plaque psoriasis [Samarasekera, 2013], and expert opinion in review articles on psoriasis [Cohen, 2012; Johnson, 2013; Weigle, 2013; Boehncke, 2015; BMJ Best Practice, 2021] and psoriatic arthropathy [Lenman, 2014].

Using the Psoriasis Epidemiology Screening Tool (PEST)

• The recommendation on using the Psoriasis Epidemiology Screening Tool (PEST) is based on the NICE clinical guideline, which found it had good validity and was simple and easy to use [NICE, 2017].
  • A review article on psoriatic arthropathy in primary care cites a sensitivity of 0.92 and specificity of 0.78 for the PEST [Lenman, 2014].

Assessing the severity and impact of psoriasis

• The recommendation on using tools in primary care to assess disease severity and impact has been extrapolated from the NICE clinical guideline, as their use in specialist settings allows improved awareness of disease impact on the person, and monitoring of disease progression and treatment effectiveness [NICE, 2017].
  • The information that the impact of psoriasis on the person may not correlate with objective disease extent or severity is based on a systematic review of treatment for plaque psoriasis [Samarasekera, 2013].

Asking about family history

• The recommendation on asking about family history is based on the fact that population studies suggest a higher incidence of psoriasis in first-degree and second-degree relatives than in the general population, and concordance rates in monozygotic twins are up to three times higher than in dizygotic twins [Boehncke, 2015].
  • This is supported by a US review article on psoriasis, which states that about one-third of people with psoriasis have a first-degree relative with the condition [Weigle, 2013].

Assessing the body surface area (BSA)

• The recommendation on assessing the BSA on examination is based on the NICE clinical guideline, which highlights the importance of getting a baseline measurement of the extent of psoriasis, to allow assessment of skin response following the start of treatment, and to prompt specialist dermatology referral if the BSA affected is more than 10% [NICE, 2017].

Pustular psoriasis

Pustular psoriasis may be generalized or localized.

• Generalized pustular psoriasis (a potentially life-threatening medical emergency).
  • Rapidly developing widespread erythema, followed by the eruption of white, sterile non-follicular pustules which coalesce to form large lakes of pus.
  • Lesions associated with systemic illness, such as fever, malaise, tachycardia, weight loss, and arthralgia.
  • Usually presents in people with existing or previous chronic plaque psoriasis, but can also occur in people without a history of psoriasis.
• Localized (palmoplantar) pustular psoriasis
  • Lesions on the palms and soles, such as yellow-brown pustules within established psoriasis plaques, or redness, scaling, and pustules at the tips of the fingers and toes.
• Considered the most severe of all psoriatic disease variants, pustular psoriasis is an orphan skin and multisystemic inflammatory disease characterised by intermittent flares or attacks with partial or complete remission between episodes.

[SIGN, 2010a; Boehncke, 2015; BMJ Best Practice, 2021; Bachlez 2020]

Erythrodermic psoriasis

Erythrodermic psoriasis is a potentially life-threatening medical emergency.

• Diffuse, widespread severe psoriasis that affects more than 90% of the body surface area [Cohen, 2012].
  • It can develop gradually from chronic plaque psoriasis or appear abruptly, even in people with mild psoriasis [Weigle, 2013].
  • It can be precipitated by various factors such as systemic infection; irritants such as coal tar or ciclosporin; phototherapy; or sudden withdrawal of corticosteroids [Myers et al, 2006].
• Lesions may feel warm, and may be associated with systemic illness, such as fever, malaise, tachycardia, lymphadenopathy, and peripheral oedema [Meier and Sheth, 2009].

Chronic plaque psoriasis

Chronic plaque psoriasis typically presents as:

• Monomorphic, erythematous plaques covered by adherent silvery-white scale, usually on the scalp, behind the ears, trunk, buttocks, periumbilical area, and extensor surfaces (such as forearms, shins, elbows, and knees).
• Lesions which are typically distributed symmetrically and can coalesce to form larger lesions.
  • On white skin, the plaques are pink or red; in deeply pigmented skin, plaques usually have a grey colour and may cause marked post-inflammatory hyperpigmentation.
  • Most lesions are 1 cm to several centimetres in diameter, with an oval or irregular shape.
  • There is usually a clear delineation between normal and affected skin.
  • Scale is usually present — it is usually silver-white in colour, but less commonly can be a waxy yellow or orange-brown. The thickness of the scale varies, but it can be very thick. If the scale is gently removed, a glossy red membrane with pinpoint bleeding points (Auspitz's sign) is revealed.
  • Occasionally, a halo-like effect is seen around a plaque, due to vasoconstriction (Woronoff's ring).
  • Fissures may form if the plaque is over a joint line or on the palm or sole.

[SIGN, 2010a; Cohen, 2012; Johnson, 2013; Boehncke, 2015; BMJ Best Practice, 2021]

Scalp psoriasis

Scalp psoriasis affects 75–90% of people with psoriasis.

• It typically presents as chronic plaque psoriasis affecting the scalp area.
• The whole scalp can be affected, or individual plaques may be visible. Plaques may be very thick, particularly in the occipital region.
• It may be associated with areas of non-scarring alopecia in some people, particularly if there is:
  • Thick, adherent scale extending up the hair shaft (pityriasis amiantacea).
  • Erythrodermic psoriasis — this can cause severe alopecia.
  • Repeated scratching of the scalp due to itch (usually reversible).

[Griffiths et al, 2004; Boehncke, 2015]

Facial psoriasis

Facial psoriasis typically presents as:

• Well-demarcated plaques on the face, similar to those of chronic plaque psoriasis.
• Lesions which may affect the hairline.
• Possible mild scaling around the eyebrows and nasolabial folds, which may be due to co-existent seborrhoeic dermatitis (so-called 'sebo-psoriasis') — see the CKS topic on Seborrhoeic dermatitis for more information.

[van de Kerkhof et al, 2007; Boehncke, 2015]

Flexural psoriasis

Flexural psoriasis typically presents as:

• Itchy psoriasis lesions affecting areas such as the groin, genital area, axillae, inframammary folds, abdominal folds, sacral and gluteal cleft.
  • The elderly, immobile, and people who are overweight or obese are at increased risk of being affected [Menter et al, 2008].
• Lesions of chronic plaque psoriasis which are well-defined, but there may be little or no scaling, due to friction and occlusion at these sites.
  • Lesions are often red and glazed in appearance, and there may be a fissure in the skin crease.

[Cohen, 2012; Johnson, 2013; Boehncke, 2015]

Guttate psoriasis

Guttate psoriasis typically presents as:

• Small, scattered, round or oval (2 mm to 1 cm in diameter - water drop appearance) scaly papules, which may be pink or red.
• Multiple lesions which may occur all over the body over a period of 1–7 days, particularly on the trunk and proximal limbs. Lesions may occur on the face, ears, and scalp, but rarely affect the soles of the feet.
• Guttate psoriasis mostly occurs in children, teenagers and young adults, although it can also occur in older adults.
• A first presentation of psoriasis (classically after acute streptococcal upper respiratory tract infection), or as an acute exacerbation of plaque psoriasis.
  • Cases of guttate psoriasis following COVID-19 infection have been described in the literature [Rouai et al, 2021; Gananandan et al, 2020]. There was a history of mild chronic plaque psoriasis in one of the affected individuals [Gananandan et al, 2020].

[SIGN, 2010a; Young, 2017; BMJ Best Practice, 2021; Saleh and Tanner 2022]

Nail psoriasis

Nail psoriasis more commonly affects fingernails than toenails (50% and 35% respectively), and may affect all parts of the nail and surrounding structures.

• Nail changes can occur with any type of psoriasis, and are particularly common in people with psoriatic arthritis (up to 90% of people are affected). The incidence of nail involvement increases with the duration of psoriasis, and is less common in children.
• Nail psoriasis may present with a wide spectrum of symptoms including: 
  • Nail pitting (depressions in the nail plate) is the most common finding.
  • Discolouration (for example the 'oil drop sign') — orange-yellow discolouration of the nail bed.
  • Subungual hyperkeratosis — hyperproliferation of the nail bed, with accumulation of keratinocytes under the nail.
  • Onycholysis — detachment of the nail from the nail bed, which may allow bacteria and fungi to enter and cause infection.
  • Complete nail dystrophy.

[Cohen, 2012; Johnson, 2013; Weigle, 2013; de Vries, 2013; Crowley, 2015; Boehncke, 2015; Bardazzi, 2019; Thomas et al, 2021]

Basis for recommendation

The information on the differential diagnosis of psoriasis is based on the Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline Diagnosis and management of psoriasis and psoriatic arthritis in adults [SIGN, 2010a], and expert opinion in review articles on psoriasis [Cohen, 2012; Boehncke, 2015; Young, 2017; Armstrong and Read 2020; BMJ Best Practice, 2021].

How should I manage suspected pustular or erythrodermic psoriasis?

• If a person presents with suspected generalized pustular psoriasis or erythrodermic psoriasis, this should be managed as a medical emergency:
  • Arrange for immediate same-day specialist dermatology assessment and ongoing management.
• If a person presents with suspected localized pustular psoriasis:
  • Provide advice on sources of information and support, such as:
    • The Psoriasis and Psoriatic Arthritis Alliance (PAPAA; website available at www.papaa.org) is a national charity which provides information and advice on all aspects of psoriasis and psoriatic arthritis, including a leaflet on Pustular psoriasis.
    • The Psoriasis Association (website available at www.psoriasis-association.org.uk) is a national charity and membership organization for people affected by psoriasis, which provides a leaflet on Pustular psoriasis.
    • The British Association of Dermatologists has an information leaflet on Palmoplantar pustulosis.
  • Arrange for referral to a dermatologist, the urgency depending on clinical judgement, for specialist assessment and management.
  • Consider seeking specialist dermatology advice whilst awaiting specialist assessment, regarding interim treatment options that may be initiated in primary care.

How should I manage chronic plaque psoriasis of the trunk and limbs?

If the person has chronic plaque psoriasis of the trunk and/or limbs:

• Offer advice on the nature of psoriasis, and explain that treatment is aimed at control of symptoms rather than cure, and that complete clearance of skin lesions may not be possible.
• Reassure that it is not an infectious condition, and provide advice on sources of information and support, such as:
  • The Psoriasis and Psoriatic Arthritis Alliance (PAPAA; website available at www.papaa.org) is a national charity which provides information and advice on all aspects of psoriasis and psoriatic arthritis, including a leaflet on What is psoriasis?.
  • The Psoriasis Association (website available at www.psoriasis-association.org.uk) is a national charity and membership organization for people affected by psoriasis.
  • The British Association of Dermatologists information leaflet on Psoriasis - an overview.
  • The NHS patient leaflet on Psoriasis.
• Give general lifestyle advice to reduce the risk of exacerbations, such as advice on:
  • Smoking cessation if appropriate. See the CKS topic on Smoking cessation for more information.
  • Drinking alcohol within recommended limits. See the CKS topic on Alcohol - problem drinking for more information.
  • Weight loss if the person is overweight or obese. See the CKS topic on Obesity for more information. The PAPAA has an information leaflet on Psoriatic lifestyle and nutrition.
• Assess for associated stress, distress, anxiety and/or depression, and manage appropriately. See the CKS topics on Generalized anxiety disorder and Depression for more information.
  • The PAPAA has an information leaflet on Psychological aspects of psoriasis.
• Offer treatment with topical preparations, depending on the person's preferences, cosmetic acceptability, practical aspects of application, and the site(s) and extent of psoriasis to be treated.
  • Topical preparations are the main treatments used for people with mild to moderate psoriasis and are frequently used as adjunctive treatments in those with more severe disease requiring phototherapy, systemic, or biologic therapy.
  • The PAPAA has an information leaflet on Treatments for psoriasis: an overview.
  • The British Association of Dermatologists has an information leaflet on Topical treatments for psoriasis.
  • Advise that topical treatments may take several weeks to start to work, and if treatment is stopped suddenly, there may be a risk of relapse.
    • Creams, lotions, or gels are suitable for widespread psoriasis.
    • Ointments are suitable for areas of skin with thick scale.
    • Lotions, solutions, or gels are suitable for hair-bearing areas.
  • Advise that topical treatment alone may not be sufficient to control the condition, particularly where the psoriasis is extensive (e.g. more than 10% of body surface area or where the psoriasis has been classified as moderate or above).
  • Topical corticosteroids are only suitable for treating localized areas of psoriasis. Note: repeat prescriptions for topical corticosteroids should be carefully reviewed and supervised to identify any adverse effects, and to avoid use on widespread psoriasis where there is a risk of unstable disease.
• Arrange to review the person within four weeks after treatment has started  and regularly thereafter, depending on clinical judgement, to:
  • Assess the initial response to treatment, including the severity and impact of psoriasis.
  • Assess for any issues with topical application or adverse effects.
  • Reinforce the importance of adherence to treatments.
• Advise the person to seek urgent medical advice if they experience unexplained joint pain or swelling, as this may be a sign of psoriatic arthritis that requires specialist referral.
• Arrange to review the person at least annually if they are using multiple intermittent or short-term courses of potent topical corticosteroids to:
  • Optimize treatment and assess for adverse effects such as skin atrophy. See the CKS topic on Corticosteroids - topical (skin), nose, and eyes for more information.
  • Assess disease severity and impact, and assess for new joint symptoms that may suggest psoriatic arthritis, and arrange specialist referral if appropriate.
  • Note: seek urgent specialist dermatology advice if there is any uncertainty about adverse effects or drug safety if the person is taking specialist drug treatments.
• Assess the person's risk of cardiovascular disease at least every five years, especially if psoriasis is severe, depending on clinical judgement. See the CKS topic on CVD risk assessment and management for more information.
  • The PAPAA has an information leaflet on Psoriasis and the heart.
• Advise the person on how to reduce the risk of venous thromboembolism, especially if psoriasis is severe. See the CKS topics on Deep vein thrombosis and DVT prevention for travellers for more information.

What topical drug treatments should I offer?

• Offer treatment with topical preparations, and consider whether referral is needed if lesions are extensive, severe, or not responding to treatment. Options include:
  • An emollient to reduce scale and help relieve itch. See the section on Emollients in Prescribing information for more information.
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Moisturisers or the Psoriasis and Psoriatic Arthritis Alliance leaflet on Emollients and Psoriasis.
  • A potent topical corticosteroid plus a topical vitamin D preparation (both applied once a day, but at different times of day). See the CKS topic on Corticosteroids - topical (skin), nose, and eyes and the section on Vitamin D preparations in Prescribing information for more information.
    • Give advice on how to minimize the risk of corticosteroid adverse effects, such as stopping the topical corticosteroid once the skin is clear or nearly clear.
    • Provide advice on sources of information such as the Psoriasis Association leaflets on Topical steroids and Vitamin D.
    • Note: very potent corticosteroid preparations should not normally be used in primary care, due to the risk of adverse effects.
  • Consider a salicylic acid preparation if scale is problematic. See the section on Salicylic acid in Prescribing information for more information.
• Review the person after four weeks:
  • If there has been a good initial response, continue topical treatment until the skin is clear or nearly clear.
  • Advise the person not to apply potent corticosteroids for more than eight weeks at any one site.
    • Treatment may be restarted after a four-week 'treatment break' — during this time topical vitamin D preparations may be continued.
  • Advise that courses of topical treatments (including corticosteroids) can be used as needed to maintain satisfactory control of psoriasis, reinforcing the advice on the safe use of potent topical corticosteroids.
    • Offer a prescription for topical treatments to allow self-management on an as-needed basis.
• If there is a poor initial response after the first four weeks:
  • Check adherence to treatment, and ask about any issues with application, cosmetic acceptability, or tolerability of topical treatments.
  • If there is no obvious explanation for treatment failure, consider:
    • Continuing treatment with a potent topical corticosteroid plus a topical vitamin D preparation (both applied once a day, but at different times of day) for another four weeks or
    • Stopping the potent corticosteroid and only applying a topical vitamin D preparation twice a day for up to 12 weeks.
• If there is a poor response after an additional four weeks of treatment with a potent corticosteroid plus a vitamin D preparation (eight weeks treatment in total):
  • Advise the person to stop the potent corticosteroid and only apply a vitamin D preparation twice a day.
• If there is still a poor response after 8–12 weeks of treatment with a vitamin D preparation alone twice a day, offer:
  • A potent corticosteroid, applied twice a day for up to 4 weeks, or
  • A coal tar preparation applied once or twice daily. See the section on Coal tar products in Prescribing information for more information.
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Coal Tar Applications.
• If there is ongoing treatment failure:
  • Consider offering a combined topical preparation containing a potent corticosteroid and vitamin D, applied once a day for up to four weeks.
• If there is ongoing treatment-resistant psoriasis:
  • Consider whether there may be an alternative diagnosis, and manage appropriately.
  • Offer treatment with short-contact dithranol if educational support for self-use can be given. The Psoriasis Association leaflet on Dithranol may be helpful. See the section on Dithranol - short contact in Prescribing information for more information, or
  • Arrange referral to a dermatologist for specialist assessment and management.

When should I refer a person with chronic plaque psoriasis of the trunk and limbs?

• If the person presents with suspected generalized pustular psoriasis or erythrodermic psoriasis, this should be managed as a medical emergency:
  • Arrange for urgent same-day specialist dermatology assessment and ongoing management.
• Arrange referral to a dermatologist for specialist assessment and management, the urgency depending on clinical judgement, if:
  • There is uncertainty about the diagnosis.
  • Psoriasis is extensive, for example more than 10% of the body surface area is affected.
  • Psoriasis is at least moderately severe, as measured by the Physician's Global Assessment.
  • Psoriasis is resistant to topical drug treatments in primary care, or treatments are not tolerated.
  • There is a significant impact on the person's physical, psychological, or social wellbeing.
  • Additional information or education for self-use is needed (for example about application of topical treatments, such as short-contact dithranol).
• Arrange an urgent referral to a rheumatologist if a diagnosis of psoriatic arthritis is suspected.

How should I manage scalp psoriasis?

If the person has scalp psoriasis:

• Offer advice on the nature of psoriasis, and explain that treatment is aimed at control of symptoms rather than cure, and that complete clearance of skin lesions may not be possible.
• Reassure that it is not an infectious condition, and provide advice on sources of information and support, such as:
  • The Psoriasis and Psoriatic Arthritis Alliance (PAPAA; website available at www.papaa.org) is a national charity which provides information and advice on all aspects of psoriasis and psoriatic arthritis, including a leaflet on Scalp psoriasis.
  • The Psoriasis Association (website available at www.psoriasis-association.org.uk) is a national charity and membership organization for people affected by psoriasis, which provides a leaflet on Scalp psoriasis.
• Give general lifestyle advice to reduce the risk of exacerbations, such as advice on:
  • Smoking cessation if appropriate. See the CKS topic on Smoking cessation for more information.
  • Drinking alcohol within recommended limits. See the CKS topic on Alcohol - problem drinking for more information.
  • Weight loss if the person is overweight or obese. See the CKS topic on Obesity for more information. The PAPAA has an information leaflet on Psoriatic lifestyle and nutrition.
• Assess for associated stress, distress, anxiety and/or depression, and manage appropriately. See the CKS topics on Generalized anxiety disorder and Depression for more information.
  • The PAPAA has an information leaflet on Psychological aspects of psoriasis.
• Offer treatment with topical preparations, depending on the person's preferences, cosmetic acceptability, practical aspects of application, and the site(s) and extent of psoriasis to be treated.
  • The PAPAA has an information leaflet on Treatments for psoriasis: an overview.
  • The British Association of Dermatologists has an information leaflet on Topical treatments for psoriasis.
  • Advise that topical treatments may take several weeks to start to work, and if treatment is stopped suddenly, there may be a risk of relapse.
    • Lotions, solutions or gels are suitable for the scalp or hair-bearing areas.
  • Advise that topical treatment alone may not be sufficient to control the condition, particularly where the psoriasis is extensive (e.g. more than 10% of body surface area or where the psoriasis has been classified as moderate or above on the static Physician's Global Assessment).
  • Topical corticosteroids are only suitable for treating localized areas of psoriasis. Note: repeat prescriptions for topical corticosteroids should be carefully reviewed and supervised to identify any adverse effects, and to avoid use on widespread psoriasis where there is a risk of unstable disease.
• Arrange to review the person within four weeks after treatment has started and regularly thereafter, depending on clinical judgement, to:
  • Assess the initial response to treatment, including the severity and impact of psoriasis.
  • Assess for any issues with topical application or adverse effects.
  • Reinforce the importance of adherence to treatments.
• Advise the person to seek urgent medical advice if they experience unexplained joint pain or swelling, as this may be a sign of psoriatic arthritis that requires specialist referral.
• Arrange to review the person at least annually if they are using multiple courses of potent- or very-potent topical corticosteroids to:
  • Optimize treatment and assess for adverse effects such as skin atrophy. See the CKS topic on Corticosteroids - topical (skin), nose, and eyes for more information.
  • Assess disease severity and impact, and assess for new joint symptoms that may suggest psoriatic arthritis, and arrange specialist referral if appropriate.
  • Note: seek urgent specialist dermatology advice if there is any uncertainty about adverse effects or drug safety if the person is taking specialist drug treatments.
• Assess the person's risk of cardiovascular disease at least every five years, especially if psoriasis is severe, depending on clinical judgement. See the CKS topic on CVD risk assessment and management for more information.
  • The PAPAA has an information leaflet on Psoriasis and the heart.

What topical drug treatments should I offer?

• Offer treatment with topical preparations, and consider whether referral is needed if lesions are extensive, severe, or not responding to treatment. Options include:
  • A potent topical corticosteroid (applied once a day). See the CKS topic on Corticosteroids - topical (skin), nose, and eyes for more information.
    
    • Advise on how to minimize the risk of corticosteroid adverse effects, such as stopping the topical corticosteroid once the psoriasis is clear or nearly clear.
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Topical steroids.
  • A vitamin D preparation alone (applied once a day). These preparations can be used where corticosteroids are not tolerated, or if there is mild to moderate scalp psoriasis. See the section on Vitamin D preparations in Prescribing information for more information.
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Vitamin D.
  • A coal tar shampoo, but this should not be used alone for people who have severe scalp psoriasis. See the section on Coal tar products in Prescribing information for more information.
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Coal Tar Applications.
• Review the person after four weeks:
  • If there has been a good initial response, continue topical treatment until the skin is clear or nearly clear.
  • Advise the person not to apply potent corticosteroids for more than eight weeks at any one site.
    • Treatment may be restarted after a four-week 'treatment break'.
  • Advise that courses of topical treatments (including corticosteroids) can be used as needed to maintain satisfactory control of psoriasis, reinforcing the advice on the safe use of potent topical corticosteroids.
    • Offer a prescription for topical treatments to allow self-management on an as-needed basis.
• If there is a poor initial response to treatment after the first four weeks:
  • Check adherence to treatment, and ask about any issues with application, cosmetic acceptability, or tolerability of topical treatments.
  • If there is no obvious explanation for treatment failure, consider:
    • A different topical formulation of a potent corticosteroid such as a shampoo or mousse and/or
    • A scalp treatment such as salicylic acid, olive oil, coconut oil, arachis oil, or an emollient to remove thick scale (before further applications of the potent corticosteroid).
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Moisturisers.
• If there is a poor response after an additional four weeks, offer:
  • A combined topical preparation containing a potent corticosteroid and vitamin D (applied once a day for up to four weeks) or
  • A vitamin D preparation applied once a day (only for people who cannot tolerate corticosteroids and have mild to moderate scalp psoriasis).
• If there is still a poor response after up to eight weeks of treatment:
  • Consider whether there may be an alternative diagnosis, and manage appropriately.
  • Consider prescribing a very-potent corticosteroid applied up to twice a day for two weeks (adults only). See the CKS topic on Corticosteroids - topical (skin), nose, and eyes for more information, or
  • Consider prescribing a coal tar preparation applied once or twice a day. See the section on Coal tar products in Prescribing information for more information.
  • Arrange referral to a dermatologist for specialist assessment and management.

When should I refer a person with scalp psoriasis?

• If the person presents with suspected generalized pustular psoriasis or erythrodermic psoriasis, this should be managed as a medical emergency:
  • Arrange for urgent same-day specialist dermatology assessment and ongoing management.
• Arrange referral to a dermatologist for specialist assessment and management, the urgency depending on clinical judgement, if:
  • There is uncertainty about the diagnosis.
  • Psoriasis is extensive, for example, more than 10% of the body surface area is affected.
  • Psoriasis is at least moderately severe, as measured by the Physician's Global Assessment.
  • Psoriasis is resistant to topical drug treatments in primary care, or treatments are not tolerated.
  • There is a significant impact on the person's physical, psychological, or social well-being.
  • Additional information or education is needed (for example about application of topical treatments).
• Arrange an urgent referral to a rheumatologist if a diagnosis of psoriatic arthritis is suspected.

How should I manage facial, flexural and genital psoriasis?

If the person has facial, flexural, or genital psoriasis:

• Offer advice on the nature of psoriasis, and explain that treatment is aimed at control of symptoms rather than cure and that complete clearance of skin lesions may not be possible.
• Reassure that it is not an infectious condition, and provide advice on sources of information and support, such as:
  • The Psoriasis and Psoriatic Arthritis Alliance (PAPAA; website available at www.papaa.org) is a national charity which provides information and advice on all aspects of psoriasis and psoriatic arthritis, including leaflets on Psoriasis and sensitive areas and Genital psoriasis.
  • The Psoriasis Association (website available at www.psoriasis-association.org.uk) is a national charity and membership organization for people affected by psoriasis, which has a leaflet on Psoriasis in sensitive areas.
• Give general lifestyle advice to reduce the risk of exacerbations, such as advice on:
  • Smoking cessation if appropriate. See the CKS topic on Smoking cessation for more information.
  • Drinking alcohol within recommended limits. See the CKS topic on Alcohol - problem drinking for more information.
  • Weight loss if the person is overweight or obese. See the CKS topic on Obesity for more information. The PAPAA has an information leaflet on Psoriatic lifestyle and nutrition.
• Assess for associated stress, distress, anxiety and/or depression, and manage appropriately. See the CKS topics on Generalized anxiety disorder and Depression for more information.
  • The PAPAA has an information leaflet on Psychological aspects of psoriasis.
• Offer treatment with topical preparations, depending on the person's preferences, cosmetic acceptability, practical aspects of application, and the site(s) and extent of psoriasis to be treated.
  • The PAPAA has an information leaflet on Treatments for psoriasis: an overview.
  • The British Association of Dermatologists has an information leaflet on Topical treatments for psoriasis.
  • Advise that topical treatments may take several weeks to start to work, and if treatment is stopped suddenly, there may be a risk of relapse.
    • Creams, lotions, or gels are suitable for widespread psoriasis.
    • Ointments are suitable for areas of skin with thick scale.
    • Lotions, solutions or gels are suitable for hair-bearing areas.
  • Advise that topical treatment alone may not be sufficient to control the condition, particularly where the psoriasis is extensive (e.g. more than 10% of body surface area or where psoriasis has been classified as moderate or above on the static Physician's Global Assessment).
  • Topical corticosteroids are only suitable for treating localized areas of psoriasis. Note: repeat prescriptions for topical corticosteroids should be carefully reviewed and supervised to identify any adverse effects, and to avoid use on widespread psoriasis where there is a risk of unstable disease.
• Arrange to review the person within four weeks after treatment has started and regularly thereafter, depending on clinical judgement, to:
  • Assess the initial response to treatment, including the severity and impact of psoriasis.
  • Assess for any issues with topical application or adverse effects.
  • Reinforce the importance of adherence to treatments.
• Arrange to review the person at least annually if they are using multiple intermittent or short-term courses of potent topical corticosteroids to:
  • Optimize treatment and assess for adverse effects such as skin atrophy. See the CKS topic on Corticosteroids - topical (skin), nose, and eyes for more information.
  • Assess disease severity and impact, and assess for new joint symptoms that may suggest psoriatic arthritis, and arrange specialist referral if appropriate.
  • Note: seek urgent specialist dermatology advice if there is any uncertainty about adverse effects or drug safety if the person is taking specialist drug treatments.
• Assess the person's risk of cardiovascular disease at least every five years, especially if psoriasis is severe, depending on clinical judgement. See the CKS topic on CVD risk assessment and management for more information.
  • The PAPAA has an information leaflet on Psoriasis and the heart.
• Advise the person on how to reduce the risk of venous thromboembolism, especially if psoriasis is severe. See the CKS topics on Deep vein thrombosis and DVT prevention for travellers for more information.

What topical drug treatments should I offer?

• Offer treatment with topical preparations, and consider whether referral is needed if lesions are extensive, severe, or not responding to treatment. Options include:
  • An emollient to reduce scale and help relieve itch — see the section on Emollients in Prescribing information for more information, and
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Moisturisers or the Psoriasis and Psoriatic Arthritis Alliance leaflet on Emollients and Psoriasis.
    • Advise the person to avoid soap where possible if there is flexural or genital psoriasis, as soap is likely to irritate inflamed skin.
  • A short-term mild- or moderately-potent topical corticosteroid preparation (applied once or twice daily) for up to two weeks. See the CKS topic on Corticosteroids - topical (skin), nose, and eyes for more information.
    • Advise on how to minimize the risk of corticosteroid adverse effects, such as stopping the topical corticosteroid once the skin is clear or nearly clear.
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Topical steroids.
    • Note: do not prescribe potent- or very-potent topical corticosteroids to the face, flexures, or genital areas. Corticosteroid application to these areas may cause skin irritation, and there is a greater risk of adverse effects, such as skin atrophy, compared with use in other areas of the body.
• Review the person after four weeks.
  • If there is a good initial response, advise that repeated short courses of topical corticosteroids may be used to maintain disease control, however:
    • A 'treatment break' of four weeks between corticosteroid courses is required.
    • Topical corticosteroids should only be used for 1–2 weeks each month.
  • If there is a poor initial response, check adherence to treatment, and ask about any issues with application, cosmetic acceptability, or tolerability of topical treatments.
• If there is ongoing treatment failure:
  • Consider whether there may be an alternative diagnosis, and manage appropriately.
  • Arrange referral to a dermatologist for specialist assessment and management.

When should I refer a person with facial, flexural, or genital psoriasis?

• If the person presents with suspected generalized pustular psoriasis or erythrodermic psoriasis, this should be managed as a medical emergency:
  • Arrange for urgent same-day specialist dermatology assessment and ongoing management.
• Arrange referral to a dermatologist for specialist assessment and management, the urgency depending on clinical judgement, if:
  • There is uncertainty about the diagnosis.
  • Psoriasis is extensive, for example more than 10% of the body surface area is affected.
  • Psoriasis is at least moderately severe, as measured by the Physician's Global Assessment tool.
  • Psoriasis is resistant to topical drug treatments in primary care, or treatments are not tolerated.
  • Continuous treatment with topical corticosteroids is needed to maintain control of psoriasis and there is a significant risk of adverse effects.
  • There is a significant impact on the person's physical, psychological, or social wellbeing.
  • Additional information or education is needed (for example about application of topical treatments).
• Arrange an urgent referral to a rheumatologist if a diagnosis of psoriatic arthritis is suspected.

How should I manage guttate psoriasis?

If the person has suspected guttate psoriasis:

• Reassure that it is usually a self-limiting condition that typically resolves within 3–4 months of onset, and reassure that it is not infectious.
• Provide advice on sources of information and support, such as:
  • The Psoriasis and Psoriatic Arthritis Alliance (PAPAA; website available at www.papaa.org) is a national charity which provides information and advice on all aspects of psoriasis and psoriatic arthritis.
  • The Psoriasis Association (website available at www.psoriasis-association.org.uk) is a national charity and membership organization for people affected by psoriasis, which has an information leaflet on Guttate psoriasis.
• Assess for associated stress, distress, anxiety and/or depression, and manage appropriately. See the CKS topics on Generalized anxiety disorder and Depression for more information.
  • The PAPAA has an information leaflet on Psychological aspects of psoriasis.
• If lesions are widespread (for example more than 10% of the body surface area is affected), arrange urgent referral to a dermatologist, for consideration of phototherapy.
• If lesions are not widespread, options include:
  • No treatment, if the person is not concerned about the appearance or impact of the lesions.
  • Topical treatments, depending on the person's preferences, cosmetic acceptability, practical aspects of application, and the site(s) and extent of psoriasis to be treated.
  • Note: do not use anti-streptococcal antibiotics to treat guttate psoriasis triggered by a recent upper respiratory tract infection, or recurrent episodes of guttate psoriasis.
• If treatment with topical preparations is offered:
  • The PAPAA has an information leaflet on Treatments for psoriasis: an overview.
  • The British Association of Dermatologists has an information leaflet on Topical treatments for psoriasis.
  • Advise that topical treatments may take several weeks to start to work, and if treatment is stopped suddenly, there may be a risk of relapse.
    • Creams, lotions, or gels are suitable for widespread psoriasis.
    • Ointments are suitable for areas of skin with thick scale.
    • Lotions, solutions or gels are suitable for hair-bearing areas.
  • Advise that topical treatment alone may not be sufficient to control the condition, particularly where the psoriasis is extensive (e.g. more than 10% of body surface area or where psoriasis has been classified as moderate or above on the static Physician's Global Assessment).
  • Topical corticosteroids are only suitable for treating localized areas of psoriasis. Note: repeat prescriptions for topical corticosteroids should be carefully reviewed and supervised to identify any adverse effects, and to avoid use on widespread psoriasis where there is a risk of unstable disease.
• Arrange to review the person within four weeks after treatment has started and regularly thereafter, depending on clinical judgement, to:
  • Assess the initial response to treatment, including the severity and impact of psoriasis.
  • Assess for any issues with topical application or adverse effects.
  • Reinforce the importance of adherence to treatments.
  • Assess for new joint symptoms that may suggest psoriatic arthritis, and arrange specialist referral if appropriate.

Topical drug treatment

• Offer treatment with topical preparations, and consider whether referral is needed if lesions are extensive, severe, or not responding to treatment. Options include:
  • An emollient to reduce scale and help relieve itch. See the section on Emollients in Prescribing information for more information.
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Moisturisers or the Psoriasis and Psoriatic Arthritis Alliance leaflet on Emollients and Psoriasis.
  • A potent topical corticosteroid plus a topical vitamin D preparation (both applied once a day, but at different times of day). See the CKS topic on Corticosteroids - topical (skin), nose, and eyes and the section on Vitamin D preparations in Prescribing information for more information.
    • Give advice on how to minimize the risk of corticosteroid adverse effects, such as stopping the topical corticosteroid once the skin is clear or nearly clear.
    • Provide advice on sources of information such as the Psoriasis Association leaflets on Topical steroids and Vitamin D.
    • Note: very potent corticosteroid preparations should not be used in primary care, due to the risk of adverse effects.
  • Consider a salicylic acid preparation if scale is problematic. See the section on Salicylic acid in Prescribing information.
• Review the person after four weeks:
  • If there has been a good initial response, continue topical treatment until the skin is clear or nearly clear.
  • Advise the person not to apply potent corticosteroids for more than eight weeks at any one site.
    • Treatment may be restarted after a four-week 'treatment break' — during this time topical vitamin D preparations may be continued.
  • Advise that courses of topical treatments (including corticosteroids) can be used as needed to maintain satisfactory control of psoriasis, reinforcing the advice on the safe use of potent topical corticosteroids.
    • Offer a prescription for topical treatments to allow self-management on an as-needed basis.
• If there is a poor initial response after the first four weeks:
  • Check adherence to treatment, and ask about any issues with application, cosmetic acceptability, or tolerability of topical treatments.
  • If there is no obvious explanation for treatment failure, consider:
    • Continuing treatment with a potent topical corticosteroid plus a topical vitamin D preparation (both applied once a day, but at different times of day) for another four weeks or
    • Stopping the potent corticosteroid and only applying a topical vitamin D preparation twice a day for up to 12 weeks.
• If there is a poor response after an additional four weeks of treatment with a potent corticosteroid plus a vitamin D preparation (8 weeks treatment in total):
  • Advise the person to stop the potent corticosteroid and only apply a vitamin D preparation twice a day.
• If there is still a poor response after 12 weeks of treatment with a vitamin D preparation alone twice a day, offer:
  • A potent corticosteroid, applied twice a day for up to 4 weeks, or
  • A coal tar preparation applied once or twice daily. See the section on Coal tar products in Prescribing information for more information.
    • Provide advice on sources of information such as the Psoriasis Association leaflet on Coal Tar Applications.
• If there is ongoing treatment failure:
  • Consider offering a combined topical preparation containing a potent corticosteroid and vitamin D, applied once a day for up to four weeks.
• If there is ongoing treatment-resistant psoriasis:
  • Consider whether there may be an alternative diagnosis, and manage appropriately.
  • Arrange referral to a dermatologist for specialist assessment and management.

When should I refer a person with guttate psoriasis?

• If the person presents with suspected generalized pustular psoriasis or erythrodermic psoriasis, this should be managed as a medical emergency:
  • Arrange for urgent same-day specialist dermatology assessment and ongoing management.
• Arrange urgent referral to a dermatologist for specialist assessment and management if:
  • Acute guttate psoriasis lesions are widespread (for example more than 10% of the body surface area is affected), for consideration of phototherapy.
• Arrange referral to a dermatologist, the urgency depending on clinical judgement, if:
  • There is uncertainty about the diagnosis.
  • Guttate psoriasis is at least moderately severe, as measured by the Physician's Global Assessment tool.
  • Guttate psoriasis is resistant to topical drug treatments in primary care, or treatments are not tolerated or impractical to use for the person.
  • There is a significant impact on the person's physical, psychological, or social wellbeing.
  • Additional information or education for self-use is needed (for example about application of topical treatments).
• Consider arranging referral to an ear, nose, and throat (ENT) specialist if guttate psoriasis is exacerbated by recurrent tonsillitis. See the CKS topic on Sore throat - acute for more information.
• Arrange an urgent referral to a rheumatologist if a diagnosis of psoriatic arthritis is suspected.

How should I manage nail psoriasis?

If the person has suspected nail psoriasis:

• Provide advice on sources of information and support, such as:
  • The Psoriasis and Psoriatic Arthritis Alliance (PAPAA; website available at www.papaa.org) is a national charity which provides information and advice on all aspects of psoriasis and psoriatic arthritis, including an information leaflet on Nail psoriasis.
  • The Psoriasis Association (website available at www.psoriasis-association.org.uk) is a national charity and membership organization for people affected by psoriasis, which has an information leaflet on Nails.
• Discuss that psoriasis which affects the nails is generally refractory to topical treatment.
  • Advise the person that improvements in nail psoriasis may lag behind improvements in skin and joint disease (if affected).
• Advise the person to:
  • Keep their nails short — this avoids exacerbating onycholysis (detachment of the nail from the nail bed) and reduces the accumulation of material under the nail.
  • Avoid manicure of the cuticle — this may provoke paronychia (infection of the nail bed). See the CKS topic on Paronychia - acute for more information.
  • Avoid prosthetic nails.
• If nail disease is mild and is not causing discomfort or distress:
  • No treatment is needed.
  • Nail varnish can be used to disguise pitting, but the person should avoid abrasive acetone-based nail varnish removers.
• If nail disease is moderate to severe and has a major functional or cosmetic impact:
  • Consider whether there may be an alternative diagnosis, and manage appropriately.
  • Arrange referral to a dermatologist for specialist assessment and management.

Availability and choice

Available products

• There are a large number of emollients available in the UK, including creams, ointments, gels, lotions, sprays, washes, and bath and shower additives, available as non-proprietary and/or proprietary products.
  • For a complete list of all the emollient products available in the UK, see the British National Formulary (BNF).
• Most emollient products are plain (containing no active ingredients).
  • However, some emollients contain active ingredients:
    • Urea (a keratin softener and hydrating agent), for example Aquadrate^®, Balneum^® Plus, Calmurid^®, E45^® Itch Relief Cream, Eucerin^® Intensive, Hydromol® Intensive and ImuDERM®.
    • Lauromacrogols (which have local anaesthetic properties, and soothe and relieve itchy skin), for example Balneum^® Plus and E45^® Itch Relief Cream.
    • Lanolin or lanolin derivatives, for example hydrous ointment, E45^® cream and lotion, and Oilatum^® emollient bath additive.
    • Antiseptic, for example Dermol^® preparations (cream, lotion, shower, and bath emollient), Emulsiderm^® liquid emulsion, and Oilatum Plus^® bath additive.
  • Emollients containing active ingredients are not generally recommended because they increase the risk of skin reactions. However, they may be useful in some people.
    • Aqueous cream is generally not recommended because of the high risk of developing skin reactions [MHRA, 2013].
• All emollients are available on the NHS, but some are classified as borderline substances and as such their prescriptions should be endorsed with 'ACBS' (Advisory Committee on Borderline Substances). These include Aveeno^® products (bath oil, cream, and lotion) and E45^® products (emollient bath oil, emollient wash cream, and lotion).
  • Preparations marked ‘ACBS’ are regarded as drugs when prescribed in accordance with the advice of the ACBS for the clinical conditions listed. See the Drug Tariff for more information.
• Emollients are also available over-the-counter, although availability may be limited.

[BNF, 2022]

Choice of products

• There is no evidence from controlled trials to support the use of one emollient over another [van Zuuren, 2017].
• Prescribe an emollient according to the dryness of the skin, and the person's preference and tolerance to treatments. The key to successful management is finding the correct balance between these factors.
  • Creams and lotions are preferred for red, inflamed areas of skin because the evaporation of water-based products cools the skin.
  • Ointments are preferred for dry skin (that is not inflamed) because they are more effective than creams, however they may be poorly tolerated compared with creams.
  • Experience has shown that proprietary products are often preferred to non-proprietary products; it may be a false economy to prescribe solely on the basis of price.
  • Several different emollients may be required (for example for different areas of skin, different stages of flare, or for use in different locations).
• Do not prescribe aqueous cream as a leave-on emollient, as it contains the ingredient sodium lauryl sulphate, which can irritate the skin.  
  • See the section on Adverse effects for more information.
• Where possible, prescribe an emollient with a pump dispenser to minimize the risk of bacterial contamination.
  • For emollients that come in pots, advise that using a clean spoon or spatula (rather than fingers) to remove the emollient helps to minimize contamination.
• Emollients containing active ingredients are not generally recommended because they increase the risk of skin reactions, however they may be useful in some people. For example, products containing:
  • Lauromacrogols are reputed to relieve itch.
  • Urea may improve skin hydration. It can enhance the moisture-retaining ability of emollients, thereby improving their efficacy.
  • Antiseptics (for example benzalkonium chloride) have a limited role in protecting skin which is prone to infection.
• Prescribe emollients to replace soap in people with dry skin requiring treatment.
  • Ointments dissolved in hot water are suitable soap substitutes.
  • Bath additives and shower products are an option for people with extensive areas of dry skin, although the evidence to support their use is limited, and there is no universal consensus on their benefit [Eichenfield, 2014a; Santer, 2018]
  • If bath emollients are used, it is essential that they do not replace standard emollients [NIHR, 2018]. The person should be advised to continue using standard emollients in addition to any bath emollient product.
• The effectiveness and acceptability of a particular emollient may vary with time.
  • If the person feels that a particular product has become unsuitable for them (or if they have developed sensitivity to it), prescribe an alternative emollient.
  • It may be necessary to try a range of emollients before the person finds the best combination for their skin.

[SIGN, 2011; Arkwright, 2013; RCN, 2013; Eichenfield, 2014b; Eichenfield, 2015; NICE, 2007]

Adverse effects

• Emollients are usually well tolerated, and skin reactions are the most common adverse effects. They are caused by sensitivity of the skin to additives in the emollient, such as perfumes, preservatives, and biological components, such as lanolin (although newer hypoallergenic formulations of lanolin are less problematic).
  • If a skin reaction occurs, stop the emollient and use a different one.
  • If the person has had previous skin reactions to emollients, consider testing a small quantity on the skin before widespread application.
  • If sensitivity to emollients is a known problem, prescribe a cream with few additives, or an ointment (ointments do not require preservatives and generally have fewer excipients), to reduce the chance of a further reaction.
• The occlusive effect of ointments can cause folliculitis. If this occurs, stop the ointment (consider switching to a cream), and prescribe an antibiotic, if necessary.
• Aqueous cream is generally not recommended because of the high risk of developing skin reactions.
  • A clinical audit found that the use of aqueous cream results in a significant proportion of people developing sensitization reactions, so it should be avoided [Cork et al, 2003].
• The Medicines and Healthcare products Regulatory Agency (MHRA) warns that aqueous cream may cause local skin reactions, such as stinging, burning, itching, and redness, when it is used as a leave-on emollient [MHRA, 2013].
  • The reactions, which are not generally serious, often occur within 20 minutes of application but can occur later, and may be due to sodium lauryl sulfate or other additives.
• The MHRA state that both paraffin-containing (any concentration) and paraffin-free emollients present fire hazard risks [MHRA, 2018a].
  • Case reports have described both severe and fatal burns with paraffin-containing emollient products, and paraffin-free emollients may also have a fire accelerant effect.
• Bath emollients can pose a slip hazard.

[NICE, 2007]

Application

It is essential to provide instructions on the correct use of emollients, with clear demonstrations where appropriate.

• Advise the person to use emollients liberally and frequently, even when their skin appears improved or is clear.
  • It is recommended that 250–500 g of emollient be applied every week [NICE, 2007].
  • The frequency of application will vary depending on the person's skin disease, but for very dry skin, application of an emollient every 2–3 hours should be considered normal.
  • To facilitate frequent application, the person should consider keeping separate packs of emollients at work or school.
• Advise on the appropriate use of emollients.
  • Advise the person to use emollients during or after washing to help trap moisture in the skin. The skin should be gently dried and the emollient applied while the skin is still moist.
  • Smooth the emollient gently into the skin along the line of hair growth, rather than rubbing them in.
  • It may be more convenient to use better tolerated products (such as creams and lotions) during the day, and ointments (which are usually less well tolerated) at night.
  • If an active topical treatment is used, such as corticosteroids, the person should wait about 15–30 mins if possible after application of an emollient, before applying the active treatment [SPS, 2020].
    • Due to a lack of quality evidence, the optimal order and timing of application of emollients and topical steroids is not known.
  • Emollient products should not be shared with other people as they may become contaminated with pathogens.
    • Pump dispensers minimize the risk of contamination.
    • For emollients that come in pots, using a clean spoon or spatula (rather than fingers) to remove the emollient helps to minimize the risk of contamination.
• Advise the person:
  • To avoid the use of soaps, detergents, and bubble bath when washing, as these have an emulsifying effect on the lipids of the skin and can be damaging to the skin. Instead, a suitable soap substitute should be used, for instance an ointment dissolved in hot water (or lotion in warm water).
  • Both paraffin-containing (any concentration) and paraffin-free emollients present fire hazard risks [MHRA, 2018a].
    • It is important that people using emollients and their parents or carers understand the fire risk associated with the build-up of emollient residue on clothing and bedding. People using emollient products should be instructed not to smoke or go near naked flames because clothing or fabric such as bedding or bandages that have been in contact with an emollient or emollient-treated skin can rapidly ignite. Washing clothing or fabric at a high temperature may reduce emollient build-up but not totally remove it.

[SIGN, 2011; RCN, 2013; Eichenfield, 2014b; NICE, 2007]

Quantity

• Emollients are typically under-prescribed and under-used. This results in sub-optimal treatment of dry skin, and may increase the occurrence of flares.
• Encourage appropriate usage by prescribing generous amounts (for example 500 g per week) to be used regularly (often four times daily).
• Pump-dispensers should be prescribed when large quantities of cream or lotion are required, where possible. They are more convenient than other containers and are less likely to become contaminated by potential pathogens.
• The amount of emollient used should far exceed other topical treatments (for example corticosteroids) by a factor of at least ten.

[NICE, 2007; PCDS, 2022]

Availability and choice

• Topical vitamin D preparations are available as ointments, gels, scalp solutions, and lotions.
• Three vitamin D preparations are available on prescription in the UK:
  • Calcipotriol (Dovonex^®) — available as an ointment.
  • Calcipotriol (non-branded) — available as an ointment and scalp solution.
  • Calcitriol (Silkis^®) — available as an ointment.
  • Tacalcitol (Curatoderm^®) — available as an ointment or lotion.
  • Note: calcitriol and tacalcitol may be less irritating than calcipotriol.
• Combination topical corticosteroid and vitamin D preparations (calcipotriol with betamethasone) are available as an ointment or gel (Dovobet^®), or a foam (Enstilar^®).

[ABPI, 2018; ABPI, 2019; ABPI, 2022; BNF, 2022]

Contraindications and cautions

Topical vitamin D preparations are contraindicated in people with:

• Calcium metabolism disorders — these preparations may cause hypercalcaemia.
• Severe liver and kidney disease.
• Hypersensitivity to the active substance(s) or to any of the excipients.

Topical vitamin D preparations should be used with caution in people:

• With erythrodermic or generalized pustular psoriasis — increased risk of hypercalcaemia.
• Who are pregnant or breastfeeding — manufacturers advise to avoid in pregnancy unless essential. There is no information available regarding drug safety in breastfeeding. Seek specialist advice from the UK Teratology Information Service when needed.
• Taking medications known to increase the serum calcium level, such as thiazide diuretics, or medications with pharmacological effects impacted by a change in calcium levels, such as digoxin.

Calcipotriol should not be used on the face, as it may cause skin irritation.

[ABPI, 2020a; ABPI, 2020b; BNF, 2022]

Adverse effects

• Local adverse effects include skin burning, dermatitis, erythema, itching, local skin reactions, and paraesthesia. Local adverse effects often reduce with time.
  • If there is significant skin irritation, stop the treatment.
  • Advise the person to wash their hands thoroughly after application, to avoid transfer of the product to other parts of the body.
• Systemic adverse effects are rare and include hypercalcemia, hypercalciuria, and parathyroid hormone suppression. 
• Photosensitivity has been reported.
  • Advise the person to avoid excessive exposure to sunlight and sunlamps.

[ABPI, 2020a; BNF, 2022]

Application

Advise the person not to exceed the maximum recommended weekly dose due to the increased risk of adverse effects such as hypercalcaemia.

• Calcipotriol
  • Calcipotriol cream, ointment, and gel — should be applied once or twice a day; to a maximum of 100 grams each week.
  • Calcipotriol scalp solution — should be applied twice a day; to a maximum of 60 mL each week.
  • If an ointment and scalp solution are used together, the maximum dose is calcipotriol 5 mg each week, for example:
    • Cream or ointment 30 grams plus scalp solution 60 mL.
    • Cream or ointment 60 grams plus scalp solution 30 mL.
• Calcipotriol and betamethasone combination product
  • Calcipotriol combined with betamethasone ointment or foam — should be applied once daily for 4 weeks.
  • Calcipotriol combined with betamethasone scalp gel — 1–4 g should be applied once daily for 4 weeks (4 g is about one teaspoonful).
    • The total amount of calcipotriol-containing product(s) applied should not exceed a maximum of 30% of body surface area, or 15 grams daily, or 100 grams each week.
• Calcitriol
  • Calcitriol ointment — should be applied twice daily; to a maximum of 30 grams each day.
• Tacalcitol
  • Tacalcitol ointment — should be applied once daily; to a maximum of 10 grams each day.
  • Tacalcitol lotion — should be applied once daily; to a maximum of 10 mL each day.
    • The total amount of tacalcitol should not exceed 280 micrograms/week (for example 30 mL of lotion plus 40 g of ointment).

Advise the person that paraffin-containing topical preparations present fire hazard risks.

• It is important that people using topical preparations and their parents or carers understand the fire risk associated with the build-up of residue on clothing and bedding. People using these products should be instructed not to smoke or go near naked flames because clothing or fabric such as bedding or bandages that have been in contact with these preparations or treated skin can rapidly ignite. Washing clothing or fabric at a high temperature may reduce emollient build-up but not totally remove it.

[MHRA, 2018a; ABPI, 2020a; ABPI, 2022; BNF, 2022]

Availability and choice

• Products suitable for the scalp include:
  • Sebco^® or Cocois^®scalp ointment (coal tar 12%, salicylic acid 2%, sulphur 4%, coconut oil).
  • Capasal® shampoo (coal tar 1%, coconut oil 1%, salicylic acid 0.5%).

[BNF, 2022]

Contraindications and cautions

Do not prescribe topical salicylic acid preparations for people:

• Who are allergic to aspirin, or any other of the ingredients in the topical preparation.
• Who have inflamed or broken skin.
• Who have acute local infections, or acute pustular psoriasis.

Prescribe topical salicylic with caution:

• If applied on large areas of skin — risk of salicylate toxicity.
• To people who are pregnant or breastfeeding — use on limited areas for a limited time period.
• To people with diabetes who are at risk of neuropathic ulcers.
• To people with severe peripheral neuropathy.

[ABPI, 2021a; BNF, 2022]

Adverse effects

• Topical salicylic acid may cause irritation and excessive drying of the skin.
  • Advise the person to avoid contact with their mouth, mucous membranes, and eyes; and to wash their hands immediately after use.
• Salicylate toxicity may occur if large areas of the skin are treated.
  • Salicylic acid preparations should not be applied to more than 20% of the body surface area.
  • The symptoms of salicylic acid toxicity include frontal headache, tinnitus, nausea and vomiting

[ABPI, 2021a; BNF, 2022]

Application

Salicylic acid preparations should not be applied to more than 20% of the body surface area, due to the risk of systemic salicylate toxicity.

• Cocois^® or Sebco^® scalp ointment should be applied in the following way:
  • The hair is parted in sections and the treatment rubbed along the exposed areas, working around the hair. Assistance may be needed to apply it correctly to the top of the head.
  • It is left on for 1 hour and then washed off with a detergent shampoo or a coal tar shampoo (for example Alphosyl 2 in 1^®, or Capasal^®).
    • If psoriasis is severe, advise the person it should be applied once a day for the first 3–7 days, and once a week thereafter.
    • If scale is thick and adherent the person should apply it, then leave it on overnight under occlusion (for example using a shower cap); it can then be washed off in the morning with a detergent shampoo or a coal tar shampoo. Note: this method of application is off-label.
• Other salicylic acid products should be used in the following way:
  
  • Capasal^® shampoo — used as a shampoo, daily if necessary.
  • Zinc and salicylic acid paste BP (Lassar's paste) — applied twice a day.
• Advise the person that paraffin-containing topical preparations present fire hazard risks.
  • It is important that people using topical preparations and their parents or carers understand the fire risk associated with the build-up of residue on clothing and bedding. People using these products should be instructed not to smoke or go near naked flames because clothing or fabric such as bedding or bandages that have been in contact with these preparations or treated skin can rapidly ignite. Washing clothing or fabric at a high temperature may reduce emollient build-up but not totally remove it.

[MHRA, 2018a; BNF, 2022]

Availability and choice

• Several coal tar preparations are available in the UK including ointments, shampoos, and bath additives. Various preparations are combined with other topical treatments for the management of psoriasis (for example salicylic acid).
• The choice of coal tar preparation should take into consideration product availability, the skin site, previous response to treatment, and the person's preference.
  • Newer, branded products are preferred because older, non-branded products contain crude coal tar (coal tar BP) which is smellier and usually messier to use.
• Preparations suitable for treating scalp psoriasis include:
  • Alphosyl 2 in 1^® shampoo (alcoholic coal tar extract 5%).
  • Capasal^® shampoo (coal tar 1%, coconut oil 1%, salicylic acid 0.5%).
  • Polytar Scalp^® shampoo (coal tar 4%).
  • Psoriderm^® — scalp lotion is also a shampoo (coal tar 2.5%, lecithin 0.3%).
  • T/Gel^®shampoo (coal tar extract 2%).
  • Exorex^® lotion (coal tar 5%).
  • Sebco^® or Cocois^® scalp ointment (coal tar solution 12%, salicylic acid 2%, sulphur 2%).
  • Note: do not use coal tar shampoos such as Polytar^®, Alphosyl 2 in 1^®, or Capasal^® alone for treating severe scalp psoriasis.
• Preparations suitable for treating psoriasis on the trunk and limbs include:
  • Exorex^® lotion (coal tar 5%).
  • Psoriderm^® cream (coal tar 6%).

[BNF, 2022]

Contraindications and cautions

Do not prescribe coal tar preparations to people:

• With known hypersensitivity to the active substance(s) or any of the product excipients.
• With broken or inflamed skin.
• With skin infection.
• With sore, acute, or pustular psoriasis.
• With genital or rectal psoriasis.
• Who are pregnant — avoid the use of coal tar preparations in the first trimester of pregnancy.

Prescribe coal tar with caution to people:

• Applying to the face (particularly around the eyes) or skin flexures.
• Who are pregnant — use coal tar preparations with caution in the second and third trimesters of pregnancy if the expected benefit to the mother outweighs the potential risk to the infant.
• Who are breastfeeding — use coal tar preparations with caution if the expected benefit to the mother outweighs the potential risk to the infant, and ensure the infant does not come into direct contact with treated skin to avoid accidental ingestion by the infant.

[ABPI, 2021b; BNF, 2022]

What adverse effects are associated with coal tar products?

• Coal tar preparations can cause adverse effects such as:
  • Photosensitivity — advise the person to minimize exposure to sunlight and avoid sunlamps after treatment (unless this is specifically indicated).
  • Skin irritation, acneiform eruptions, folliculitis.
  • Staining of skin, hair, or fabric.

[ABPI, 2021b; BNF, 2022]

Application

The method of application depends on the coal tar product:

• Creams, ointments, and pastes — these are generally applied by wiping onto the entire plaque once or twice a day (away from flexural areas).
• Scalp preparations — these are applied once a week, left on for one hour and then shampooed off. For severe psoriasis, this can be repeated daily for the first 3–7 days; thereafter, they are usually applied once a week (and shampooed off after one hour).
• Shampoos — directions for use vary. Some preparations may be used daily, and others are restricted to use once or twice a week.

[BNF, 2022]

Availability and choice

• Dithranol treatments are available as branded and non-branded products (dithranol ointment [BP] and paste [BP]). Branded preparations include Dithrocream^® (dithranol 0.1%, 0.25%, 0.5%, 1%, and 2%).
• Creams are particularly suitable because they wash off more easily than ointments.

[BNF, 2022]

Contraindications and cautions

Do not prescribe dithranol to people with:

• Known sensitivity to any of the product ingredients or excipients.
• Acute or pustular psoriasis, or inflamed psoriasis.
• Facial psoriasis.
• Sensitive areas of skin.

[ABPI, 2021c; BNF, 2022]

Adverse effects

• Dithranol may cause adverse effects such as:
  • Skin irritation, burning sensation (if left on the skin for too long).
  • Staining of the skin, hair, or fabrics (temporary effect).
  • Staining of fabric and bathroom fittings (permanent effect).
• There are no known adverse effects of dithranol use in pregnancy and breastfeeding.

[ABPI, 2021c; BNF, 2022]

Application

• Treatment with dithranol should start with the lowest strength (0.1%) cream and gradually increase over about four weeks to the highest tolerated strength that produces the optimum therapeutic effect. Clinical improvement may take up to six weeks.
  • Dithranol cream should be applied once a day to psoriasis areas only (avoid application to normal skin between plaques), to avoid excessive skin irritation.
  • The cream is left on for 30–60 minutes, and then washed off.
  • This is continued for at least one week, and if necessary increased at weekly intervals to the 0.25% strength, followed by the 0.5%, the 1.0%, and finally the 2.0% strength.
  • Note: the optimum strength varies from person to person and depends on the thickness of the plaques and the person's tolerance to adverse effects.
• If the areas being treated become inflamed, stop the treatment. When the inflammation settles, restart the treatment at a lower concentration.
• If an emollient is being used, the person should apply this first and then wait 30 minutes before applying the dithranol (only after the emollient has been fully absorbed) [SPS, 2020].
• Once lesions are palpably flat, dithranol should be discontinued.
• Advise the person that paraffin-containing topical preparations present fire hazard risks.
  • It is important that people using topical preparations and their parents or carers understand the fire risk associated with the build-up of residue on clothing and bedding. People using these products should be instructed not to smoke or go near naked flames because clothing or fabric such as bedding or bandages that have been in contact with these preparations or treated skin can rapidly ignite. Washing clothing or fabric at a high temperature may reduce emollient build-up but not totally remove it.

[MHRA, 2018b; ABPI, 2021c; BNF, 2022]