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 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

  • 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 the NICE guideline on medicines adherence. Also see the NICE guideline on medicines optimisation.

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, 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.

Phototherapy (broad- or narrow-band 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

    • 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)[6] 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[7] as the first choice of systemic agent for people with psoriasis who fulfil the criteria for systemic therapy (see previous recommendation except in the circumstances described in recommendations and

Changing to an alternative biological drug (systemic biological therapy)

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

    • the psoriasis does not respond adequately to a first biological drug as defined in NICE technology appraisals[8] (at 10 weeks after starting treatment for infliximab, 12 weeks for etanercept, ixekizumab and secukinumab, and 16 weeks for adalimumab and ustekinumab; primary failure) or

    • the psoriasis initially responds adequately but subsequently loses this response, (secondary failure) or

    • the first biological drug cannot be tolerated or becomes contraindicated.

[6] The PASI is also available from the British Association of Dermatologists website.

[7] At the time of publication (October 2012), methotrexate 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.

[8] NICE technology appraisal guidance 103, 134, 146, 180, 350 and 442.

  • National Institute for Health and Care Excellence (NICE)