Index

NICE Clinical guideline [CG153] Psoriasis: assessment and management. Last updated Sep 2017. NICE CKS Psoriasis. Last revised Dec 2024.

Gudielines

Approach:

Refer to dermatology if:

There is uncertainty about the diagnosis.
Extensive psoriasis (>10% of body surface area)
Moderately severe or above psoriasis, as measured by the Physician's Global Assessment.
Psoriasis is resistant to topical therapy in primary care
There is a significant impact on the person's physical, psychological, or social wellbeing.

If psoriatic arthritis is suspected → urgent referral to rheumatology.

Regular topical emollients should be offered to ALL patients in addition to the following topical therapy.

Step	Topical Therapy	Description
1st line	Potent corticosteroid + vitamin D once daily for 4 weeks 1 in the morning and 1 in the evening.	If not effective after 4 week course of steroid → attempt another 4 week course After 4 weeks of steroid therapy, a 4 week break in between is needed During the 4 week break, vitamin D can still be used If poor response after 8 week → step up to 2nd line
2nd line	Vitamin D twice daily (Stop the corticosteroid)	If poor response after 8-12 weeks → step up to 3rd line
3rd line	Stop the vitamin D and offer: Potent corticosteroid twice daily for 4 weeks, OR Coal tar preparation twice daily
4th line	Consider combined potent corticosteroid and vitamin D once daily for 4 weeks
5th line	Consider short-contact dithranol	Also: Consider alternative diagnosis Refer to dermatology

Note that topical vitamin D preparations should be avoided in:

1st line: narrowband UVB light therapy

Other options:

Frequency and doses:

2-3 times a week
Dose is based on the person's 'minimal erythema dose' and sun-reactive skin type

First offer conventional systemic therapy

2nd line: ciclosporin, should be offered instead of methotrexate as first line if any of the following:
- Rapid / short-term disease control needed (e.g. psoriasis flare)
- Patient is considering conception
- Palmoplantar pustulosis

If conventional systemic therapy failed → consider targeted immunomodulatory therapy (initiated and supervised only by consultant dermatologists)

1st line: topical potent corticosteroid once daily for 4 eeks

If no improvement after 4 weeks:

Try different formulation of topical potent corticosteroid, and/or
Apply topical agents to remove adherent scale before application of topical steroid

1st line: topical mild / moderate potent corticosteroid once / twice daily for 2 weeks

NICE Psoriasis: assessment and management
NICE CKS Psoriasis

Author: Adams Lau
Reviewer:
Last edited: 05/05/25