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Psoriasis

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

NICE CKS Psoriasis. Last revised Dec 2024.

Article Last Updated:08/12/2025

Gudielines

Management

General Approach:

Step 1: topical therapy in primary care
Step 2: phototherapy in secondary care
Step 3: systemic therapy in secondary care

Although with slight variations depending on the site affected

Referral Criteria

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 well-being

If psoriatic arthritis is suspected → urgent referral to rheumatology.

Topical Therapy (Primary Care)

All patients:

Offer regular topical emollient (to reduce scale & itch) PLUS
Further topical therapy (depending on site affected as shown below)

Trunk & Limbs

Step	Topical Therapy	Description
1st line	Potent corticosteroid + vitamin D once daily for 4 weeks Administered at different times: 1 in the morning and 1 in the evening.	Good response: continue topical treatment until skin is clear/nearly clear If not effective after 4-week course of steroid → attempt another 4-week course After 4 weeks of steroid therapy, a 4-week break is needed During the 4-week break, vitamin D can still be used If poor response after 8 weeks → 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 once/twice daily
4th line	Consider combined preparation containing potent corticosteroid and vitamin D once daily for 4 weeks
5th line	Consider short-contact dithranol	Also: Consider an alternative diagnosis Refer to dermatology

Note that topical vitamin D preparations should be avoided in:

Use on face
Pregnancy
Breastfeeding

Scalp

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

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

Face / Flexural / Genital

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

Phototherapy

1st line: narrow-band UVB light therapy

Other options:

Broad-band UVB light therapy
Psoralen plus UVA (PUVA) phototherapy

Frequency and doses:

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

Systemic Therapy

First offer conventional systemic therapy:

1st line: methotrexate

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

3rd line: acitretin

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

TNF-alpha inhibitors (e.g. adalimumab, etanercept, infliximab)
IL-12/23 inhibitor (ustekinumab)
IL-17 inhibitor (brodalumab)
IL-23 inhibitor (e.g. guselkumab)

Summary of Topical Corticosteroid Use in Psoriasis

Examples

The potency of a topical corticosteroid preparation is determined solely by the corticosteroid molecule/component itself, regardless of the formulation or concentration used

The following examples were derived from the BNF: ^[Ref]

Potency Class	Examples of Topical Corticosteroids
Mild	Hydrocortisone
Moderate	Alclometasone dipropionate Clobetasone butyrate Hydrocortisone butyrate
Potent	Beclometasone dipropionate Betamethasone Fludroxycortide Fluocinolone acetonide Fluocinonide Fluticasone Mometasone furoate
Very Potent	Clobetasol propionate

Summary of Topical Corticosteroid Use in Psoriasis (By Site)

TCS = Topical Corticosteroid

Site of Psoriasis	First-Line Steroid Potency	Maximum Duration / Recommended Use Schedule	Key Restriction
Trunk, Limbs	Potent TCS (often used initially in combination with a topical Vitamin D preparation)	Not more than eight weeks at any one site Treatment may be restarted after a four-week ‘treatment break’	Very potent preparations should not normally be used in primary care
Scalp Psoriasis	Potent TCS
Facial, Flexural, and Genital Psoriasis	Mild/Moderately potent TCS	Initial course: Not more than two weeks Maintenance courses should be used for 1-2 weeks each month, with a four-week ‘treatment break’ between courses	Do NOT prescribe potent/very potent TCS to these areas due to the greater risk of adverse effects like skin atrophy

Site of Psoriasis

First-Line Steroid Potency

Maximum Duration / Recommended Use Schedule

Key Restriction

Trunk, Limbs

Potent TCS

(often used initially in combination with a topical Vitamin D preparation)

Not more than eight weeks at any one site

Treatment may be restarted after a four-week ‘treatment break’

Very potent preparations should not normally be used in primary care

Scalp Psoriasis

Potent TCS

Facial, Flexural, and Genital Psoriasis

Mild/Moderately potent TCS

Initial course: Not more than two weeks

Maintenance courses should be used for 1-2 weeks each month, with a four-week ‘treatment break’ between courses

Do NOT prescribe potent/very potent TCS to these areas due to the greater risk of adverse effects like skin atrophy

References

Original Guideline

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