Assessment that changes management
- Severity and impact: extent (BSA), site (face/flexures/genitals/scalp/palms/soles), symptoms (itch/pain), and functional/psychological impact.
- Look for psoriatic arthritis: joint pain/swelling, morning stiffness, dactylitis, enthesitis, new back pain; refer urgently if suspected inflammatory arthritis.
- Comorbidity snapshot: CVD risk factors, obesity, diabetes, NAFLD, depression/anxiety; many pathways bundle metabolic review.
Topical treatment (pragmatic sequencing)
- Foundations: emollients regularly; avoid irritants; address triggers (infection, stress, smoking, alcohol).
- Trunk/limbs: start with a potent topical corticosteroid ± vitamin D analogue (often as a combined product) for plaques; step down once controlled.
- Face/flexures/genitals: use lower potency steroids for short courses; consider calcineurin inhibitors per local formulary for sensitive sites.
- Scalp: consider steroid scalp application and adjunct keratolytic/shampoo approach to lift scale.
When to refer (dermatology/secondary care)
- Severe disease (extensive BSA, major QoL impairment) or failure of topical therapy.
- High-risk phenotypes: erythrodermic or pustular psoriasis (urgent same-day assessment), widespread unstable disease, or significant nail disease affecting function.
- Systemic/phototherapy candidates: those needing phototherapy, systemic agents or biologics — typically specialist-led with monitoring.
Frequently asked questions
How often should I screen for psoriatic arthritis?
Screen at diagnosis and periodically, especially if the patient reports new joint pain, stiffness, swelling, heel pain, or new back pain with inflammatory features.
When is psoriasis an urgent referral?
Erythroderma, pustular psoriasis, rapid deterioration with systemic symptoms, or suspected inflammatory arthritis should trigger urgent same-day / rapid referral pathways.
What is the “high-yield” primary care work?
Optimise topical adherence and technique, manage metabolic/cardiovascular risk, and identify psoriatic arthritis early.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.