Red Flags
- Erythrodermic or generalised pustular psoriasis — admit; fluid balance, supportive care; rapid-onset systemic therapy (cyclosporine, infliximab, spesolimab); risk of sepsis and high-output cardiac failure[1]
- Severe psoriatic arthritis with new joint deformity — joint rheumatology; DMARD/biologic[1]
- Latent or active TB starting biologic — IGRA + chest X-ray; treat latent TB before starting; vigilance in TB-endemic settings[1]
- Pregnancy or planning pregnancy on methotrexate, acitretin, or some biologics — switch to safer agent (certolizumab, phototherapy) ≥3–6 months pre-conception[1]
First-line treatment
Interventions
- Education, emollients, lifestyle[1]Daily emollients reduce flare frequency; smoking cessation; alcohol moderation; weight reduction in obesity (improves response to therapy); manage cardiovascular risk
- Topical therapy for mild–moderate disease[1]Potent corticosteroid ± vitamin D analogue (calcipotriol) once or twice daily for 4 weeks; tapering with intermittent maintenance; coal tar shampoo or solution for scalp; salicylic acid for scale
- Phototherapy[1]Narrowband UVB 2–3×/week for 8–12 weeks; PUVA second-line; useful for widespread disease where systemic therapy avoided; pre-screen skin for cancer risk; cumulative dose tracking
- Stepwise systemic therapy for moderate–severe[1]First-line conventional systemic: methotrexate. Second: ciclosporin (rapid). Third: acitretin (especially pustular/erythrodermic). Biologic if conventional inadequate, contraindicated, or significant impact on quality of life
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Topical betamethasone (potent steroid)[1] | Topical glucocorticoid | Apply once or twice daily × up to 4 weeks then taper; switch to lower potency for face/intertriginous | — | First-line topical for mild-moderate plaque psoriasis; scalp solution and gel preparations; avoid prolonged use on thin skin (atrophy, telangiectasia) |
| Calcipotriol ± betamethasone (combination)[1] | Vitamin D analogue ± topical steroid | Once-daily ointment, gel, or foam combination | — | Steroid-sparing; effective in mild–moderate plaque; faster onset than monotherapy; check calcium with extensive use |
| Methotrexate[1] | Conventional systemic DMARD (anti-folate) | Start 7.5–15 mg PO/SC weekly with folic acid 5 mg weekly; titrate to 25 mg weekly | — | First-line systemic; LFT and FBC monitoring; alcohol restriction; teratogen — strict contraception; PJP prophylaxis if prolonged |
| Ciclosporin[1] | Calcineurin inhibitor | 2.5–5 mg/kg/day PO BD; max 16 weeks course | — | Rapid onset for severe flares; nephrotoxicity, hypertension limit duration; not suitable for chronic maintenance |
| Acitretin[1] | Oral retinoid | 25–50 mg PO daily | — | Useful in pustular and erythrodermic psoriasis; severely teratogenic — contraception 3 years after stopping in women; mucocutaneous, hepatic, lipid effects |
| Adalimumab or etanercept (anti-TNF)[1] | TNF-alpha inhibitor (biologic) | Adalimumab 80 mg SC then 40 mg every 2 weeks; etanercept 50 mg SC twice weekly × 12 weeks then weekly | — | Moderate–severe psoriasis with conventional therapy failure or contraindication; latent TB and HBV screen; biosimilars widely available |
| Secukinumab or ixekizumab (anti-IL-17)[1] | IL-17A inhibitor | Secukinumab 300 mg SC weekly × 5 doses then monthly; ixekizumab 160 mg SC then 80 mg every 2 weeks × 5 doses then every 4 weeks | — | Excellent skin response (PASI 90 at 16 weeks ≈70%); avoid in active IBD (exacerbation risk); candidiasis monitoring |
| Risankizumab or guselkumab (anti-IL-23)[1] | IL-23 inhibitor | Risankizumab 150 mg SC at 0, 4 then every 12 weeks; guselkumab 100 mg SC at 0, 4 then every 8 weeks | — | Selective IL-23 inhibition; durable response; favourable safety profile; less effective for psoriatic arthritis than anti-IL-17 |
Topical betamethasone (potent steroid)[1]
Topical glucocorticoid
- Adult
- Apply once or twice daily × up to 4 weeks then taper; switch to lower potency for face/intertriginous
- Paediatric
- —
First-line topical for mild-moderate plaque psoriasis; scalp solution and gel preparations; avoid prolonged use on thin skin (atrophy, telangiectasia)
Calcipotriol ± betamethasone (combination)[1]
Vitamin D analogue ± topical steroid
- Adult
- Once-daily ointment, gel, or foam combination
- Paediatric
- —
Steroid-sparing; effective in mild–moderate plaque; faster onset than monotherapy; check calcium with extensive use
Methotrexate[1]
Conventional systemic DMARD (anti-folate)
- Adult
- Start 7.5–15 mg PO/SC weekly with folic acid 5 mg weekly; titrate to 25 mg weekly
- Paediatric
- —
First-line systemic; LFT and FBC monitoring; alcohol restriction; teratogen — strict contraception; PJP prophylaxis if prolonged
Ciclosporin[1]
Calcineurin inhibitor
- Adult
- 2.5–5 mg/kg/day PO BD; max 16 weeks course
- Paediatric
- —
Rapid onset for severe flares; nephrotoxicity, hypertension limit duration; not suitable for chronic maintenance
Acitretin[1]
Oral retinoid
- Adult
- 25–50 mg PO daily
- Paediatric
- —
Useful in pustular and erythrodermic psoriasis; severely teratogenic — contraception 3 years after stopping in women; mucocutaneous, hepatic, lipid effects
Adalimumab or etanercept (anti-TNF)[1]
TNF-alpha inhibitor (biologic)
- Adult
- Adalimumab 80 mg SC then 40 mg every 2 weeks; etanercept 50 mg SC twice weekly × 12 weeks then weekly
- Paediatric
- —
Moderate–severe psoriasis with conventional therapy failure or contraindication; latent TB and HBV screen; biosimilars widely available
Secukinumab or ixekizumab (anti-IL-17)[1]
IL-17A inhibitor
- Adult
- Secukinumab 300 mg SC weekly × 5 doses then monthly; ixekizumab 160 mg SC then 80 mg every 2 weeks × 5 doses then every 4 weeks
- Paediatric
- —
Excellent skin response (PASI 90 at 16 weeks ≈70%); avoid in active IBD (exacerbation risk); candidiasis monitoring
Risankizumab or guselkumab (anti-IL-23)[1]
IL-23 inhibitor
- Adult
- Risankizumab 150 mg SC at 0, 4 then every 12 weeks; guselkumab 100 mg SC at 0, 4 then every 8 weeks
- Paediatric
- —
Selective IL-23 inhibition; durable response; favourable safety profile; less effective for psoriatic arthritis than anti-IL-17
Safety-net
- Apply topical treatment as prescribed and use plenty of emollient — adherence is the commonest reason for poor response[1]
- On biologic or methotrexate: any infection, persistent fever, or persistent cough — same-day medical review; pause therapy[1]
- Tell every healthcare worker about your psoriasis treatment — affects vaccination, infection management, and surgery planning[1]
Referral criteria
- Erythrodermic or generalised pustular psoriasisDermatology admission; consider rapid-onset systemic[1]
- Failure of two adequate topical regimens or moderate–severe psoriasis with quality-of-life impactDermatology for systemic therapy or phototherapy initiation[1]
- Suspected psoriatic arthritis (joint pain, dactylitis, enthesitis, nail changes)Joint rheumatology and dermatology[1]
- Pregnancy planning on systemic psoriasis therapyJoint dermatology and obstetric pre-conception clinic[1]
Clinical summary
Stepwise topical, phototherapy, conventional systemic, and biologic management of plaque psoriasis in adults.