Plaque psoriasis

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.

References

1.IADVL Recommendations for Management of Psoriasis (2022); AAD-NPF Guidelines on Psoriasis Treatment; EuroGuiDerm Psoriasis Guideline (2022)