Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Unstable widespread psoriasis
Generalised pustules or near-total skin inflammation with fever, malaise, shivering, dehydration or circulatory compromise can represent generalised pustular psoriasis or erythroderma.
Action: Assess ABCDE and observations, stop non-essential possible triggers, and arrange immediate same-day specialist assessment; do not manage systemic upset as an ordinary plaque flare.
Synopsis
Distinguish three common psoriasis phenotypes, assess severity and whole-person impact, recognise instability, and choose site-appropriate first treatment and referral without relying on erythema alone.
Chronic plaque psoriasis produces persistent, well-demarcated scaly plaques, classically on extensor elbows and knees, scalp, sacrum and umbilicus; colour may be red, violaceous, brown or grey according to skin tone.
Guttate psoriasis is an acute shower of small scaly papules, often one to three weeks after streptococcal pharyngitis; inspect the throat but do not promise that antibiotics will clear the eruption.
Flexural psoriasis is smooth, sharply bordered and minimally scaly in axillae, groin, inframammary folds or natal cleft; exclude candidiasis, dermatophyte infection and contact irritation when atypical.
Morning stiffness, swollen joints, whole-digit swelling, heel pain or inflammatory back pain can precede or follow cutaneous disease. A negative PEST does not exclude axial arthritis or inflammatory back pain.
Investigation priorities
01
First assessment: morphology and full skin examinationFirst step
Establish plaque, guttate or flexural phenotype and detect scalp, nail, palmoplantar or genital involvement.
Management branches
First-lineLimited chronic plaques on trunk or limbs
Adult plaque psoriasis amenable to topical treatment and without unstable features.
Agree a formulation the person can use, demonstrate fingertip-unit quantities, and use emollient or soap substitute to soften scale while explaining fabric fire risk.
Use a potent topical corticosteroid once daily plus a vitamin-D analogue once daily, applied separately morning and evening, for up to four weeks as NICE initial trunk-and-limb treatment.
Key medicines
Potent topical corticosteroid plus vitamin-D analogueApply the potent corticosteroid thinly once daily and the vitamin-D analogue once daily at a different time, one in the morning and one in the evening, for up to 4 weeks.
Mild or moderate potency topical corticosteroid for sensitive sitesApply a thin layer once or twice daily to affected face, flexural or genital skin for no longer than 2 weeks, using the prescribed potency and quantity.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.