Synopsis
Select and sequence specialist psoriasis treatment beyond topicals, obtain informed consent, prevent phototherapy and medicine harm, and monitor response using skin, joint and life-impact outcomes.
- NICE offers narrowband UVB to plaque or guttate psoriasis not controlled with topical treatment alone; two or three sessions weekly are options, with faster response commonly achieved at three.
- Phototherapy is prescribed treatment, not advice to sunbathe: consent covers burns, photosensitivity, photoageing, cumulative skin-cancer risk, attendance and eye or genital protection where required.
- Do not use phototherapy routinely as maintenance; change strategy after poor tolerance, inadequate response, rapid relapse beyond half of baseline within three months, impractical access or especially high skin-cancer risk.
- NICE systemic eligibility requires failed topical control plus important physical, psychological or social impact and extensive, functionally severe local, or phototherapy-resistant or unsuitable disease.
- Methotrexate is NICE first-choice conventional systemic treatment for most eligible psoriasis; it is taken once weekly, never daily, with one named day and toxicity monitoring.
- Ciclosporin is NICE first-choice when rapid or short-term control is needed, for palmoplantar pustulosis, or around conception when conventional systemic treatment cannot be avoided.
- Acitretin is considered when methotrexate and ciclosporin are unsuitable or failed, and for pustular forms; the MHRA pregnancy-prevention programme continues for three years after stopping where pregnancy is possible.
- Targeted immunomodulatory treatments are consultant-initiated and supervised; screen infection, vaccination and reproductive risks and follow the current NICE technology appraisal for the selected agent.
Key red flags
Fever, diffuse pustules, extensive tender inflammation, haemodynamic change or reduced urine output requires acute specialist assessment before routine treatment selection.
Mouth ulcers, sore throat, unexplained bruising, bleeding, breathlessness or fever during methotrexate may indicate marrow, pulmonary or infectious toxicity and needs urgent review.
Rising blood pressure, reduced renal function, severe headache or interacting medicine exposure during ciclosporin requires prompt specialist assessment.
Pregnancy or possible conception during acitretin exposure, or within the mandated post-treatment prevention interval, requires immediate specialist teratology and pregnancy-prevention pathway advice.
A severe phototherapy burn, blistering, eye pain after PUVA or a suspicious changing lesion needs treatment interruption and urgent unit review.
Generalised pustulation, erythroderma, fever, malaise, fluid loss or physiological deterioration bypasses routine outpatient sequencing and needs same-day specialist treatment.
Oral ulceration, sore throat, fever, bruising, bleeding, new cough or breathlessness may signal serious marrow, infection or pulmonary toxicity; verify the dosing day and stop-seek-advice plan.
Investigation priorities
Confirm treatment eligibility and provide a comparator for response across skin, high-impact sites and quality of life.
Management branches
Plaque or guttate psoriasis not controlled by topical treatment alone and no urgent instability.
- Confirm diagnosis, extent, skin cancer and photosensitivity history, medicines, previous ultraviolet exposure, ability to attend and informed consent.
- Offer supervised narrowband UVB two or three times weekly; explain that three sessions weekly may achieve response faster while total course and doses remain unit-prescribed.
- At each visit report burns, new medicines and illness; use assigned shielding and do not add deliberate sun or home ultraviolet exposure.
- Do not continue routine maintenance. Choose another second- or third-line option after intolerance, inadequate response, rapid relapse, access failure or especially high skin-cancer risk.