Synopsis
Prescribe vitamin-D analogues and topical corticosteroids by psoriasis site and formulation, give usable quantities and stop points, prevent calcium and steroid toxicity, and review before repeating treatment.
- Topical treatment is first-line for most psoriasis, but the safest active ingredient, potency, formulation, frequency and duration are site-specific.
- For adult trunk or limb plaques, NICE initial treatment is a potent corticosteroid once daily plus vitamin-D analogue once daily, applied separately morning and evening, for up to four weeks.
- For scalp psoriasis, NICE starts a potent corticosteroid once daily for up to four weeks; check hair-parting, vehicle and scale before switching.
- For face, flexures or genitals, use mild or moderate potency corticosteroid once or twice daily for no more than two weeks; do not use potent or very potent products there.
- Do not use very potent corticosteroid continuously beyond four weeks or potent corticosteroid continuously beyond eight weeks at any site; repeated courses require deliberate review.
- Calcipotriol 50 micrograms/g ointment is licensed once or twice daily on adult trunk or limbs with a 100 g weekly maximum; avoid calcium disorders and severe renal or hepatic impairment.
- Fixed calcipotriol 50 micrograms/g plus betamethasone 0.5 mg/g ointment is licensed once daily for four weeks, maximum 15 g daily and no more than 30% body surface area.
- Teach fingertip units, wash hands after application, separate emollient and active products, and warn that emollient-contaminated fabrics burn more intensely even after drying.
Key red flags
Widespread pustulation, erythroderma, fever, shivering or haemodynamic disturbance requires urgent specialist treatment rather than a larger topical prescription.
Progressive weakness, vomiting, constipation, confusion, polyuria or thirst during excessive calcipotriol exposure may signal hypercalcaemia and needs urgent biochemical and medication review.
Facial rounding, growth suppression in a child, extensive atrophy or symptoms of adrenal insufficiency after high-potency or occluded steroid exposure requires prompt assessment.
Painful spreading warmth, purulence, clustered blisters or erosions suggests bacterial or herpetic infection; reassess before increasing topical immunosuppression.
Atrophy, easy bruising, telangiectasia, striae, acneiform eruption, perioral dermatitis and rebound suggest excessive exposure; widespread or occluded use can suppress the hypothalamic-pituitary-adrenal axis.
New weeping, honey crust, pustules, grouped painful vesicles or spreading tenderness should trigger infection assessment. Corticosteroid can alter appearance and worsen untreated infection.
Investigation priorities
Choose corticosteroid potency, vitamin-D formulation and quantity according to anatomy and plaque characteristics.
Management branches
Stable plaque psoriasis suitable for topical treatment away from face, flexures and genitals.
- Agree ointment, cream, gel or foam according to thickness, hair, daily routine and preference; demonstrate the exact plaques and quantity to treat.
- Apply a potent corticosteroid once daily plus vitamin-D analogue once daily at different times, morning and evening, for up to four weeks under NICE guidance.
- Review by four weeks for clearance, irritation, atrophy, amount used and adherence; if continuing a fixed combination after its licensed course, require medical review and supervision.
- Use the subsequent NICE sequence rather than continuous potent steroid, and refer when extent, impact or correct topical failure makes phototherapy or systemic treatment appropriate.