Referral

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Psoriasis

  • Affects around 3% of the population
  • It is uncommon in certain populations such as oriental people, native American Indians and West Africans
  • Both sexes are equally affected
  • Mild to moderate psoriasis can usually be managed in primary care
  • Psoriasis may worsen (sometimes months after) the introduction of some drugs e.g. B blockers, NSAIDs, ACE inhibitors
  • Remember it is an independent risk factor for cardiovascular disease / cancer/anxiety and depression
  • Adherence to treatment is low and only just over 50% even in clinical trials – try to consider cosmetic acceptability, side effect profiles, formulation and practicalities of application

Referral Criteria:

Suggested referral of psoriasis to secondary care:

  • If diagnosis uncertain
  • If too widespread to make treatment by patient at home practical
  • Failure of topical treatments including calcipotriol / betamethasone diporopionate foam if appropriate (not appropriate for face/flexures)
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History and Examination

Skin

  • Psoriasis may develop at any age although it most frequently presents in young adults as well as in the sixth and seventh decades
  • It is generally asymptomatic although some patients experience itch

Psoriatic arthropathy

  • Recent studies suggest that the prevalence of psoriatic arthritis in patients with psoriasis may be up to 30%
  • There is a strong link with nail disease
  • All patients with psoriasis should be assessed for psoriatic arthropathy as early intervention can reduce joint damage, refer to related chapter on Psoriatic arthritis for more information

Clinical findings

  • Distribution of plaques
  • Symmetrical
  • Extensor surfaces or can be widespread

Morphology

  • Most cases of chronic plaque psoriasis are described as large plaque psoriasis or small plaque psoriasis
  • Plaques are ruby-red, and well-defined with a silvery surface scale. The plaques can join together to involve very extensive areas of the skin particularly on the trunk and limbs
  • Auspitz sign - when adherent psoriatic scales are scraped or picked off pinpoint bleeding, known as the Auspitz sign, may occur from capillaries which undulate vertically throughout the thickened psoriatic skin
  • Lesions on lower legs may be less typical

Referral Criteria:

Suggested referral of psoriasis to secondary care:

  • If diagnosis uncertain
  • If too widespread to make treatment by patient at home practical
  • Failure of topical treatments including calcipotriol / betamethasone diporopionate foam if appropriate (not appropriate for face/flexures)

Treatments available in hospital:

  • UVB Phototherapy
  • Photochemotherapy (PUVA)
  • Retinoids e.g. Acitretin
  • Methotrexate and other cytotoxic drugs
  • Ciclosporin and mycophenolate
  • Biologic therapy

Evidence

North and East Devon formulary - Skin

Primary Care Dermatology Society website

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: 30 January 2017

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