This guideline gives a step by step guide to what different treatments to try. It also gives a good guide to what we should be asking about in history taking to judge the impact and severity of the disease. The management is a bit difficult to explain in words, so I’ve done a flow-chart, which hopefully will make it a bit easier to follow. Remember that Portsmouth has its own guidance on management of psoriasis on the PIP.
Judging the Severity of Psoriasis:
You can do a ‘Physician’s Global Assessment’ and ask the patient to do a ‘Patient’s Global Assessment’. This involves grading the psoriasis as clear, nearly clear, mild, moderate, severe or very severe and allows changes to be monitored.
Judging the Impact of Psoriasis:
Remember that most patients find that psoriasis has a considerable impact on their lives, in terms of the appearance of it, the itching or scaling and also from associated nail and joint problems. Ask the patient what impact it has. The following tools can be used to assess impact:
Assessing for Psoriatic Arthritis:
Consider using the PEST tool. If the patient answers 3 or more, it is indicative of arthritis:
- Have you ever had a swollen joint?
- Has a doctor ever told you that you have arthritis?
- Do your finger or toenails have pits or holes?
- Have you had pain in your heal?
- Have you had a finger or toe that was completely swollen and painful for no apparent reason?
Remember that patients with psoriasis have an increased risk of the following:
- CVD - do CV risk score for all people with severe arthritis and repeat at least every 5 yrs or more.
- VTE – increased risk of VTE (with any degree of psoriasis)
When should you refer?
- Diagnostic uncertainty
- Severe (eg more than 10% body surface affected)
- Can’t be controlled by topical therapy
- Acute Guttate psoriasis
- Nail disease having major functional or cosmetic impact
- Major impact on individual
- Psoriatic Arthritis suspected – refer to rheumatology
- Erythroderma / Generalised pustular psoriasis – need same day referral
How should you manage psoriasis?
Plaque psoriasis on the trunk and limbs: