Psoriasis

Prescribing Notes:

• Emollients may also be used, see emollient pathway within the Eczema condition page.
• Emollients are useful in softening scaling and reducing irritation in inflammatory / plaque psoriasis.
• Treatment choice depends on site, extent of psoriasis and patient preference and tolerance. It may be appropriate to treat psoriasis in specific sites, such as the face and flexures, usually with a mild corticosteroid, and psoriasis of the scalp, palms, and soles with a potent corticosteroid.
• “Lotion” should be specified when prescribing Exorex since the cream is “pay and report”.
• Phototherapy, methotrexate, ciclosporin, acitretin should be initiated on specialist advice only, with responsibility for monitoring agreed.
• Coconut oil is an effective emollient for use in scalp dermatitis, psoriasis and keratosis and can be purchased over the counter.
• Mild scalp psoriasis should be treated with a tar based shampoo.
• For moderate scalp psoriasis or for itchy scalps a steroid scalp application can be used short-term. Normally applied in the morning.
• Mousse/foam formulations of steroids can be used in patients with sensitive skin or where there is local scalp irritation.
• Scalp psoriasis is usually scaly, and the scale may be thick and adherent. This requires softening with an ointment, cream, or oil and usually combined with salicylic acid as a keratolytic.
• Salicyclic acid preparations may be useful where there is a marked scaling of the skin or scalp.
• Sebco should be left on for at least an hour, often more conveniently overnight, before washing it off.

Unlicensed / Special Manufacture Preparations

• The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations (‘Specials’) is available at the BAD website.
• Use a licensed product wherever available. Consider cost versus benefit of a licensed preparation versus an unlicensed preparation (often in excess of £100). If an unlicensed topical preparation is required, consider only those listed on the BAD list.
• If prescribing specials, prescribe appropriate quantities, as expiry dates are likely to be short for these unlicensed specials products. Do not put the special onto a repeat prescription and ensure that the condition is reviewed regularly.
• If a ‘Specials’ product is required Dermatologists in the East Region have agreed to use only BAD approved ‘Specials’ whenever possible.

Prescribing Notes:

• Rarely, severe adverse effects can occur on stopping treatment with topical corticosteroids, often after long-term continuous or inappropriate use of moderate to high potency products. To reduce the risks of these events, prescribe the topical corticosteroid of lowest potency needed and ensure patients know how to use it safely and effectively. See MHRA warning - Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.
• Treatment choice depends on site, extent of psoriasis and patient preference and tolerance.
• Topical use of potent corticosteroids on widespread psoriasis can lead to systemic as well as to local side-effects. It is reasonable, however, to prescribe a mild to moderate topical corticosteroid for a short period (2–4 weeks) for flexural and facial psoriasis and to use a more potent corticosteroid such as betamethasone for psoriasis of the scalp, palms, or soles.
• Emollients are useful adjuncts to other more specific treatments for psoriasis.
• Emollients are useful in softening scaling and reducing irritation in inflammatory / plaque psoriasis.
• It may be appropriate to treat psoriasis in specific sites, such as the face and flexures, usually with a mild corticosteroid, and psoriasis of the scalp, palms, and soles with a potent corticosteroid.
• Topical vitamin D analogues may be alternated with a moderately potent steroid.
• Topical use of potent corticosteroids on widespread psoriasis can lead to systemic as well as to local side-effects. It is reasonable, however, to prescribe a mild to moderate topical corticosteroid for a short period (2–4 weeks) for flexural and facial psoriasis and to use a more potent corticosteroid such as betamethasone for psoriasis of the scalp, palms, or soles.

Prescribing Notes:

• Rarely, severe adverse effects can occur on stopping treatment with topical corticosteroids, often after long-term continuous or inappropriate use of moderate to high potency products. To reduce the risks of these events, prescribe the topical corticosteroid of lowest potency needed and ensure patients know how to use it safely and effectively. See MHRA warning - Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.
• Calcitriol may be less irritant than calcipotriol and therefore better tolerated.
• Treatment choice depends on site, extent of psoriasis and patient preference and tolerance.
• Emollients are useful in softening scaling and reducing irritation in inflammatory / plaque psoriasis.
• Coconut oil is an effective emollient for use in scalp dermatitis, psoriasis and keratosis and can be purchased over the counter.
• Mild scalp psoriasis should be treated with a tar based shampoo.
• For moderate scalp psoriasis or for itchy scalps a steroid scalp application can be used short-term. Normally applied in the morning.
• Mousse/foam formulations of steroids can be used in patients with sensitive skin or where there is local scalp irritation.
• Scalp psoriasis is usually scaly, and the scale may be thick and adherent. This requires softening with an ointment, cream, or oil and usually combined with salicylic acid as a keratolytic.
• Salicyclic acid preparations may be useful where there is a marked scaling of the skin or scalp.
• It may be appropriate to treat psoriasis in specific sites, such as the face and flexures, usually with a mild corticosteroid, and psoriasis of the scalp, palms, and soles with a potent corticosteroid.
• To gain rapid improvement in plaque psoriasis, short term (4 weeks) and intermittent use of a potent topical corticosteroid or a potent topical corticosteroid plus a topical vitamin D analogue is recommended.
• For the long term topical treatment of plaque psoriasis, a vitamin D analogue is recommended.
• Potent to very potent topical corticosteroids are not recommended for regular use over prolonged periods because of concern over long term adverse effects.
• Very potent topical corticosteroids are used infrequently in psoriasis, they should be used with caution (or under specialist supervision) as they can make the disease more unstable.
• Topical vitamin D analogues may be alternated with a moderately potent steroid.
• Phototherapy, methotrexate, ciclosporin, acitretin should be initiated on specialist advice only, with responsibility for monitoring agreed.
• When different preparations containing calcipotriol are used e.g. cream and scalp solution, the total maximum weekly dose should not be exceeded e.g. 60g cream or ointment with 30ml of scalp solution or 60ml of scalp solution with 30g of cream or ointment.

Prescribing Notes:

General notes

• Systemic treatments for psoriasis are initiated by specialists and include phototherapy, methotrexate, ciclosporin or acitretin. Alternative systemic treatments for specialist initiation include apremilast and dimethyl fumarate or pSoralen and ultraviolet A light (PUVA). See recommendations for treatment of skin conditions with methoxyPsoralen and UltraViolet A light (PUVA).
• Biologic therapy should be offered to patients requiring systemic therapy if methotrexate and ciclosporin have failed, are not tolerated or are contraindicated and the psoriasis has a large impact on physical, psychological or social functioning, clinically relevant depressive or anxiety symptoms and one or more of the following disease severity criteria apply:
  • the psoriasis is extensive, defined as BSA > 10% or PASI ≥ 10
  • the psoriasis is severe at localized sites and associated with significant functional impairment and/or high levels of distress (for example nail disease or involvement of high-impact and difficult to treat sites such as the face, scalp, palms, soles, flexures and genitals).
• See the pathways for biologic treatment of psoriasis and alternative systemic therapies (apremilast and dimethyl fumarate) for more details.

Methotrexate

• Methotrexate can be used for severe psoriasis.
• To avoid prescribing, dispensing and administration errors only the 2.5mg strength of methotrexate should be prescribed and dispensed. The patient should be advised on the dose and frequency for taking methotrexate. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice see MHRA Drug Safety Update September 2020.
• The patient should be advised to report immediately any signs of methotrexate toxicity.
• Regular monitoring of full blood count, renal function and liver function should be undertaken in line with local protocols.

Ciclosporin

• Ciclosporin can be prescribed for severe psoriasis where conventional therapy is ineffective or inappropriate. Preparations should be prescribed by brand name only due to differences in bio-availability.
• The formulary choice for ciclosporin is Capimune (10mg capsules and liquid formulation must be prescribed as Neoral).
• Patients on ciclosporin should be regularly monitored for adverse effects including hypertension and renal impairment.

Acitretin

• Oral acitretin is a toxic and teratogenic drug which is only prescribable by, or under the supervision of, a consultant dermatologist and is dispensed by a hospital-based pharmacy. Prescribers include medical and non-medical prescribers with competence to prescribe acitretin as a systemic treatment for severe psoriasis. Prescription of systemic acitretin for women is only possible if adequate contraception is undertaken (Pregnancy prevention programme). Refer to MHRA/CHM advice: Oral retinoid medicines: revised and simplified pregnancy prevention educational materials for healthcare professionals and women (June 2019).

Prescribing Notes:

General notes

• Systemic treatments for psoriasis are initiated by specialists and include phototherapy, methotrexate, ciclosporin or acitretin. Alternative systemic treatments for specialist initiation include apremilast and dimethyl fumarate or pSoralen and ultraviolet A light (PUVA). See recommendations for treatment of skin conditions with methoxyPsoralen and UltraViolet A light (PUVA).
• Biologic therapy should be offered to patients requiring systemic therapy if methotrexate and ciclosporin have failed, are not tolerated or are contraindicated and the psoriasis has a large impact on physical, psychological or social functioning, clinically relevant depressive or anxiety symptoms and one or more of the following disease severity criteria apply:
  • the psoriasis is extensive, defined as BSA > 10% or PASI ≥ 10
  • the psoriasis is severe at localized sites and associated with significant functional impairment and/or high levels of distress (for example nail disease or involvement of high-impact and difficult to treat sites such as the face, scalp, palms, soles, flexures and genitals).
• See the pathways for biologic treatment of psoriasis and alternative systemic therapies (apremilast and dimethyl fumarate) for more details.
• Refer to British Association of Dermatologists guidelines for biologic therapy for psoriasis 2020: a rapid update. Br J Dermatol 2020; 183 (4) 6328-637.
• In NHS Fife refer to NHS Fife High cost drugs pathway for adults with psoriasis.
• All biological medicines, including biosimilars, should be prescribed by brand name.

Restrictions

• Adalimumab is recommended for the treatment of chronic plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contra-indications. Its use should be restricted to severe disease (PASI score > or equal to 10 and a DLQI score of >10). Adalimumab should be withdrawn if the response is not adequate after 16 weeks (PASI 75 response from baseline).
• Bimekizumab is recommended for treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Brobalumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Certolizumab is recommended for patients with moderate to severe psoriasis who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have contraindications to these treatments.
• Certolizumab is first line biologic in women of childbearing age who have not yet completed their family as it is safe to use in pregnancy and breastfeeding.
• Etanercept, within its licensed indications is recommended for the treatment of adults with plaque psoriasis only when the following criteria are met. The disease is severe as defined by a total Psoriasis Area Severity Index (PASI) of 10 or more and a Dermatology Life Quality Index (DLQI) of more than 10; the psoriasis has failed to respond to standard systemic therapies including ciclosporin, methotrexate and PUVA (psoralen and long-wave ultraviolet radiation); or the person is intolerant to, or has a contraindication to, these treatments.
• Guselkumab is recommended for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy. It is for patients who have failed to respond to conventional systemic therapies (including methotrexate, ciclosporin and phototherapy), are intolerant to, or have a contraindication to these treatments.
• Infliximab is recommended for the treatment of severe plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contraindications. Infliximab should be withdrawn if the response is not adequate after 10 weeks (PASI 75 response from baseline or a 50% reduction and a 5 point reduction in DLQI from baseline).
• Ixekizumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Risankizumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Secukinumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Tildrakizumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Ustekinumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments. Continued treatment should be restricted to patients who achieve a PASI 75 response within 16 weeks.

Prescribing Notes:

General notes

• Systemic treatments for psoriasis are initiated by specialists and include phototherapy, methotrexate, ciclosporin or acitretin. Alternative systemic treatments for specialist initiation include apremilast and dimethyl fumarate or pSoralen and ultraviolet A light (PUVA). See recommendations for treatment of skin conditions with methoxyPsoralen and UltraViolet A light (PUVA).
• Biologic therapy should be offered to patients requiring systemic therapy if methotrexate and ciclosporin have failed, are not tolerated or are contraindicated and the psoriasis has a large impact on physical, psychological or social functioning, clinically relevant depressive or anxiety symptoms and one or more of the following disease severity criteria apply:
  • the psoriasis is extensive, defined as BSA > 10% or PASI ≥ 10
  • the psoriasis is severe at localized sites and associated with significant functional impairment and/or high levels of distress (for example nail disease or involvement of high-impact and difficult to treat sites such as the face, scalp, palms, soles, flexures and genitals).
• See the pathways for biologic treatment of psoriasis and alternative systemic therapies (apremilast and dimethyl fumarate) for more details.
• Refer to British Association of Dermatologists guidelines for biologic therapy for psoriasis 2020: a rapid update. Br J Dermatol 2020; 183 (4) 6328-637.
• In NHS Fife refer to NHS Fife High cost drugs pathway for adults with psoriasis.
• All biological medicines, including biosimilars, should be prescribed by brand name.

Restrictions

• Adalimumab is recommended for the treatment of chronic plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contra-indications. Its use should be restricted to severe disease (PASI score > or equal to 10 and a DLQI score of >10). Adalimumab should be withdrawn if the response is not adequate after 16 weeks (PASI 75 response from baseline).
• Brobalumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Certolizumab is recommended for patients with moderate to severe psoriasis who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have contraindications to these treatments.
• Etanercept, within its licensed indications is recommended for the treatment of adults with plaque psoriasis only when the following criteria are met. The disease is severe as defined by a total Psoriasis Area Severity Index (PASI) of 10 or more and a Dermatology Life Quality Index (DLQI) of more than 10; the psoriasis has failed to respond to standard systemic therapies including ciclosporin, methotrexate and PUVA (psoralen and long-wave ultraviolet radiation); or the person is intolerant to, or has a contraindication to, these treatments.
• Guselkumab is recommended for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy. It is for patients who have failed to respond to conventional systemic therapies (including methotrexate, ciclosporin and phototherapy), are intolerant to, or have a contraindication to these treatments.
• Infliximab is recommended for the treatment of severe plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contraindications. Infliximab should be withdrawn if the response is not adequate after 10 weeks (PASI 75 response from baseline or a 50% reduction and a 5 point reduction in DLQI from baseline).
• Ixekizumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Risankizumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Secukinumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Ustekinumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments. Continued treatment should be restricted to patients who achieve a PASI 75 response within 16 weeks.

Prescribing Notes:

General notes

• Systemic treatments for psoriasis are initiated by specialists and include phototherapy, methotrexate, ciclosporin or acitretin. Alternative systemic treatments for specialist initiation include apremilast and dimethyl fumarate or pSoralen and ultraviolet A light (PUVA). See recommendations for treatment of skin conditions with methoxyPsoralen and UltraViolet A light (PUVA).
• Biologic therapy should be offered to patients requiring systemic therapy if methotrexate and ciclosporin have failed, are not tolerated or are contraindicated and the psoriasis has a large impact on physical, psychological or social functioning, clinically relevant depressive or anxiety symptoms and one or more of the following disease severity criteria apply:
  • the psoriasis is extensive, defined as BSA > 10% or PASI ≥ 10
  • the psoriasis is severe at localized sites and associated with significant functional impairment and/or high levels of distress (for example nail disease or involvement of high-impact and difficult to treat sites such as the face, scalp, palms, soles, flexures and genitals).
• See the pathways for biologic treatment of psoriasis and alternative systemic therapies (apremilast and dimethyl fumarate) for more details.
• Refer to British Association of Dermatologists guidelines for biologic therapy for psoriasis 2020: a rapid update. Br J Dermatol 2020; 183 (4) 6328-637.
• In NHS Fife refer to NHS Fife High cost drugs pathway for adults with psoriasis.
• All biological medicines, including biosimilars, should be prescribed by brand name.

Restrictions

• Adalimumab is recommended for the treatment of chronic plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contra-indications. Its use should be restricted to severe disease (PASI score > or equal to 10 and a DLQI score of >10). Adalimumab should be withdrawn if the response is not adequate after 16 weeks (PASI 75 response from baseline).
• Certolizumab is recommended for patients with moderate to severe psoriasis who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have contraindications to these treatments.
• Etanercept, within its licensed indications is recommended for the treatment of adults with plaque psoriasis only when the following criteria are met. The disease is severe as defined by a total Psoriasis Area Severity Index (PASI) of 10 or more and a Dermatology Life Quality Index (DLQI) of more than 10; the psoriasis has failed to respond to standard systemic therapies including ciclosporin, methotrexate and PUVA (psoralen and long-wave ultraviolet radiation); or the person is intolerant to, or has a contraindication to, these treatments.
• Guselkumab is recommended for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy. It is for patients who have failed to respond to conventional systemic therapies (including methotrexate, ciclosporin and phototherapy), are intolerant to, or have a contraindication to these treatments.
• Infliximab is recommended for the treatment of severe plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contraindications. Infliximab should be withdrawn if the response is not adequate after 10 weeks (PASI 75 response from baseline or a 50% reduction and a 5 point reduction in DLQI from baseline).
• Risankizumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.
• Ustekinumab is recommended for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments. Continued treatment should be restricted to patients who achieve a PASI 75 response within 16 weeks.

Prescribing Notes:

General notes

• Refer to British Association of Dermatologists guidelines for biologic therapy for psoriasis 2020: a rapid update. Br J Dermatol 2020; 183 (4) 6328-637.
• In NHS Fife refer to NHS Fife High cost drugs pathway for adults with psoriasis.
• Certolizumab is recommended for patients with moderate to severe psoriasis who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have contraindications to these treatments.
• Certolizumab is first line biologic in women of childbearing age who have not yet completed their family as it is safe to use in pregnancy and breastfeeding.

Restrictions

• Certolizumab is recommended for patients with moderate to severe psoriasis who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have contraindications to these treatments.

Prescribing Notes:

• In NHS Fife refer to NHS Fife High cost drugs pathway for adults with psoriasis.
• Treatment selection is based on patient specific factors, side-effect profile, acquisition cost and shared decision making between the patient and the specialist.

Apremilast

• Apremilast is approved for use for the treatment of moderate to severe chronic plaque psoriasis in adult patients who have failed to respond to or who have a contraindication to, or are intolerant to other systemic therapy including ciclosporin, methotrexate or pSoralen and ultraviolet A light (PUVA).
• Where more than one treatment is suitable for an individual (including options from the biologic therapies) select the most cost-effective choice taking into account administration costs and medicine acquisition costs.
• Apremilast may be considered as a suitable treatment option prior to biologic therapy in those patients whom adherence to blood monitoring is considered to be a concern, those patients who would prefer a tablet over injection and as a treatment when other drugs are contraindicated.
• Apremilast can be considered as an alternative for patients with either psoriasis alone or psoriasis in combination with psoriatic arthtitis.
• Refer to MHRA Drug Safety Update February 2017: Apremilast (Otezla): Risk of suicidal thoughts and behaviour.

Deucravacitinib 

• Deucravacitinib (Sotyktu) is accepted for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy. It is restricted for use in patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments. 
• It is not known whether Deucravacitinib, an inhibitor of tyrosine kinase 2 (TYK2), is associated with the adverse reactions of Janus kinase (JAK) inhibition. Risks that have been identified as a class effect of JAK inhibitors include major cardiovascular events, malignancy, venous thromboembolism, serious infections and increased mortality. See MHRA Drug Safety Update April 2023: Janus kinase (JAK) inhibitors: new measures to reduce risks of major cardiovascular events, malignancy, venous thromboembolism, serious infections and increased mortality. 

Dimethyl fumarate

• Dimethyl Fumarate (Skilarence) is accepted for the treatment of moderate to severe plaque psoriasis in adults in need of systemic medicinal therapy. It is restricted for use in patients in whom other non-biologic systemic treatments (methotrexate, ciclosporin and acitretin) are not appropriate or have failed and who are considered unsuitable for biologic therapy given their current disease state or personal preference.
• See MHRA Drug Safety Update January 2021: Dimethyl fumarate (Tecfidera): updated advice on the risk of progressive multifocal leukoencephalopathy (PML) associated with mild lymphopenia.

Prescribing Notes:

• Emollients may also be used, see emollient pathway within the Eczema condition page.
• Emollients are useful in softening scaling and reducing irritation in inflammatory / plaque psoriasis.
• Treatment choice depends on site, extent of psoriasis and patient preference and tolerance. It may be appropriate to treat psoriasis in specific sites, such as the face and flexures, usually with a mild corticosteroid, and psoriasis of the scalp, palms, and soles with a potent corticosteroid.
• “Lotion” should be specified when prescribing Exorex since the cream is “pay and report”.
• Phototherapy, methotrexate, ciclosporin, acitretin should be initiated on specialist advice only, with responsibility for monitoring agreed.
• Coconut oil is an effective emollient for use in scalp dermatitis, psoriasis and keratosis and can be purchased over the counter.
• Mild scalp psoriasis should be treated with a tar based shampoo.
• For moderate scalp psoriasis or for itchy scalps a steroid scalp application can be used short-term. Normally applied in the morning.
• Mousse/foam formulations of steroids can be used in patients with sensitive skin or where there is local scalp irritation.
• Scalp psoriasis is usually scaly, and the scale may be thick and adherent. This requires softening with an ointment, cream, or oil and usually combined with salicylic acid as a keratolytic.
• Salicyclic acid preparations may be useful where there is a marked scaling of the skin or scalp.
• Sebco should be left on for at least an hour, often more conveniently overnight, before washing it off.
• Guttate psoriasis requires emollients and perhaps a mild tar preparation such as Exorex lotion.

Unlicensed / Special Manufacture Preparations

• The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations (‘Specials’) is available at the BAD website.
• Use a licensed product wherever available. Consider cost versus benefit of a licensed preparation versus an unlicensed preparation (often in excess of £100). If an unlicensed topical preparation is required, consider only those listed on the BAD list.
• If prescribing specials, prescribe appropriate quantities, as expiry dates are likely to be short for these unlicensed specials products. Do not put the special onto a repeat prescription and ensure that the condition is reviewed regularly.
• If a ‘Specials’ product is required Dermatologists in the East Region have agreed to use only BAD approved ‘Specials’ whenever possible.

Prescribing Notes:

• Rarely, severe adverse effects can occur on stopping treatment with topical corticosteroids, often after long-term continuous or inappropriate use of moderate to high potency products. To reduce the risks of these events, prescribe the topical corticosteroid of lowest potency needed and ensure patients know how to use it safely and effectively. See MHRA warning - Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.
• Treatment choice depends on site, extent of psoriasis and patient preference and tolerance.
• Topical use of potent corticosteroids on widespread psoriasis can lead to systemic as well as to local side-effects. It is reasonable, however, to prescribe a mild to moderate topical corticosteroid for a short period (2-4 weeks) for flexural and facial psoriasis and to use a more potent corticosteroid such as betamethasone for psoriasis of the scalp, palms, or soles.
• Emollients are useful adjuncts to other more specific treatments for psoriasis.
• Emollients are useful in softening scaling and reducing irritation in inflammatory / plaque psoriasis.
• It may be appropriate to treat psoriasis in specific sites, such as the face and flexures, usually with a mild corticosteroid, and psoriasis of the scalp, palms, and soles with a potent corticosteroid.
• Topical vitamin D analogues may be alternated with a moderately potent steroid.
• Topical use of potent corticosteroids on widespread psoriasis can lead to systemic as well as to local side-effects. It is reasonable, however, to prescribe a mild to moderate topical corticosteroid for a short period (2-4 weeks) for flexural and facial psoriasis and to use a more potent corticosteroid such as betamethasone for psoriasis of the scalp, palms, or soles.

Prescribing Notes:

• Rarely, severe adverse effects can occur on stopping treatment with topical corticosteroids, often after long-term continuous or inappropriate use of moderate to high potency products. To reduce the risks of these events, prescribe the topical corticosteroid of lowest potency needed and ensure patients know how to use it safely and effectively. See MHRA warning - Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.
• Calcitriol may be less irritant than calcipotriol and therefore better tolerated.
• Treatment choice depends on site, extent of psoriasis and patient preference and tolerance.
• Emollients are useful in softening scaling and reducing irritation in inflammatory / plaque psoriasis.
• Coconut oil is an effective emollient for use in scalp dermatitis, psoriasis and keratosis and can be purchased over the counter.
• Mild scalp psoriasis should be treated with a tar-based shampoo.
• For moderate scalp psoriasis or for itchy scalps a steroid scalp application can be used short-term. Normally applied in the morning.
• Mousse/foam formulations of steroids can be used in patients with sensitive skin or where there is local scalp irritation.
• Scalp psoriasis is usually scaly, and the scale may be thick and adherent. This requires softening with an ointment, cream, or oil and usually combined with salicylic acid as a keratolytic.
• Salicyclic acid preparations may be useful where there is a marked scaling of the skin or scalp.
• It may be appropriate to treat psoriasis in specific sites, such as the face and flexures, usually with a mild corticosteroid, and psoriasis of the scalp, palms, and soles with a potent corticosteroid.
• To gain rapid improvement in plaque psoriasis, short term (4 weeks) and intermittent use of a potent topical corticosteroid or a potent topical corticosteroid plus a topical vitamin D analogue is recommended.
• For the long-term topical treatment of plaque psoriasis, a vitamin D analogue is recommended.
• Potent to very potent topical corticosteroids are not recommended for regular use over prolonged periods because of concern over long term adverse effects.
• Very potent topical corticosteroids are used infrequently in psoriasis, they should be used with caution (or under specialist supervision) as they can make the disease more unstable.
• Topical vitamin D analogues may be alternated with a moderately potent steroid.
• Phototherapy, methotrexate, ciclosporin, acitretin should be initiated on specialist advice only, with responsibility for monitoring agreed.
• When different preparations containing calcipotriol are used e.g. cream and scalp solution, the total maximum weekly dose should not be exceeded.

Prescribing Notes:

General notes

• Systemic treatments for psoriasis are initiated by specialists and include phototherapy, methotrexate, ciclosporin or acitretin. Alternative systemic treatments for specialist initiation include apremilast and dimethyl fumarate or pSoralen and ultraviolet A light (PUVA). See recommendations for treatment of skin conditions with methoxyPsoralen and UltraViolet A light (PUVA).
• Biologic therapy should be offered to patients requiring systemic therapy if methotrexate and ciclosporin have failed, are not tolerated or are contraindicated and the psoriasis has a large impact on physical, psychological or social functioning, clinically relevant depressive or anxiety symptoms and one or more of the following disease severity criteria apply:
  
  • the psoriasis is extensive, defined as BSA > 10% or PASI ≥ 10
  • the psoriasis is severe at localized sites and associated with significant functional impairment and/or high levels of distress (for example nail disease or involvement of high-impact and difficult to treat sites such as the face, scalp, palms, soles, flexures and genitals).
• See the pathways for biologic treatment of psoriasis and alternative systemic therapies (apremilast and dimethyl fumarate) for more details.

Methotrexate

• Methotrexate can be used for severe psoriasis.
• To avoid prescribing, dispensing and administration errors with tablets only the 2.5mg strength of methotrexate tablets should be prescribed and dispensed. The patient should be advised on the dose and frequency for taking methotrexate. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice see MHRA Drug Safety Update September 2020.
• The patient should be advised to report immediately any signs of methotrexate toxicity.
• Regular monitoring of full blood count, renal function and liver function should be undertaken in line with local protocols.

Ciclosporin

• Ciclosporin can be prescribed for severe psoriasis where conventional therapy is ineffective or inappropriate. Preparations should be prescribed by brand name only due to differences in bio-availability.
• The formulary choice for ciclosporin is Capimune (10mg capsules and liquid formulation must be prescribed as Neoral).
• Patients on ciclosporin should be regularly monitored for adverse effects including hypertension and renal impairment.

Acitretin

• Oral acitretin is a toxic and teratogenic drug which is only prescribable by, or under the supervision of, a consultant dermatologist and is dispensed by a hospital-based pharmacy. Prescribers include medical and non-medical prescribers with competence to prescribe acitretin as a systemic treatment for severe psoriasis. Prescription of systemic acitretin for women is only possible if adequate contraception is undertaken (Pregnancy prevention programme). Refer to MHRA/CHM advice: Oral retinoid medicines: revised and simplified pregnancy prevention educational materials for healthcare professionals and women (June 2019).

Prescribing Notes:

General notes

• Systemic treatments for psoriasis are initiated by specialists and include phototherapy, methotrexate, ciclosporin or acitretin. Alternative systemic treatments for specialist initiation include apremilast and dimethyl fumarate or pSoralen and ultraviolet A light (PUVA). See recommendations for treatment of skin conditions with methoxyPsoralen and UltraViolet A light (PUVA).
• Biologic therapy should be offered to patients requiring systemic therapy if methotrexate and ciclosporin have failed, are not tolerated or are contraindicated and the psoriasis has a large impact on physical, psychological or social functioning, clinically relevant depressive or anxiety symptoms and one or more of the following disease severity criteria apply:
  
  • the psoriasis is extensive, defined as BSA > 10% or PASI ≥ 10
  • the psoriasis is severe at localized sites and associated with significant functional impairment and/or high levels of distress (for example nail disease or involvement of high-impact and difficult to treat sites such as the face, scalp, palms, soles, flexures and genitals).
• See the pathways for biologic treatment of psoriasis and alternative systemic therapies (apremilast and dimethyl fumarate) for more details.
• Refer to British Association of Dermatologists guidelines for biologic therapy for psoriasis 2020: a rapid update. Br J Dermatol 2020; 183 (4) 6328-637.
• In NHS Fife refer to NHS Fife High cost drugs pathway for adults with psoriasis.
• All biological medicines, including biosimilars, should be prescribed by brand name.

Restrictions

• Adalimumab is recommended for the treatment of severe chronic plaque psoriasis in children and adolescents from 4 years of age who have had an inadequate response to or are inappropriate candidates for topical therapy and phototherapies. Its use should be restricted to severe disease (PASI score > or equal to 10 and a DLQI score of >10). Adalimumab should be withdrawn if the response is not adequate after 16 weeks (PASI 75 response from baseline).
• Etanercept is recommended for the treatment of chronic severe plaque psoriasis in children and adolescents from the age of 6 years who are inadequately controlled by, or are intolerant to, other systemic therapies or phototherapies. The disease is severe as defined by a total Psoriasis Area Severity Index (PASI) of 10 or more and a Dermatology Life Quality Index (DLQI) of more than 10; the psoriasis has failed to respond to standard systemic therapies including ciclosporin, methotrexate and PUVA (psoralen and long-wave ultraviolet radiation); etanercept treatment should be discontinued in patients whose psoriasis has not responded adequately at 12 weeks.
• Ixekizumab is indicated for the treatment of moderate to severe plaque psoriasis in children from the age of 6 years and with a body weight of at least 25 kg and adolescents who are candidates for systemic therapy.
• Secukinumab is indicated for the treatment of moderate to severe plaque psoriasis in children and adolescents from the age of 6 years who are candidates for systemic therapy.
• Ustekinumab is recommended for the treatment of moderate to severe plaque psoriasis in adolescent patients from the age of 6 years and older, who are inadequately controlled by, or are intolerant to, other systemic therapies or phototherapies. Continued treatment should be restricted to patients who achieve a PASI 75 response within 16 weeks. Ustekinumab has previously been accepted for restricted use in adults for this indication. For the small number of adolescent patients weighing >100kg that require a dose of 90mg, a 90mg prefilled syringe is available at the same price as the 45mg prefilled syringe.