Psoriasis

Prescribing Notes:

• Emollients may also be used, see emollient pathway within the Eczema condition page.
• “Lotion” should be specified when prescribing Exorex since the cream is “pay and report”.
• Coconut oil is an effective emollient for use in scalp dermatitis, psoriasis and keratosis and can be purchased over the counter.
• Salicyclic acid preparations may be useful where there is a marked scaling of the skin or scalp.
• The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations (‘Specials’) is available at the BAD website.

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 Drug Safety Update (September 2021) – Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.

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 Drug Safety Update (September 2021) – Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.
• For moderate scalp psoriasis or for itchy scalps a steroid scalp application can be used short-term.

Prescribing Notes:

General notes

• 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).

Methotrexate

• To avoid prescribing, dispensing and administration errors only the 2.5mg strength of methotrexate tablets should be prescribed and dispensed. 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).
• 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 bioavailability.
• Patients on ciclosporin should be regularly monitored for adverse effects including hypertension and renal impairment.

Acitretin

• Oral acitretin is a toxic and teratogenic drug. Prescription of systemic acitretin for women is only possible if adequate contraception is undertaken (Pregnancy prevention programme). Refer to MHRA Drug Safety Update (June 2019).

Prescribing Notes:

• Refer to local board prescribing guidelines and the BAD Decision Aid on Biologic Therapy for Psoriasis.
• 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).

Prescribing Notes:

• Treatment selection is based on patient specific factors, side-effect profile, acquisition cost and shared decision making between the patient and the specialist.

Refer to:

• MHRA Drug Safety Update (February 2017) – Apremilast (Otezla): Risk of suicidal thoughts and behaviour.
• 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.
• 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.
• “Lotion” should be specified when prescribing Exorex since the cream is “pay and report”.
• Salicyclic acid preparations may be useful where there is a marked scaling of the skin or scalp.
• The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations (‘Specials’) is available at the BAD website.

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 Drug Safety Update (September 2021) – Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.

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 Drug Safety Update (September 2021) – Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.
• For moderate scalp psoriasis or for itchy scalps a steroid scalp application can be used short-term.

Prescribing Notes:

General notes

• 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).

Methotrexate

• To avoid prescribing, dispensing and administration errors only the 2.5mg strength of methotrexate tablets should be prescribed and dispensed. 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).
• 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 bioavailability.
• Patients on ciclosporin should be regularly monitored for adverse effects including hypertension and renal impairment.

Acitretin

• Oral acitretin is a toxic and teratogenic drug. Prescription of systemic acitretin for women is only possible if adequate contraception is undertaken (Pregnancy prevention programme). Refer to MHRA Drug Safety Update (June 2019).

Prescribing Notes:

General notes

• Refer to local board prescribing guidelines.
• 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).

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).
• 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.