Psoriasis

First-line treatment is usually a topical combining a vitamin D analogue with a steroid. More extensive disease may need phototherapy or systemic treatment, which we refer for.

Book if

• Plaques are not responding to what you have been given
• Scalp psoriasis is persisting — often simply the wrong preparation
• Nails are affected
• You want to understand the condition properly rather than manage it blindly

Do not ignore joint symptoms

Joint pain, stiffness or swelling may indicate psoriatic arthritis, which affects a significant minority of people with psoriasis and causes permanent joint damage if untreated. It needs rheumatology, and early referral matters.

Urgent

Widespread pustular or erythrodermic psoriasis requires hospital care, not a remote consultation.

Worth knowing

Psoriasis is associated with raised cardiovascular risk. Cholesterol and HbA1c testing is often worth arranging alongside.

1. Match the treatment to the site

Scalp psoriasis needs a preparation that will actually get through hair. Facial and flexural psoriasis needs something gentler than a trunk plaque. Using the wrong vehicle is the commonest reason treatment fails.

2. First-line topical

Usually a combined vitamin D analogue and steroid.

3. Defined courses

Potent steroids are used for set periods, then reduced. Stopping abruptly can trigger a flare.

4. Escalate where needed

More extensive disease needs phototherapy or systemic treatment, which we refer for.

Four to eight weeks for a fair trial

• Weeks 1–4 — plaques flatten and scale reduces before the redness fades. Post-inflammatory discolouration persists for months after the plaque has gone, and it is not active disease
• Weeks 4–8 — the review, and a fair point at which to judge

Steroids are used in defined courses

Potent steroids for set periods, then reduced or switched — not continued indefinitely. Stopping a potent steroid abruptly after long use can trigger a rebound flare, and occasionally a serious one.

Vitamin D analogues can be continued longer term, which is one reason the combined preparations are so useful.

Matching the preparation to the site is what usually fixes "treatment failure"

• Scalp — needs a gel, foam or solution that reaches skin through hair. A thick ointment does not, and this is the commonest reason scalp psoriasis persists
• Face and flexures — gentler preparations only
• Nails — slow to respond and frequently need specialist input
• Thick plaques — ointments, and sometimes a salicylic acid preparation first to lift the scale so the active treatment can reach the skin

The two things that matter more than the plaques

Joints. Psoriatic arthritis affects a significant minority of people with psoriasis and causes permanent joint damage if untreated. Joint pain, morning stiffness lasting over 30 minutes, a swollen finger or toe, or heel pain all need rheumatology referral, and early referral genuinely changes outcomes.

Cardiovascular risk. Psoriasis is an inflammatory condition associated with raised cardiovascular risk. Cholesterol, HbA1c and blood pressure are worth checking rather than treating the skin in isolation.

Urgent

• Widespread pustular or erythrodermic psoriasis — hospital care, not a remote consultation
• Sudden widespread flare with fever or feeling unwell
• Any new joint swelling

Flares are part of it

Psoriasis is managed rather than cured, and it comes and goes. Common triggers include stress, infection — particularly streptococcal throat infection — skin injury, alcohol, smoking, and certain medicines including lithium, beta blockers and antimalarials.

Oral steroids are a recognised trigger for severe rebound, which is one reason they are avoided in psoriasis.

The basics that get skipped

• Emollients, generously. They reduce scale, itch and cracking, and make the active treatments work better
• Salicylic acid preparations to lift thick scale first — without which the treatment underneath never reaches the skin
• Coal tar preparations, old-fashioned, cheap, effective, and available over the counter
• Sunlight in moderation, which genuinely helps most people — though sunburn triggers flares

Prescription topicals

• Combined vitamin D analogue and steroid — first-line for most plaque psoriasis
• Vitamin D analogue alone for longer-term use, since it can be continued where potent steroids cannot
• Site-specific preparations — scalp foams and gels, gentler options for face and flexures

Where secondary care changes everything

If topicals are not controlling it, referral is worth pushing for — the options are far better than they were a decade ago.

• Phototherapy — hospital narrowband UVB, effective and NHS-funded. Not the same as a sunbed, which is not a treatment and raises skin cancer risk
• Systemic treatments — methotrexate, ciclosporin, acitretin, apremilast
• Biologics, which are transformative for moderate to severe psoriasis and available on the NHS to those who meet the criteria

NHS dermatology referral is free.

Things that make a real difference

• Stopping smoking, which is strongly associated with psoriasis severity, and reducing alcohol
• Weight loss where relevant, which measurably improves psoriasis and reduces the associated cardiovascular risk
• Treating a streptococcal throat infection, which triggers guttate psoriasis
• Reviewing medicines — lithium, beta blockers and antimalarials can all worsen it

What does not work

Expensive "psoriasis" creams and supplements, and sunbeds, which are not phototherapy. Also worth knowing: some herbal preparations sold for psoriasis have contained undeclared potent steroids.

What you pay us

• £40 for the consultation, with photograph review
• £40 for review at four to eight weeks
• Blood tests where indicated — cholesterol and HbA1c, given the cardiovascular association — quoted first

What you pay the pharmacy

Emollients, coal tar preparations and standard steroids are inexpensive. The combined vitamin D and steroid products cost more, and scalp preparations more again.

We earn nothing from what is prescribed. Ask for emollient in large tubs rather than small tubes — much cheaper per gram, and you are less likely to ration it.

The cheaper things worth trying

• Coal tar shampoos and creams, available over the counter, cheap, and genuinely effective for some people
• Emollients, which reduce how much active treatment is needed
• Sunlight in moderation, which costs nothing

Why the NHS route matters here

Psoriasis is a long-term condition, and the treatments that change severe disease — phototherapy and biologics — are hospital treatments funded by the NHS. No private prescribing service can substitute for that.

If your psoriasis is not controlled by topicals, the most valuable thing we can do is refer you, and NHS dermatology referral is free.

Where not to spend money

• Sunbeds. Not phototherapy, not supervised, and they raise skin cancer risk
• Expensive "natural" psoriasis creams — several sold in the UK have been found to contain undeclared potent steroids
• Supplements and elimination diets, which lack useful evidence

We sell nothing.

Why is my scalp psoriasis not improving?

Nearly always the wrong preparation rather than the wrong drug. A thick ointment cannot get through hair to reach the skin.

Scalp psoriasis needs a gel, foam or solution designed for it, and thick scale often needs lifting with a salicylic acid preparation first so the active treatment can reach the skin at all.

Is psoriasis just a skin condition?

No, and this is the most important thing on the page. It is a systemic inflammatory condition.

Psoriatic arthritis affects a significant minority and causes permanent joint damage if untreated — and psoriasis is associated with raised cardiovascular risk, so blood pressure, cholesterol and blood sugar matter as much as the plaques.

What joint symptoms should I report?

Any of these, and promptly: joint pain or swelling, morning stiffness lasting more than 30 minutes, a whole finger or toe swollen like a sausage, heel or lower back pain, or nail pitting alongside joint symptoms.

Early rheumatology referral genuinely changes outcomes. Do not wait for a routine appointment.

Is it contagious?

No, not in any way. It is an immune-mediated condition, not an infection, and it cannot be passed to anyone by any kind of contact.

Are steroid creams safe here?

Yes, used in defined courses — which is how they are prescribed for psoriasis.

The specific issue in psoriasis is rebound: stopping a potent steroid abruptly after prolonged use can trigger a flare, occasionally a severe one. That is why courses are defined and treatment is stepped down rather than stopped dead.

Will oral steroids help a bad flare?

No — they are avoided in psoriasis, because withdrawal can trigger a severe rebound, including pustular psoriasis.

If you are offered oral steroids for a psoriasis flare, it is worth questioning.

Does sunlight help? What about sunbeds?

Sunlight in moderation helps most people. Sunbeds are not treatment — unsupervised, the wrong wavelengths, and they raise skin cancer risk.

Hospital phototherapy is a different thing entirely: narrowband UVB, supervised, dosed, effective and NHS-funded. That is what to ask for.

What triggers a flare?

Stress, infection — particularly streptococcal throat infection — skin injury, alcohol, smoking, and certain medicines including lithium, beta blockers and antimalarials.

Smoking is strongly associated with severity, which makes stopping one of the more effective things available.

My skin has cleared but the marks remain. Is it still active?

Usually not. Post-inflammatory discolouration can persist for months after the plaque itself has resolved, particularly on darker skin.

Flat and non-scaly means treated. Raised and scaly means still active.

What if the creams do not work?

Then it needs dermatology, and the options there are excellent. Phototherapy, systemic treatments, and biologics which are transformative for moderate to severe disease and available on the NHS to those who meet the criteria.

Referral is free and worth pushing for. Nobody should spend years on a cream that is not controlling it.

Will it ever go away?

It is managed rather than cured, and it comes and goes. Some people have long clear periods.

Well-controlled psoriasis is entirely compatible with a normal life, and the treatments available now make that a realistic goal.