Psoriasis – PLAB 2 High-Yield Clinical Guide
- Ann Augustin
- Aug 11
- 3 min read
Updated: 6 days ago
1. Overview
Chronic, relapsing–remitting immune-mediated inflammatory skin condition.
Non-infectious; affects ~2% of UK population.
Driven by genetic predisposition + environmental triggers.
Impacts skin, nails, joints, eyes and can be associated with systemic complications.
2. Typical Presentations
History
Skin lesions: Onset, progression, itch, scale, redness, bleeding after scratching (Auspitz sign).
Pattern: Chronic plaques, guttate (post-strep), pustular, inverse.
Triggers: Infection, trauma (Koebner phenomenon), stress, drugs (β-blockers, lithium, antimalarials, NSAIDs).
Systemic symptoms: Joint pain/swelling (psoriatic arthritis), fatigue, eye symptoms (uveitis).
Impact: Quality of life, embarrassment, work, social life.
Examination
Skin: Well-demarcated erythematous plaques with silvery-white scale, symmetrical distribution (extensor surfaces, scalp, lumbosacral, periumbilical).
Nails: Pitting, onycholysis, subungual hyperkeratosis.
Joints: Asymmetrical oligoarthritis most common.
Special signs:
Auspitz sign – pinpoint bleeding after scale removal.
Koebner phenomenon – lesions at trauma sites.
Woronoff ring – pale halo around healing plaques.
3. Progression
Variable course: Some have mild, intermittent disease; others have chronic, widespread, and treatment-resistant psoriasis.
Risk of progression:
Localised → generalised disease
Cutaneous → joint involvement
Flares triggered by stress, infection, medication changes (especially rapid corticosteroid withdrawal).
4. Complications
Local
Skin infection
Erythroderma (>90% BSA redness/scaling; dermatology emergency)
Generalised pustular psoriasis (systemic illness, urgent referral)
Systemic
Psoriatic arthritis (up to 30%)
Eye: anterior uveitis
Metabolic syndrome, obesity, NAFLD
Cardiovascular disease: ↑ risk MI, stroke, VTE
Psychological: depression, anxiety, low self-esteem
IBD association (esp. Crohn’s)
5. PLAB 2 – Management Approach
A. Core principles
Reassure: psoriasis is not infectious.
Aim: symptom control + flare prevention.
Involve patient in decision-making; check understanding.
B. NICE-Aligned Management Ladder (Adults)
Baseline for all:
Daily emollients – soften skin, reduce itch, help active treatments work better.
Manage triggers (medication review, infection treatment, stress management, smoking/alcohol reduction).
First-line (Trunk/Limbs – Mild/Moderate)
Morning – Potent steroid (e.g., betamethasone valerate 0.1%)Evening – Vitamin D analogue (e.g., calcipotriol)
Directions to patient:
Wash hands before and after applying.
Apply emollient first to all affected and dry areas; wait at least 30 minutes before applying active treatments.
Steroid cream/ointment (morning):
Apply a thin layer directly to plaques only, using fingertip units (one fingertip length covers ~2 adult hand areas).
Gently rub in until absorbed.
Avoid face, skin folds, and genitals unless told otherwise.
Vitamin D cream/ointment (evening):
Apply to same plaques, thin layer, rub in gently.
Do not apply at the same time as steroid — space by several hours.
Treatment length:
Potent steroid for up to 8 weeks/site, then take a 4-week steroid-free break.
Vitamin D analogue can be continued longer for maintenance.
Second-line
If not controlled after 8 weeks: Vitamin D analogue twice daily (no steroid) for 8 more weeks.
Third-line
Potent steroid twice daily for 4 weeks OR coal tar preparation once/twice daily.
Short-contact dithranol only if trained nurse/specialist support.
Scalp Psoriasis
First step: Potent steroid scalp lotion/gel once daily.Directions:
Part hair, apply directly to scalp lesions, massage in gently.
Leave on; wash hair as normal later in the day or next morning.
Use keratolytic oils (e.g., coconut oil, salicylic acid) overnight to soften scale before shampooing.
Face/Flexures/Genitals (Inverse psoriasis)
Mild/moderate steroid (e.g., hydrocortisone 1% or clobetasone butyrate 0.05%) once daily for 1–2 weeks only.
Consider calcineurin inhibitors (tacrolimus, pimecrolimus) for maintenance.
6. Follow-Up
Review at 4 weeks → assess % improvement, symptoms, and side effects.
Adjust treatment up or down per ladder.
Once clear/nearly clear → stop steroid, continue vitamin D analogue for maintenance.
7. Lifestyle & Self-Management Advice
Stop smoking, limit alcohol, maintain healthy weight, manage stress.
Avoid scratching; moisturise frequently.
Treat strep throat promptly to reduce guttate flares.
Avoid medicines that may worsen psoriasis unless essential (review with GP).
Keep up regular cardiovascular risk checks (every 5 years or earlier if severe).
8. Red Flags – Seek Urgent Help
Rapidly spreading redness or pustules, fever, or feeling unwell (erythroderma/generalised pustular psoriasis).
New joint pain, swelling, or eye redness/pain (possible psoriatic arthritis or uveitis).
9. Advice & Education for PLAB 2 Counselling Stations
Lifestyle: Stop smoking, limit alcohol, maintain healthy weight, manage stress.
Steroid safety:
Potent: ≤8 weeks/site, then 4-week break.
Very potent: ≤4 weeks/site, then 4-week break.
Avoid face/flexures/genitals unless directed.
Application: Apply thin layer to affected skin, rub in gently, wash hands after.
Maintenance: Vitamin D analogue for ongoing control between steroid courses.
Follow-up: Review at 4 weeks; earlier if worsening or systemic symptoms.
Seek urgent help if:
Skin becomes red all over, pustules spread, you feel feverish/unwell.
New joint pain, swelling, or eye redness/pain.
10. PLAB 2 Communication Tips
Use layman’s terms for skin findings (“red patches with dry, silvery skin” instead of “erythematous plaques with scale”).
Check patient’s emotional wellbeing; acknowledge impact on confidence and daily life.
Offer printed information (NHS psoriasis leaflets, Psoriasis Association contacts).
📚 References
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