Skip to main content
  1. Right Decisions
  2. Back
  3. Dermatology pathways
  4. Psoriasis
Announcements and latest updates

Right Decision Service newsletter: May 2024

Welcome to the Right Decision Service (RDS) newsletter for May 2024.

Issues with RDS and Umbraco access

A fix was deployed on Thursday 30th May to address the stability issues experienced with the Right Decision Service over recent weeks. These arose principally when multiple toolkits were built simultaneously or successively to the mobile app  We are hopeful that the stability issues are now resolved. If you encounter any problems with this newly deployed site, please email ann.wales3@nhs.scot and onivarova@tactuum.com immediately as well as raising an Urgent support ticket.

Thank you again for your patience while we have been resolving these issues.

New editor request form

A form to request creation of new editors, or updates to existing editor details, is available in the Standard Operating Procedures toolkit  .

Redesign and improvements to RDS

The timeline for this work has been slightly delayed because effort has been diverted to addressing the recent stability issues.  However, the redesign of search, browse, archiving and version control have now been through a second round of testing and Tactuum is beginning to work on amendments.  We now plan to go out to user acceptance testing in July 2024 and will let you know when we are ready to do this.

Deep linking direct to individual toolkits on the mobile app

We are awaiting clarification from Tactuum on the time and effort required for this development. We should hear this week and I will let you know as soon as information is available.

New feature requests

Once we have completed the current redesign and deep linking we will be able to take stock of outstanding new feature requests and update you on what can be achieved within available resource.

Training

Introductory webinars for new RDS editors will be held on the following dates:

  • Thursday 27 June 11 am – 12 pm
  • Wednesday 3rd July 3.15 pm – 4.15 pm

To book to attend one of these webinars, please contact Olivia.graham@nhs.scot , stating your name, job title, health board and preferred date for training.

The RDS Learning working group is also progressing work on “train the trainer” resources for RDS editors and toolkit leads. These resources include:

  • A module on clinical and care governance for RDS content
  • A step by step introduction to the toolkit development process.
  • Video learning bytes to introduce key editorial features and functions.

We aim to have initial content available on the RDS Learning area by end of June/early July.

Evaluation

Thanks to Fergus Donachie in NHS Dumfries and Galloway and Sheila Grecian in NHS Lothian, who have shared the results of user surveys for their referral management and diabetes & endocrinology toolkits. The results provide excellent insights into how RDS is improving practice and saving time for clinicians. And there are also helpful suggestions for improving the service.

This all provides valuable material to support the business case to Scottish Government for the next stages of RDS development. If you have carried out local evaluation we would be very pleased to hear from you.

New toolkits

The following RDS toolkits are now live:

The Right Decisions toolkit for SIGN 171: Management of diabetes in pregnancy.

SIGN 168: Assessment, diagnosis, care and support for people with dementia and their carers. This toolkit is live and just awaiting final editorial review to remove the “in development” status.

Living well with dementia - for everyone. We recommend that you use the mobile version of this toolkit, as the web version contains only informational resources. The mobile app provides access to the Dementia wellbeing diary, which enables people in early post-diagnostic stages and their carers to keep track of their wellbeing outcomes. Each wellbeing outcome is linked to resources and services supporting that outcome. The mobile toolkit also provides a digital version of the “Getting to know me” form, and a range of resources and tools for people living with dementia and their carers. Four HSCPs have localised this app to include directories of local support services, but this generic app is available for anyone in any location to use.

The following toolkits are due to go live imminently:

  • SARCS (Sexual Assault Response Coordination Service)
  • Child protection procedures (North Lanarkshire)
  • NHS Lothian neonatal guidelines

Toolkits in development

Some of the toolkits the RDS team is currently working on:

Waiting Well – national toolkit for healthcare professionals. This toolkit is being developed for the Scottish Government Waiting Well team in collaboration with NHS GGC knowledge services staff. It provides healthcare teams in NHS Boards and HSCPs with guidance and tools to develop and implement their action plans to support people on waiting lists with access to information, signposting to local community assets and services, and to professional support and services.

NHS Borders RefHelp – referral guidance for NHS Borders. Work is about to start on a similar toolkit for NHS Tayside.

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit

Thank you to everyone who has completed the retrospective Quality Assurance checklist. I am pleased to say that the latest report was well-received within Healthcare Improvement Scotland, with positive comments on the commitment shown by NHS Boards and other organisations to ensuring the quality and safety of their content on the RDS.

 

Implementation projects

A knowledge exchange session to share learning about implementation of patient and public-facing RDS apps is scheduled for 28th June 11 am – 12 pm.  This will include sharing key points from a recent literature review, and the results of early tests of change of implementing the ‘Being a partner in my care’ app, which aims to help citizens to become active partners in Realistic Medicine. 

If you would like to attend this session and have not yet received an invitation, please contact ann.wales3@nhs.scot .

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

Psoriasis

Warning

Psoriasis: A common, chronic, inflammatory skin disorder that is characterized by scaly plaques affecting scalp, elbows, knees and sacrum but in more severe forms can affect any part of the body. Incidence up to 2% of the UK population. Nail changes including pitting, onycholysis and sub-ungual hyperkeratosis may be seen in 50% and an inflammatory polyarthritis in up to 14%. Palmoplantar pustulosis (PPP) is characterized by crops of sterile pustules on the palms and soles that erupt repeatedly over months or years and is strongly associated with smoking. Guttate psoriasis consists of a widespread eruption of many small scaly plaques and often follows a streptococcal throat infection. Generalised pustular psoriasis with background erythema studded with small pustules is a rare but severe form of psoriasis that may be life threatening. Psoriasis is a systemic disorder associated with an increased risk of cardiovascular disease; always assess cardiovascular risk factors. 

Not all treatment options may be listed in this guidance. Please refer to local formulary for a complete list.

Treatment/ therapy

Mild: localised plaques with limited impact on quality of life usually managed with topical treatment 

Assess lifestyle factors that may precipitate or aggravate psoriasis i.e. smoking, alcohol, obesity, certain medications and infections. 

 

Emollients – prescribe to soften scale (use fingertip measurement) 

 

Vitamin D with Steroid combined: 

  • Ointment, Cream, Gel, Foam: Apply OD for 4 weeks, review and repeat as necessary 

Calcipotriol with Betamethasone preparations:  

Non-branded ointment  

Dovobet®, Dalonev®, Dalbecal® ointments Dovobet® gel  

Wynzora® cream 

Enstilar® foam  

Useful for plaques on body and limbs. Not suitable for face or flexures. 

 

Vitamin D preparations: 

 

  • Calcipotriol (non-branded) ointment and l scalp solution apply OD/BD 

Calcipotriol (Dovonex®)  ointment apply OD/BD 

Calcitriol (Silkis®)  ointment apply BD 

Tacalcitol (Curatoderm®) ointment or  lotion apply BD. 

NB: Calcitriol and Tacalcitol may be less irritating than Calcipotriol and may be more suitable for sensitive areas like face and genitals. 

 

Topical Corticoteroids: 

  • Mild: OD facial psoriasis 

Moderately potent: OD face and flexural areas 

Potent:  OD trunk/limbs, BD palms/soles 

 

Coal Tar Preparations: 

  • Cream-Psoriderm® apply OD/BD 
  • Lotion-Exorex® apply OD/BD 
  • Shampoos: - Neutrogena T-Gel®, , Psoriderm® 

Polytar®, Capasal® (with salicylic acid), use up to OD 

 

Coal Tar + Salicylic acid and Sulfur:  

  • For scalp psoriasis mainly  

Cocois® ointment 100G apply up to OD 

Sebco® ointment 100G apply up to OD

Moderate psoriasis: Localised site or more widespread psoriasis > 10% body area 

Scalp psoriasis:  

  • Prescribe a regimen of coconut, tar and salicylic ointment (Sebco/Cocois) applied OD for an hour or overnight and wash off with tar-based shampoo to soften and remove thick scale. Reduce frequency as improves. 
  • Apply potent or very potent topical corticosteroid scalp solution / gel / foam (e.g. betamethasone +/- salicylic acid, clobetasol) OD after shampooing or, Vitamin D preparation, gel / foam OD, or corticosteroid + vitamin D (e.g. Dovobet® gel). 

 

Facial/Flexural psoriasis: 

  • Steroids: mild/moderate potency topical corticosteroid OD 

Vitamin D preparations: Calcitriol / Tacalcitol OD/BD may be used as less irritant than Calcipotriol 

Calcineurin inhibitors (e.g Protopic®) may be helpful but should be initiated by specialist. 

 

Nail psoriasis:  

  • Treatment difficult, keep trimmed, potent topical corticosteroid or Calcipotriol with Betamethasone combination OD may help 

 

PalmoPlantar Pustulosis: 

  • Associated with smoking.  

Steroids, potent or very potent topical corticosteroids OD/BD 

Calcipotriol with Betamethasone combination ointment OD 

 

Guttate Psoriasis: 

  • Widespread small plaques, self-limiting, often triggered 7-10 days after streptococcal URTI.  

Will often resolve spontaneously in weeks to months, useful treatments include: 

Mildly potent topical corticosteroid OD 

Vitamin D preparations OD 

Coal tar preparations OD 

 

  • Refer to secondary care for consideration of phototherapy and/or first line systemic therapy with Methotrexate, Ciclosporin or Acitretin for moderate to severe psoriasis failing to respond to treatment. 

 

Treatment failures with phototherapy and first line systemic therapies may require novel systemic therapy with phosphodiesterase type-4 inhibitor (Apremilast) or biologic therapies. 

Severe psoriasis: Widespread inflamed psoriasis or severe localised recalcitrant psoriasis (e.g. palms and soles) or affecting high impact sites like face or groin. 

Refer same day to dermatology/ emergency care for erythrodermic or generalised pustular psoriasis 

 

Refer to rheumatology if any evidence of psoriatic arthropathy. 

Referral Management

Mild: localised plaques with limited impact on quality of life usually managed with topical treatment 

  • Manage in primary care.  

Moderate psoriasis: Localised site or more widespread psoriasis > 10% body area 

  • Refer routinely to secondary care service if failure of appropriate topical treatment after 4 weeks  

Severe psoriasis: Widespread inflamed psoriasis or severe localised recalcitrant psoriasis (e.g. palms and soles) or affecting high impact sites like face or groin.

  • Consider referring urgently if psoriasis is very widespread and inflamed 
  • Emergency referral is indicated for erythrodermic or generalised pustular psoriasis. 
  • Refer to rheumatology if any evidence of psoriatic arthropathy. 

Clinical resources

Validated tools used to evaluate psoriasis include: 

DLQI 

PASI 

Skin Diversity descriptors 

Physician’s Global assessment tool 

Cardiovascular assessment  

Psoriatic Arthritis screening tool- PEST 

NICE CKS- Psoriasis 

PCDS- Psoriasis 

DermNet NZ- Psoriasis 

Clinical tips

  • Patient preference for type of topical preparation should guide effective treatment 
  • Psoriasis is a systemic disorder associated with an increased risk of cardiovascular disease; always assess cardiovascular risk factors. 
  • Excess alcohol, smoking and obesity can make psoriasis more difficult to control. 
  • Screen for arthritis and refer to rheumatology as needed. 

ICD search category(s)

Inflammatory 

ICD11 code - EA90.0          EA90.1

Editorial Information

Last reviewed: 23/05/2023

Next review date: 23/05/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society.

Approved By: Scottish Dermatological Society