Psoriasis

Last Updated: December 12, 2025

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This tool is designed to help primary care clinicians, assess, diagnose, and manage psoriasis in adults. It integrates best practice evidence with clinical experience, refers to relevant existing tools and services where appropriate, and distills clinical guidance on the use of both topical and systemic therapies within primary care practice.

While there is no cure and complete clearance may not always be possible, treatment can effectively manage symptoms. Regular follow-up is essential to monitor response to treatment and disease control. 

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Clinical presentation

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Psoriasis is a chronic, autoimmune, and inflammatory skin condition characterized by redness of the skin, and hard, itchy, silvery scale, and sometimes painful plaques.1 It is also associated with several co-morbid conditions and requires timely and thorough assessment to inform an individualized management plan.8,10 

Risk factors11

There are several risk factors that may contribute to the onset of psoriasis including: 

  • Genetic predisposition
  • Koebner phenomenon (physical trauma to the skin) 
  • Certain medications such as lithium, betablockers, NSAIDs, antimalarials, ACE inhibitors, etc. 

Presentation of psoriasis1,3,11

Psoriasis Sub-type
Clinical Features
Visual*

Psoriasis Vulgaris (Chronic Plaque Psoriasis) 

  • Most common presentation. 
  • Dry, well-defined, and irregularly shaped lesions. 
  • Red or pink in colour may present purple, violet or brown in skin of colour.
  • Can affect any part of the body, but most common in extensor surfaces (knees and elbows), scalp, trunk, and gluteal fold. 
  • Silvery scales (plaques) over erythematous swollen patches. 
  • May be painful or itchy. 
Psoriasis vulgaris on trunk

Guttate Psoriasis

  • Second most common presentation. 
  • May be associated with an upper respiratory tract infection (URTI) trigger.
  • Commonly diagnosed in young adults under age 30. 
  • Distinct, small, droplet-shaped spots. 
  • Red or pink in colour. 
  • Fine scales, but thinner than those associated with plaque psoriasis. 
  • May be painful or itchy. 
Guttate psoriasis on trunk in skin of colour

Inverse Psoriasis (Intertriginous Psoriasis or Flexural Psoriasis)

  • Includes genital psoriasis.
  • Mainly affects parts of the body that “flex” or fold (e.g. Armpits, groin, under the breasts, around the genitals, between the buttocks).
  • Can be difficult to detect due to location of presentation. 
  • Lacks typical scaliness of psoriasis.
  • May be painful and itchy. 
  • Shiny, red, and clearly outlined lesions. 
  • May cause painful fissures or cracks which may bleed. 
  • May present similarly to a non-resolving fungal infection. 
    • Inverse psoriasis presents with well demarcated borders versus ill-defined borders in fungal infections. 
Inverse psoriasis on armpit

Scalp Psoriasis

  • Common amongst individuals living with psoriasis.
  • May be associated with any type of psoriasis – most commonly with plaque psoriasis. 
  • Red, well-defined lesions that are covered by a thick scale. 
  • Silvery scale that that can be misdiagnosed as dandruff. Dandruff tends to be diffuse across the scalp and PsO often starts at the occiput.
  • Psoriasis appears inflamed, whereas dandruff does not.
  • May extend beyond the hairline, including presentation on the ear. 
  • Itchy. 
Scalp psoriasis

Nail Psoriasis

  • Common amongst those living with plaque psoriasis. 
  • Occurs as an isolated case in only 5% of individuals living with a type of psoriasis. 
  • May affect one nail, multiple nails, both fingernails and toenails, fingernails only or toenails only. 
  • Presentations include: 
    • Pitting: Small depressions in the nail plate, ‘pits’ 
    • Leukonychia: White lines or dots across the nail plate 
    • Nail plate crumbling: Disintegration of the nail 
    • Oil drop or salmon patch: Translucent yellow-red patches in the nail bed 
    • Onycholysis: Separation of the nail plate from the nail bed, starting at the tip of the finger 
    • Subungual hyperkeratosis: Accumulation of excessive skin cells, with a grey-white appearance, under the nail 
    • Splinter hemorrhages: Faint red lines in the nail bed from small blood vessels bleeding.
  • Those living with psoriatic nails are more predisposed to onychomycosis and may present with both.
Nail psoriasis

Pustular Psoriasis

  • Rare type of psoriasis. 
  • Small, pimple-like and pus-filled eruptions. 
  • Includes: 
    • Localized palmoplantar psoriasis – mainly affects palms of hands and soles of feet. 
    • Generalized pustular psoriasis (GPP) – mainly affects large areas all over the body. 
  • May alternate between periods of recurrence and remission. 
  • Episodes typically occur rapidly with the onset of eruptions occurring within a few hours of the initial presentation of red and tender skin. 
  • Pus-filled blisters will dry and form scales typically in a few days after episode onset. 
Pustular psoriasis on foot

Erythrodermic Psoriasis

  • Least common, but most severe type of psoriasis, covering >80% body surface area. 
  • Red, scaly, and peeling lesions. 
  • May itch and burn immensely. 
  • Skin will swell and sheds in multiple layers, often in large sheets. 
  • Other symptoms may include fever, chills, general malaise, racing heart rate, joint pain, and lymph node swelling. 
Erythrodermic psoriasis on trunk

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Psoriasis in skin of colour1,2

Psoriasis in skin of colour (SOC) presents differently and requires careful assessment to ensure timely and accurate diagnosis. Lesions may lack the typical redness that is seen in lighter skin tones and instead appear violaceous, grey or deep brown, and may be less noticeable. Inflammation may be underestimated, leading to under recognition and/or misdiagnosis.

Psoriasis in Fitzpatrick phototypes

Phototype I

Phototype II

Phototype III

Phototype IV

Phototype V

Phototype VI

In addition, patients with SOC often experience thicker plaques, heavier scaling, more severe scalp involvement, and more prominent pigmentary changes following inflammation (post-inflammatory hypopigmentation (loss of pigmentation) or hyperpigmentation (darkening of pigmentation)). 

Equity considerations in psoriasis care1,2 

Psoriasis exerts a greater QoL burden in SOC due to variations in clinical presentation that often lead to under-diagnosis and misdiagnosis, cultural stigma, and underrepresentation in educational materials. Targeted assessment is therefore essential. You should also address the presence of pigmentary alteration in management plans and patient counselling.

Fitzpatrick Classification
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Fitzpatrick phototype classification33

The Fitzpatrick skin phototype is a way to classify skin based on its reaction to sun exposure. The classification depends on the amount of melanin pigment in the skin, and each phototype is determined by constitutional colour, and the effect of UV exposure (tanning ability).

Fitzpatrick classification* 
Phototype  Typical features  Tanning ability 
I  Pale white skin  Always burns, does not tan 
II  Fair skin  Burns easily, tans poorly 
III  Darker white skin  Tans after initial burn 
IV  Light brown skin  Burn minimally, tans easily 
V  Brown skin  Rarely burns, tans darkly easily 
VI  Dark brown or black skin  Never burns, always tans darkly 

Table adapted from DermNet.

Assessment

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Assessment of psoriasis 

Assessment of psoriasis severity includes a combination of skin involvement/lesion characteristics, symptom severity, and impact on quality of life. 

Skin involvement6

Calculate the Body Surface Area (BSA) percentage.

Mild = <3% | Moderate = 3-10% | Severe = >10% 

Calculating BSA: 

Estimate the body percentage by using the patient’s palm as approximately 1% of the total BSA. 

Lesion characteristics6

Assess erythema (redness), induration (thickness), and scaling. Look for Ausptiz sign (tiny, pinpoint bleeding under scales) as an indicator the scaling may be psoriasis. Assessment of these characteristics should be done at each visit. 

Note any special site involvement (e.g. face, scalp, genitals, nails, or palms/soles) as this may increase the impact on quality of life and should be treated as functionally and psychosocially severe regardless of overall BSA.

Symptom severity6

To assess the severity of itching, ask the patient to rate itch intensity on a scale of 0-10 – 0 being no itch at all and 10 being extreme itch.

Persistent moderate-to-severe itch (VAS ≥5) indicates active disease even when visible lesions appear improved.

Address itch as a primary treatment target and quality of life indicator.

Quality of Life (QoL)6

Living with psoriasis can have a significant impact on an individual’s quality of life.

Talking tips: Assessing QoL
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  • Physical Symptoms: “Over the last week, how itchy, sore, painful or stinging has your skin been?” 
  • Emotional Wellbeing: “Over the last week, how embarrassed or self-conscious have you been because of your skin?” 
  • Social & Leisure Life: “Over the last week, how much has your skin affected any social or leisure activities?” 
  • Work & Education: “Over the last week, has your skin prevented you from working or studying?” 
  • Treatment Burden: “Over the last week, how much of a problem has the treatment for your skin been (e.g., taking up time or making your home messy)?” 

Questions from Dermatology Quality of Life Index (DLQI)

Validated clinical tools for psoriasis assessment

For a more in-depth assessment of skin involvement and severity, consider using the Psoriasis Assessment Severity Index (PASI).

Use the Physician Global Assessment (PGA) scale to rate lesion severity and document the PGA score and affected areas.

 

You can use the Visual Analog Scale (VAS) to measure itch intensity. 

Measuring using the Visual Analog Scale (VAS)

Ask the patient to mark a position on the line that best represents: 

  1. Their itch, on average, in the past 24 hours 
  2. Their worst itch in the past 24 hours 

 

VAS interpretation: 

  • 0 = no itch 
  • <3 = mild itch 
  • ≥3 <7 = moderate itch 
  • ≥7 <9 = severe itch 
  • ≥9 = very severe itch 

For a comprehensive QoL assessment, use the Dermatology Quality of Life Index (DLQI).

Assessing psoriasis in SOC:1,2 

  • Erythema (redness) may be subtle. Assess for violaceous, grey, or deep brown lesions. Palpate lesions to assess for scaling. 
  • Plaques may be thicker and more extensive. Examine the scalp closely, even when minimal redness is visible.  
  • Inspect for any pigmentary changes (hyperpigmentation or hypopigmentation) at every visit and document accordingly. 
  • Consider psoriasis as a possibility even when classical redness is absent and ensure timely referral to dermatology when uncertain. 

Differential diagnosis3,6 

It is common for psoriasis to be initially misdiagnosed as clinical presentations can look similar to several other skin conditions.  

Most common conditions include: 

Condition
Clinical presentation
Visual differentiation*

Atopic dermatitis (Eczema) 

  • Can occur from environmental and/or genetic factors. 
  • Flexural distribution. 
  • Intense itch. 
  • Patches of dermatitis may be red, weeping/crusted, and/or may have blisters. 
  • Eczema tends to have ill-defined borders in contrast to well-demarcated borders in PsO. 
Eczema on elbow

Tinea (Ringworm) 

  • Fungal infection. 
  • Typically presents as a solitary red patch with a raised, scaly edge.  
  • Lesion will spread out over time forming a ring-shape with central hypopigmentation and a scaly, red border. 
  • Border can be papular or pustular. 
  • Itch is common. 
Ringworm on arm

Seborrheic dermatitis 

  • Commonly affects areas with high sebum production (scalp, nasolabial folds, eyebrows, beards, ears, etc). 
  • Winter flares, minimal itch, and combination oily and dry mid-facial skin.
  • Ill-defined and localized scaly patches on the scalp. 
  • Salmon-pink, thin, scaly, and ill-defined plaques in skin folds. 
  • Petal or ring-shaped flaky patches along the hairline or chest. 
  • Rash in intertriginous areas. 
Seborrheic dermatitis extended beyond the hairline in skin of colour

Lichen planus 

  • Autoimmune disorder with several contributing factors. 
  • Clinical presentation can range; it may cause a small number or many lesions. 
  • Symptoms can range from no itch (uncommon) to extreme itch. 
  • Size of lesions ranges from miniscule to larger than a centimeter, and distribution of lesions may be scattered, clustered, linear, annular, or limited to sun-exposed areas. 
  • Most often presents on front of the wrists, lower back and ankles. 
  • New lesions often have a purple or violet hue – lesions on the palms or soles have a yellowish-brown hue. 

Lichen planus on trunk

Pityriasis rubra pilaris 

  • Rare group of skin conditions. 
  • Reddish-orange scaling patches with well-defined borders. 
  • May cover the entire body, or parts of the body, such as the elbows and knees or palms and soles. 
  • Typically areas of uninvolved skin – “islands of sparing.” 
  • Palms and soles are often involved and become thickened and yellowish. 
Pityriasis rubra pilaris on trunk in skin of colour

Superficial basal cell carcinoma (sBCC)

  • Most common type of cancerous skin lesion in younger adults. 
  • Most common presentation on upper trunk and shoulders. 
  • Slightly scaly, irregular plaques. 
  • Thin, translucent rolled border. 
  • Multiple microerosions. 
sBCC on trunk

Subacute cutaneous lupus erythematosus (SCLE) 

  • A subtype of cutaneous lupus erythematosus (CLE). 
  • Most common presentation includes scaly, raised plaques. 
  • May present with papules. 
  • Typically ring-like or circular in shape. 
  • May have an overlaying scale. 
  • Plaques may coalesce over a large area of the skin and form polycyclic patterns. 
  • Typically presents in sun-exposed areas of the neck, upper trunk, and outer limbs. 
SCLE on upper trunk (shoulders)

If clinical presentation is atypical or involves diagnostic uncertainty, consider punch biopsy for diagnosis or refer to dermatology. 

Associated conditions3,6,12 

Psoriasis is strongly associated with several inflammatory, metabolic, and psychosocial conditions and requires proactive and routine screening to effectively manage identified co-morbidities. 

Most common associated conditions include: 

  • Psoriatic Arthritis (PsA) 
  • Anxiety and Depression (for more information on screening and management, see CEP’s Anxiety and Depression tool) 
  • Cardiovascular Disease 
  • Metabolic Syndrome/Obesity (for more information on screening and pharmacotherapy, see CEP’s Pharmacotherapy for Obesity Management tool) 
  • Metabolic-Dysfunction Associated Steatotic Liver Disease (MASLD)  
  • Inflammatory Bowel Disease (IBD) 
    • Crohn’s Disease
  • Sleep disorders (for more information on screening and management, see CEP’s Chronic Insomnia tool) 
  • Malignancies (especially Lymphoma and Nonmelanoma Skin Cancer (NMSC)) 

Pharmacological management

Guiding principles for the pharmacological management of psoriasis:3,4,7-9 

  • Balance efficacy, safety, and affordability when selecting treatments.  
  • Understand the patient’s context and life circumstances, such as: 
    • Coverage options (e.g., access to extended health coverage). 
    • Review pregnancy intentions at treatment initiation and regularly thereafter and adjust therapy accordingly. Some systemic therapies cannot be prescribed for pregnant females or those wishing to conceive. Refer to the medications table for pregnancy-related considerations.
    • Account for how the patient’s history of cancer and comorbidities may impact treatment options.
  • Tailor treatment options to disease severity and patient preferences.
  • Cost considerations: 
  • Some medications may worsen psoriasis (e.g., chloroquine, lithium, beta-blockers, systemic corticosteroids, NSAIDs). Review medication history and consider alternatives where appropriate.11  
Talking tips: Addressing steroid phobia
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Addressing steroid phobia11

One of the concerns with steroid use is skin thinning.  In psoriasis, we actually want to take advantage of this as there is have significant skin build up.  In addition, the combination products (Enstilar, Dovobet, Duobrii) have medications in them that counteract some of the side effects of the steroids. 

Pharmacotherapy for psoriasis aims to achieve and sustain minimal disease activity by reducing inflammation, clearing lesions, and improving quality of life. Use your clinical judgement to move patients through a stepwise approach from topical to systemic and biologic therapies. 3,6 

Treatment selection depends on disease severity, impact, and comorbid conditions. 3,6 

Formulations and application area
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Vehicle options for nonmedicated moisturizers34

Vehicle  Advantages  Disadvantages  Recommended area of application 
Ointment 
  • Boosts skin hydration and raises skin temperature. 
  • Greasy texture. 
  • Difficult to rinse off. 
  • Spreads less easily. 
  • Areas prone to dryness (e.g., trunk; limbs). 
  • Palms and soles. 
  • Hairless or sparsely haired skin. 
Cream 
  • Moisturizing and emollient properties. 
  • Less greasy than ointments. 
  • Spreads easily. 
  • Less hydrating than ointments. 
  • Can be more costly. 
  • All body areas. 
  • Areas of skin that are dry and weeping, especially those with serious discharge. 
  • Flexural areas and genitals. 
Lotion 
  • Cooling effect. 
  • Spreads easily and quickly on hairy areas. 
  • Less hydrating than ointments and creams. 
  • Weeping dermatoses. 
  • Hairy areas. 
Solution 
  • Spreads easily. 
  • Difficult to apply. 
  • Does not provide the protective barrier of emollients. 
  • Alcohol-based formulas may result in itching, skin irritation, or dryness. 
  • Hairy (scalp included) and non-hairy areas. 
Hydrogel 
  • Cooling effect. 
  • Dries into a non-occlusive film.
  • Cosmetically pleasing. 
  • Spreads on and rinses off easily, including hairy areas. 
  • Not an occlusive or emollient vehicle – poor skin hydration. 
  • Sweat can remove the gel. 
  • Oily gels may be difficult to rinse from hairy areas. 
  • Hairy areas (e.g., scalp). 
  • Oily areas (e.g., face). 
Hydroalcoholic foam 
  • Fragrance- and preservative-free. 
  • Spreads easily. 
  • High skin absorption. 
  • Cosmetically pleasing. 
  • May sting or burn excoriated skin. 
  • No occlusive effect – poor skin hydration. 
  • Hairy areas (e.g., scalp). 
  • Oily areas (e.g., face). 
  • Non-hairy areas. 
  • Inflamed or sensitive areas. 
Supersaturated fatty foam 
  • Spreads easily. 
  • Usually preservative-free. 
  • High skin absorption and bioavailability. 
  • Occlusive effect – hydrating. 
  • Cosmetically pleasing. 
  • Can cause contact dermatitis or eye and mucosal irritation. 
  • All body areas except folds, genitals, and face. 

Table adapted from Ribera et al., 2025 

Initiating therapy or managing flares

Non-pharmacological management

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Non-pharmacological interventions are essential adjuncts to prescribed medical therapy, supporting symptom control, quality of life, and long-term disease management.3 Incorporate education and lifestyle counselling into psoriasis management plans, and guide patients in evidence-based use of nonmedicated moisturizers and lifestyle strategies to enhance outcomes and reduce flare frequency.3,6 When selecting therapy, consider patient preferences and clinical context, and involve the patient in shared decision-making to support adherence.6 

Nonmedicated moisturizers3,6,11,34

  • Available in several forms: ointment, cream, lotion, solution, and hydrogel. Refer to a list of recognized skincare products endorsed by the Canadian Dermatology Association.
  • Recommend frequent application and continued use during remission, emphasizing adherence and skin hydration. 
  • Advise patients to apply generously and consistently to support barrier repair, reduce itching, and enhance the penetration of active agents. 
  • Considerations: 
    • Safe to use during pregnancy and lactation 
    • Likely inconvenient for patients with a large BSA of involvement

Lifestyle and behavioural strategies3,6,11,35 

To control systemic inflammation, discuss and collaboratively select lifestyle or behavioural strategies that your patient feels motivated to adopt. Focus on strategies that align with their goals, preferences, and daily routines. Provide your patient with the appropriate resources listed below to support their adoption of lifestyle or behavioural strategies.11

  • Encourage weight management through anti-inflammatory diets (e.g., Mediterranean diet) and physical activity (muscle strengthening activities and ≥150 mins/week of moderate-to-vigorous intensity aerobic exercise)33 to improve psoriasis severity and enhance response to systemic therapy. 
  • Engage in smoking cessation counselling* and encourage alcohol moderation or cessation. Smoking and alcohol consumption worsen psoriasis symptoms. 
  • Encourage stress-management techniques (e.g., meditation, mindfulness, and cognitive behavioural therapy) to improve symptom perception and quality of life. Psychological stress can trigger flare ups. 
Billing codes
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Billing codes:

E079 – initial discussion; once every 12 months.

K039 – follow up; up to two times after initial.

For rostered patients, K039 + Q042

Patient and care partner resources for long-term psoriasis management:

Education
Canadian Association of Psoriasis Patients provides information on:
Overview of psoriasis to help individuals understand their condition.
Living with psoriasis to support daily life and overall well-being.  

Weight management
The Mediterranean Diet: Practical guidance from Dieticians of Canada with meal ideas for an anti-inflammatory approach.
Canada’s Physical Activity Guide: Ideas for healthy, active living.
How to Reach and Maintain a Healthy Weight: Tips on achieving and maintaining a healthy weight through diet, activity, and goal-setting. 

Psychological stress management
Canadian Mental Health Association: 30 branches that provide community mental health services across Ontario.
BounceBack Ontario: Available through the Ontario Structured Psychotherapy Program. Guided self-led resources to support the management of low mood, stress, or worry. Delivered by phone with a coach and through online videos.
Hope for wellness: Mental health counselling and community-based cultural and emotional support for Indigenous people. 1-855-242-3310
MoodGYM: Online cognitive behavioural therapy.

Smoking cessation
Smokers’ Helpline: A Canadian Cancer Society bilingual service providing personalized quit plans, live chat, and text support for smoking and vaping cessation.
Smoking Treatment for Ontario Patients (STOP): An online program through which adult tobacco smokers can receive free nicotine replacement therapy. 

Alcohol moderation/cessation support
HelpWithDrinking.ca: Free tools and guidance for reducing or quitting alcohol. 

Complementary therapies4,6,11,12 

Evidence for complementary therapies is limited and varies by therapy. Complementary therapies should be used under clinical supervision as adjuncts, not replacements for standard care. While complementary therapies such as vitamin D or omega-3 supplementation and mindfulness practices may have modest supportive effects, phototherapy (limited availability in Ontario) and coal tar remain the only alternative modalities with sufficient evidence of efficacy. 

Discuss complementary use transparently, ensuring patients disclose supplements or topical agents to avoid interactions with prescribed therapy.

Complementary therapy options
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Complementary therapy options for psoriasis4,6,11,12

Complementary therapy / Natural Health Product  Potential benefit for psoriasis management  Risks / Harms / Key Cautions 
Aloe vera  Topical aloe vera may help mild psoriasis in non-allergic patients. 
  • Contact dermatitis risk. 
  • Avoid if allergic. 
Fish oil / Omega-3s  May augment systemic or phototherapy response. 
  • Use purified sources to minimize contamination risk (mercury, PCBs). 
  • Caution in pregnancy. 
Vitamin D  Topical vitamin D analogues are effective (see medications table); oral forms may support systemic therapy. 
  • Risk of hypercalcemia with high doses. 
  • Avoid excessive supplementation. 
Zinc  Limited evidence.  Low benefit. 
Curcumin  Oral forms may reduce inflammation and disease severity.  Generally well tolerated; data limited. 
St John’s wort  Limited evidence. 
  • Photosensitizing. 
  • Avoid in patients with skin cancer history or heavy sun exposure. 
  • Safety in pregnancy unknown. 
Traditional Chinese Medicine  Herbal blends and acupuncture may improve chronic plaque psoriasis when used by qualified practitioners. 
  • Herbal composition varies – risk of allergy, toxicity, and unpredictable effects. 
  • Indigo naturalis may stain skin. 
  • Acupuncture benefit may relate partly to placebo effect. 
  • Safety unknown in pregnancy and lactation. 
Elimination diets  Gluten-free diets are beneficial only for patients with celiac disease or positive celiac antibodies. 
  • Restrictive. 
  • Can impact nutrition and quality of life. Dietitian supervision required. 
Hypnosis  May benefit highly hypnotizable patients with mild to moderate psoriasis. 
  • Requires trained practitioner – can limit access. 
Other  Cannabis and cannabinoids – lack supporting evidence. 
  • Safety and efficacy not established. 

Considerations for complementary therapies and Natural Health Products 

Patient values and wishes are a priority in treatment selection. While there is evidence for some types of complementary therapies and natural health products, as with any treatment, the potential for harm must be considered. 

Consider the advantages: 

  • Patient places high value on treatment 
  • Likelihood of the treatment addressing factors related to the patient’s symptoms 
  • Evidence for treatment 

Consider the disadvantages: 

  • Availability 
  • Cost 
  • Risk of negative impact 
Natural Health Products 

A pharmacist can support you and patients in navigating herbal treatments. Some general considerations include: 

  • Is it a quality product? 
  • Approved, licensed products have an NPN (Natural Product Number). 
  • Is there a potential for drug interactions? (e.g., St. John’s Wort) 
  • How much does the product cost? 
  • Is there evidence of the product’s efficacy? 
Talking tips
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Talking tips 

 

  • There are many products that are safe, and some have been studied for psoriasis. 
  • Even though herbal products are natural, they may have side effects, interfere with your medications and may not be safe for you. 
  • A rule of thumb is to find a product with only one ingredient and “NPN” or Natural Product Number. Having one ingredient makes the product less likely to interfere with other medications or include things that are not safe for you. The Natural Product Number means that the company has proven to Health Canada that the product has passed safety standards and is what it claims to be. 
  • Talk to your pharmacist to confirm that the natural product is a good fit for you. 

Follow-up and monitoring

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Guiding principles for follow-up and monitoring of psoriasis:11 

  • Individualize treatment goals by recognizing that “clear skin” means different things to different patients. 
  • Assess patient experience and response to treatment, including effectiveness, tolerability, and convenience. 
  • Understand the patient’s reasons for discontinuation if topical or other therapies have been stopped. 
  • Screen for and proactively manage comorbidities (e.g., psoriatic arthritis, cardiovascular disease). 
  • Acknowledge and normalize that flare-ups are common and may be triggered by stress or seasonal changes. 
  • Consider life context and stressors by discussing upcoming life events that may influence treatment choices or urgency. 
  • Tailor therapies based on the patient’s plans for pregnancy. 
Talking tips
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Talking tips11

  • How do you feel things are going with your psoriasis? 
  • Is the treatment working well enough for you? 
  • Are there any barriers to you using your treatment as directed (getting at topical applications, cosmesis issues)? 
  • Do you wish you could do things that you can’t because of your psoriasis? 

Regular follow-up is essential to monitor treatment fatigue, response, safety, and comorbidities, and to ensure patients achieve and sustain optimal disease control. Follow-up should be structured, measurable, and patient-centered, integrating both clinical outcomes and quality-of-life indicators. 3,6 

  • Reinforce adherence and provide brief, structured counselling on modifiable factors (stress, weight, and smoking) at every review and reinforce progress over time. 
  • Proactively assess comorbidities at each annual review. Document any new co-morbid conditions and adjust treatment accordingly. See co-morbid conditions section above. 
  • Monitor for treatment fatigue or psychological distress. 
  • Use treat-to-target principles to determine whether therapy is adequately controlling disease. 3 
    • Review disease control at 2-3 months after starting or changing therapy. 
    • If minimal disease activity targets are not met, adjust treatment intensity or refer for biologic therapy initiation. 

Referral3,10,11 

Refer patients to dermatology when: 

  • Clinical presentation is atypical or involves diagnostic uncertainty
  • Moderate-to-severe psoriasis (BSA >10% or PGA ≥3) 
  • Topical therapy fails after 8-12 weeks 
  • Special sites (face, genitals, hands, feet, and nails) are significantly affected and are not being adequately treated 
  • Biologics should be considered for disease that remains unresponsive to systemic therapy or requiring discontinuation due to intolerance. When considering referral for biologic therapy, ensure that the vaccination status of the patient is up to date and they have a recent clear TB skin test.

Monitoring an individual on biologics16-31

Although biologics are prescribed and managed by specialists, primary care is the first point of contact when individuals experience side effects from these medications. You play a key role in identifying infections early, monitoring for systemic complications, and knowing when to hold doses and contact the prescribing specialist. 

TNF-α inhibitors16-21
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Includes: Humira (Adalimumab), Enbrel (Etanercept), Cimzia (Certolizumab pegol), Avsola (Infliximab biosimilar), Ifixi (Infliximab biosimilar), Omvyence (Infliximab biosimilar) 

 

Category 

Class-Level Risks 

Monitoring Actions 
Serious  Serious and opportunistic infections; TB reactivation  Screen for fever, cough, dyspnea, cellulitis, dysuria, diarrhea at each visit. Treat mild infections normally but hold biologic during active infection. ED for sepsis or pneumonia. TB symptoms → CXR + TB testing and contact specialist. 
Serious  Worsening or new heart failure  Ask about edema, orthopnea, rapid weight gain. If HF suspected → BNP/CXR and notify specialist; acute decompensation → ED. 
Serious  Demyelinating disease  New visual changes, weakness, paresthesias, gait disturbance → urgent neurology referral and inform prescriber. 
Moderate  Malignancy (lymphoma, non-melanoma skin cancer)  Maintain routine cancer screening. Perform or arrange annual skin exam. Investigate lymphadenopathy or B-symptoms. 
Moderate  Hepatic injury (more common with infliximab)  Jaundice, RUQ pain, fatigue → check LFTs; significant abnormalities → hold drug and contact specialist. 
Moderate  Cytopenias  Easy bruising, fatigue, recurrent infections → CBC; hold drug if significant cytopenia. 
Routine  Injection or infusion reactions, mild URTIs  Symptomatic care; infusion reactions coordinated with infusion clinic. 
IL-12/23 and IL-23 Inhibitors22-26
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Includes: Illumya (Tildrakizumab), Tremfya (Guselkumab), Skyrizi (Risankizumab), Finlius (Ustekinumab biosimilar), Jamteki (Ustekinumab biosimilar)

 

Category  Risks  Monitoring Action 
Serious  Serious infections  Ask about infection symptoms at routine visits. Hold biologic for moderate/severe infection; ED for systemic illness. 
Moderate  Malignancy signals (esp. non-melanoma skin cancer)  Ensure age-appropriate cancer screening and annual skin examination. Refer any suspicious lesions. 
Moderate  Injection-site reactions; headache; diarrhea; URTIs  Usually mild. Treat symptomatically; escalate if frequent or persistent. 
Routine  Mild lab abnormalities  Order CBC/LFTs only if clinically indicated; review abnormalities with prescriber. 
IL-17 Pathway Inhibitors27-30
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Includes: Cosentyx (Secukinumab), Taltz (Izekizumab), Siliq (Brodalumab), Bimzelx (Bimekizumab)

Category  Risks  Monitoring Action 
Serious  Serious infections; TB and fungal infections  Same infection approach as TNF inhibitors: screen routinely, hold drug during active infection, ED for severe/systemic illness. TB symptoms → investigate and notify specialist. 
Serious  New or worsening inflammatory bowel disease  Ask about chronic diarrhea, bloody stool, abdominal pain, weight loss. If suspected → CBC/CRP, hold biologic, urgent derm/GI contact; ED for severe bleeding or pain. 
Serious  Suicidal ideation and behaviour (brodalumab-specific risk)  Screen briefly for mood changes. Any suicidal ideation → urgent mental-health assessment, notify prescriber, do not continue dosing. 
Moderate  Mucocutaneous candidiasis (oral, genital, cutaneous)  Treat with antifungals. Recurrent or extensive disease → discuss with specialist; may require therapy change. 
Moderate  Injection-site reactions, URTIs, headache, arthralgia  Symptomatic care; escalate if frequent or QoL-limiting. 
Serious  Hypersensitivity / anaphylaxis  Angioedema, wheeze, hypotension → IM epinephrine + EMS; stop drug pending specialist review. 

 

IL-36 Inhibitor31
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Includes: Spevigo (Spesolimab)

 

Category  Risks  Monitoring Action 
Serious  Serious infections (UTI, URTI, others), TB risk  Do not continue during clinically important infection; stop subcutaneous prevention dosing and restart only after resolution, in consultation with specialist. ED for sepsis. Investigate TB symptoms and alert prescriber. 
Serious  Hypersensitivity / anaphylaxis / infusion reactions  For acute reactions (wheeze, hypotension, generalized urticaria), treat as anaphylaxis (IM epinephrine + EMS) and ensure no further doses until specialist review. 
Moderate  Peripheral neuropathy (rare signal), vaccine timing issues  Be alert to new neuropathic symptoms; discuss with specialist. Avoid live vaccines during and shortly after therapy; inactivated vaccines are fine. 
Routine  Injection/infusion-site reactions, mild infections  Manage symptomatically; escalate if symptoms worsen or recur frequently. 

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