Psoriasis

Last Updated: March 31, 2026

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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 New

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Psoriasis is a chronic, autoimmune, and inflammatory skin condition characterized by well‑demarcated erythematous plaques with overlying silvery scale, which may be itchy or painful. Psoriasis may appear on any body surface area, but it commonly affects the scalp, elbows, knees, trunk and gluteal cleft.1 It can present with variable morphology depending on subtype(s) and skin phototype and is associated with several co-morbid conditions. Psoriasis requires timely and thorough assessment to inform an individualized management plan.8,10,11

Risk factors11

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

  • Genetic predisposition (non-modifiable, primary risk factor)
  • Smoking
  • Alcohol use
  • Koebner phenomenon (physical trauma to the skin, e.g., scratching, friction, surgical scars. More about it here.) 
  • Certain medications such as lithium, betablockers, NSAIDs, antimalarials and ACE inhibitors. Medication triggers are more common in individuals with genetic predisposition to psoriasis.

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 as purple, violet or brown in skin of colour.
  • Can affect any  body part, but most common on extensor surfaces (knees and elbows), scalp, trunk, and gluteal fold. 
  • Erythematous patches with overlying silvery scales (plaques). 
  • May be painful or itchy. 
Psoriasis vulgaris on trunk

Guttate Psoriasis

  • Second most common presentation. 
  • Commonly diagnosed in young adults under age 30. 
  • May be associated with an upper respiratory tract infection (URTI) or strep throat trigger.
  • Abrupt onset of 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)

  • Affects body parts that “flex” or fold (e.g., armpits, groin, under the breasts, around the genitals, between the buttocks).
  • Shiny, red, and clearly outlined lesions. 
  • Lacks typical scaliness of psoriasis.
  • Can be difficult to detect due to location of presentation.
  • May cause painful fissures or cracks which may bleed.
  • May be painful and itchy. 
  • 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 in individuals with psoriasis and can occur with any subtype, most commonly plaque psoriasis.
  • Red, well-defined lesions that are covered by a thick scale. 
  • Silvery scales that that can be misdiagnosed as dandruff. 
    • Dandruff tends to be diffuse across the scalp, and psoriasis often starts at the occiput.
  • Scalp psoriasis appears inflamed in affected areas, 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 any psoriasis sub-type. 
  • 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.
  • May impair basic functions (e.g., picking up small objects). 
  • Those living with psoriatic nails are more predisposed to onychomycosis and may present with both.
  • Has a strong association with psoriatic arthritis.
  • Consider KOH (potassium hydroxide) testing of nail scrapings to differentiate nail fungal infection.
Nail psoriasis

Pustular Psoriasis

  • Rare type of psoriasis. 
  • 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.
  • Small pimple-like and pus-filled eruptions.  
  • Episodes typically occur rapidly with the onset of eruptions occurring within a few hours of the initial presentation of red and tender skin. 
  • May alternate between periods of recurrence and remission. 
  • 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. Skin will swell and shed in multiple layers, often in large sheets. 
  • May itch and burn immensely. 
  • Onset is a medical emergency and requires hospitalization. 
  • Other symptoms may include fever, chills, general malaise, racing heart rate, joint pain and lymph node swelling. 
Erythrodermic psoriasis on trunk
Distribution of psoriasis sub-types

Click here for printable PDF.

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 quality of life (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 (hyperpigmentation and/or hypopigmentation in affected areas) 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 Burns 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.

Differential diagnosis3,6 

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

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

The 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 psoriasis. 
  • No scales or less scaly than psoriasis plaques. Affected areas may have thickened skin due to intense itch.
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). 
  • May overlap with psoriasis. 
  • Greasy, yellowish scales due to excessive sebum production.
  • 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

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 and powdery 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 is on upper trunk and shoulders. 
  • Slightly scaly, irregular plaques. 
  • Thin, translucent rolled border. 
  • Multiple microerosions. 
sBCC on trunk

Intraepidermal squamous cell carcinoma (Bowen disease or IEC or SCC)

  • Most often found in sun-damaged individuals. 
  • Up to 50% of patients with Bowen disease have another type of kerotinocytic skin cancer, mainly basal cell carcinoma. 
  • Presents as one or more irregular scaly plaques, up to seven centimeters in diameter.
  • Often an orange-red colour but may also be brown. 
  • May arise on any area of the skin, most often in sun-exposed areas such as ears, face, hands, or lower legs. 
Bowen disease on arm

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)

Associated conditions3,6,12

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

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)) 

Assessment New

Assessment of psoriasis severity includes a combination of:

  • Skin involvement/lesion characteristics:  
    • Assess body surface area, erythema (redness), induration (thickness), and scaling.  Look for Ausptiz sign (tiny, pinpoint bleeding under scales) as an indicator the scaling may be psoriasis.
       
    • 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 severity (i.e., patient-rated itch intensity)
     
  • Impact on quality of life.

Although several validated clinical tools are available for assessment, Body Surface Area (BSA) remains the most commonly used clinical tool to guide treatment selection. The additional clinical tools are valuable during Follow-up and monitoring to monitor treatment response and changes in patient-reported outcomes and quality of life. 

Assessing psoriasis in skin of colour: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 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. 

Calculating Body Surface Area (BSA): 

Estimate the body percentage by using the patient’s palm (including fingers) as approximately 1% of the total BSA. 
Mild: <3% | Moderate: 3-10% | Severe: >10% 

Talking tips to assess quality of life
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  • Physical Symptoms: “Over the last week, how itchy, sore, painful, or stinging has your skin felt?” 
  • 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, studying, or engaging in school?” 
  • Treatment Burden: “Over the last week, how much of a problem has the treatment for your skin been (e.g., taking up time)?” 

Questions from Dermatology Quality of Life Index (DLQI)

Pharmacological management New

Guiding principles for the pharmacological management of psoriasis:3,4,7-9,11 

  • 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. Most 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.
    • Treat acute flares and consider maintenance therapy where appropriate. 
    • Use combination products to support adherence. 
    • Individualize regimens, as multiple topical options may be required for different psoriasis sub-types and body areas. 
  • Cost considerations: 
    • Reach out to drug companies to inquire about their patient financial assistance programs. 
    • Connect your patient with Ontario Works (OW) and the  Ontario Disability Support Program (ODSP) for financial assistance with drug coverage.
  • 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 to address steroid phobia
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Addressing steroid phobia11

If your patient is concerned about skin thinning from steroids, you can explain that in psoriasis the skin becomes too thick – and we actually take advantage of this effect to help reduce that buildup and bring the skin back toward normal. 

Pharmacotherapy for psoriasis aims to achieve and sustain clear or almost clear skin by reducing inflammation, clearing lesions and improving quality of life. Use your clinical judgement to guide treatment selection based on disease severity, impact and comorbid conditions, which may include topical, systemic, or biologic therapies. 3,6 See Follow-up and monitoring for guidance on dermatology referral for biologic therapy and Monitoring an individual on biologic therapy.

Topical vehicle selection: 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

Click here for PDF download.

Initiating therapy or managing flares with topical therapy

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See the Medications tables for detailed treatment options and escalation criteria.

Pharmacotherapy for psoriasis

Non-pharmacological management New

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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. See the table above to guide vehicle selection. 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 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. 

OHIP billing codes for smoking cessation

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
Decision aid for understanding psoriasis and exploring treatment options. 
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.
Best Weight: Educational video presented by the Thames Valley Family Health Team.

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 Helpline: Mental health counselling and community-based cultural and emotional support for Indigenous people.

Smoking cessation
Smokers’ Helpline: A Canadian Cancer Society bilingual service providing personalized quit plans, live chat, and text support for smoking and vaping cessation.
STOP (Smoking Treatment for Ontario Patients) program: Enroll to receive free nicotine replacement therapy.
Leave The Pack Behind: Tools To Quit Smoking: Educational video presented by the Thames Valley Family Health Team. 

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 may have modest supportive effects, phototherapy (limited availability in Ontario) remains the only alternative modality 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,  limiting access.
Other Cannabis and cannabinoids – lack supporting evidence.
  • Safety and efficacy not established.

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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 a 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
  • Interactions with medications 
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 New

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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 they have stopped topical or other therapies. 
  • Screen for and proactively manage comorbidities (e.g., psoriatic arthritis, cardiovascular disease). 
  • Acknowledge and normalize flare-ups as 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 or cosmesis issues)? 
  • Do you wish you could do things that you can’t or won’t do 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 

  • Assessment of psoriasis severity characteristics should be done at each visit. 
  • 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 Associated 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 clear or almost clear skin is not achieved, targets are not met, adjust treatment intensity or refer for biologic therapy initiation. 

Click here for downloadable PDF.

Available validated clinical tools to support psoriasis monitoring

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).

Referral3,10,11 

Refer patients to Dermatology when: 

  • Clinical presentation is atypical or involves diagnostic uncertainty.
  • Psoriasis is moderate-to-severe (BSA >10% or PGA ≥3). 
  • Topical therapy fails to achieve PASI75/PGA ≤2 or DLQI >5 after 8-12 weeks. 
  • There is involvement of high-impact sites (face, palms, soles, genitals, scalp, and nails) and they are not being adequately treated. 
  • Biologics should be considered for disease that remains unresponsive to systemic therapy or it requires discontinuation due to intolerance. When considering referral for biologic therapy, ensure the vaccination status of the patient is up to date and they have a recent clear TB skin test.

Include PASI, PGA, and DLQI scores in your referral. Reporting these scores will provide the dermatologist with a clearer, standardized assessment of disease severity and its impact on the patient’s quality of life. 

Vaccinations and biologic therapy
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Vaccinations and biologic therapy36
Scenario Non-live Vaccine Guidance
(e.g., COVID-19, Flu, Hepatitis B, Pneumococcal, Shingles, Tetanus, etc.)		 Live Vaccine Guidance
(e.g., BCG, intranasal flu, Measles, Mumps, Mpox, etc.)
Prior to initiation of biologic therapy Clinicians should review the patient’s vaccination status and recommendations before initiating biologic therapy. Whenever possible, live vaccines should be administered 2–4 weeks before starting biologic therapy.
Ongoing biologic therapy Continue biologic therapy without interruption or dose modification. Pre-vaccination: Discontinue the biologic for 2–3 half-lives.

Post-vaccination: Defer the next dose of biologic therapy for 2–4 weeks.

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 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 Risks Monitoring Actions
Serious Serious and opportunistic infections; TB reactivation Screen for fever, cough, dyspnea, cellulitis, dysuria and 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 and rapid weight gain. If HF suspected → conduct heart failure investigations and notify specialist; acute decompensation → ED.
Serious Demyelinating disease New visual changes, weakness, paresthesias, or 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 liver transaminases/LFTs; significant abnormalities or deviation from baseline → 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.

Legend:
TB = Tuberculosis; ED = Emergency department; CXR = Chest x-ray; HF = Heart failure; RUQ = Right upper quadrant; LFT = Liver function test; CBC = Complete blood count; URTI = Upper respiratory tract infection.

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 during routine visits. Hold biologic for moderate/severe infection; ED for systemic illness.
Moderate Malignancy signals (especially 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.

Legend:
ED = Emergency department; URTI = Upper respiratory tract infection; CBC = Complete blood count; LFT = Liver function test.

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 and weight loss. If suspected → CBC/CRP, hold biologic, urgent dermatology/gastroenterology 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 quality-of-life limiting.
Serious Hypersensitivity / anaphylaxis Angioedema, wheeze, hypotension → IM epinephrine + EMS; stop drug pending specialist review.

Legend:
TB = Tuberculosis; ED = Emergency department; CBC = Complete blood count; CRP = C-reactive protein; IM = Intramuscular; EMS = Emergency medical services.

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 appropriate.
Routine Injection/infusion-site reactions, mild infections Manage symptomatically; escalate if symptoms worsen or recur frequently.

Legend:
UTI = Urinary tract infection; URTI = Upper respiratory tract infection; TB = Tuberculosis; ED = Emergency department; IM = Intramuscular; EMS = Emergency medical services.

References

Note: This list excludes most medication-related references, which are in the medications table. Some references may appear in both lists where applicable.

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