such as myocardial infarction and stroke (Figure 7). Psoriasis patients are more likely to suffer from depression and anxiety disorders and have an increased rate of suicidal ideation. Screening at regular intervals for these associated diseases and for co-medication to prevent drug-drug interactions or drug-triggered psoriasis as well as recognition of trigger factors and their treatment are an essential part of psoriasis management. Management algorithms (such as shown in Figure 7) for countries with a developed social and health-care system can be adapted to the needs of local health-care environments. Psychosocial interventions may be needed such as psychological treatment, patient education and psychotherapy (144,145). One-to-one sessions, group therapy, nursing intervention (26) and support by phone or telemedicine (146) may also be helpful. Patient empowerment is a central component of successful programmes (147), as has been demonstrated in other chronic skin diseases (123). Figure 7. Psoriasis management algorithm Pos, positive; Neg, negative; UV, ultraviolet Source: Mrowietz et al. 2014 (26). Comorbidity screening Pos Specialist Neg Annual re-screening Trigger factor screening Treatment Combination therapy Mild Topicals +/- UV Moderate-to-severe Systemic therapy Scoring Obesity Smoking Weight loss intervention Stress Infections Smoking cessation programme Psychological Intervention Adequate therapy Psoriatic arthritis screening Comedication screening Interactions/ Problems Change Pos Rheumatologist Neg Annual re-screening Treatment Goals Global report on psoriasis 22 Treating the skin manifestations There are three major forms of therapy – topical therapy; phototherapy; and systemic therapy (Table 3). Treatment is based on psoriasis severity at the time of presentation. Mild psoriasis usually is treated with topical therapy, progressing to phototherapy in the case of insufficient response. Moderate to severe psoriasis requires systemic therapy. Commonly used first-line drugs include methotrexate, ciclosporin, acitretin and etretinate. In some countries, other systemic therapies such as biologic agents and fumaric acid esters are available (148). All treatments for psoriasis, apart from retinoids, are primarily anti-inflammatory, and subsequently lead to slowed epidermal keratinocyte turnover and a flattening of plaques. In many countries, other treatments may play a prominent role, including traditional Chinese medicine, self-treatment with over-the-counter products (non-prescription drugs) and climatotherapy. Table 3. Treatment options for psoriasis Topical therapies (ointments, creams, lotions, gels, or foams applied to the skin) Vitamin D3 analogues Corticosteroids e.g. betamethasone and hydrocortisone Anthralin/dithranol Topical retinoids Phototherapy (UV-light therapy) Systemic therapies (tablets or injections/infusion) Methotrexate Ciclosporin Acitretin Biologic agents Oral small molecules The WHO Model List of Essential Medicines (149) includes a small number of topical and systemic treatments that could be useful for patients with psoriasis, which should be considered as a minimum requirement for all health systems (Table 4). Table 4. Psoriasis treatment options included on the WHO Model List of Essential Medicines Core list1 Anti-inflammatory and antipruritic medicines betamethasone cream or ointment: 0.1% (as valerate) hydrocortisone cream or ointment: 1% (acetate) Medicines affecting skin differentiation and proliferation coal tar solution: 5% fluorouracil ointment: 5% salicylic acid solution: 5% urea cream or ointment: 5%; 10% Complementary list2 Systemic therapies3 methotrexate tablet: 2.5mg (as sodium salt) (for joint diseases) ciclosporin capsule: 25mg (for immunosuppression) 1 Minimum medicine needs for a basic health-care system. 2 Medicines for which specialized diagnostic, monitoring, training or care may be needed. 3 These medicines are not specifically included in the WHO Model List of Essential Medicines for dermatological conditions, but for the indications specified above. Source: WHO 2015 (149). Global report on psoriasis 23 To ensure efficacious and safe treatment, the recommendations of