Re: Diagnosis and management of psoriasis and psoriatic arthritis in adults: summary of SIGN guidance
Psoriasis is a common, chronic inflammatory skin disease that affects 1.5-3% of the UK population.1 Most patients have mild disease that can be managed with topical therapy in primary care. Patients with moderate-severe disease may require more intensive intervention in secondary care using phototherapy and/or methotrexate, ciclosporin or retinoids. Patients with severe disease unresponsive to systemic and phototherapy may be eligible for biological therapy using, for example a tumour necrosis factor inhibitor.
Clinical guidelines which provide recommendations based on current evidence for best practice are designed to help clinicians choose the most appropriate treatment. Such guidelines are costly, not only financially but also in terms of the time invested by the guideline development group. The Scottish Intercollegiate Guidelines Network (SIGN) budget circa £25000 (excludes SIGN staffing costs which makes up 70% of the total budget) for the development of a new guideline which takes around 29 months to complete (Personal communication, SIGN programme lead). The healthcare professionals involved in writing the guideline receive no payment.
The clinical guideline “SIGN 121: Diagnosis and management of psoriasis and psoriatic arthritis in adults” was published in October 2010, and summarised in the BMJ (BMJ 2010; 341:c5623)2. Amongst the recommendations is that a Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) be recorded in Dermatology secondary care at baseline, and then serially to aid assessment of efficacy of systemic and biologic interventions. The PASI is a clinical assessment tool used to monitor disease activity. A score (0-72) is calculated based on the surface area involved, erythema, induration (thickness) and desquamation (scaling). 3 Serial recordings of the PASI will highlight any change in severity of a patient’s disease, and crucially, gives objective measure as to whether or not a specific treatment is working. The DLQI questionnaire assesses the psychological burden of skin disease. It is a simple, reliable and sensitive tool that can detect any changes in a patient’s quality of life during treatment. 4
We audited the use of PASI and DLQI in a Scottish teaching hospital over a 3 month period between March and May 2013. Psoriasis patients referred from primary care are assessed in general dermatology clinics. Tertiary referrals are assessed in a dedicated psoriasis clinic.
Of 103 patients seen in the general clinics, only 6 patients (6%) had their PASI/DLQI recorded as per SIGN recommendations, with 63 (61%) never having these indices completed. In contrast, 80 of the 116 (68%) patients assessed in a dedicated psoriasis clinic had these measures recorded at baseline and serially thereafter.
On review of case records we noted 139 episodes where the prescribed systemic agent was continued with no apparent improvement in the patients’ psoriasis. In 75 (54%) of these episodes the patients continued with the medication for 6 months or longer. In the absence of more objective measures, the use of descriptive terms such as “worse”, “no improvement”, “static disease”, “and widespread disease” was assumed to mean that treatment was ineffective. The serial use of an objective assessment tool such as PASI may have prompted an earlier change in management.
Poor adherence with this part of the guideline may reflect a lack of awareness of the current SIGN recommendations. Some clinicians question the utility of using PASI to assess response to treatment as it has not been validated in a routine practice setting. In our experience, many clinicians cite time pressures as the main barrier to regular use of PASI and DLQI.
Given the significant resource allocated to guideline development, it is disappointing that such a key recommendation has not been implemented more widely. This is particularly pertinent when one considers that NICE guidance for the eligibility for biological therapies is dependent on fulfilling disease severity criteria based on PASI and DLQI.5 Recently published NICE Quality standards state that people with psoriasis should be offered an assessment of their disease activity and its impact on their physical, psychological and social wellbeing.6 The PASI/DLQI would facilitate this with serial measurement helping to encourage timely escalation along the therapeutic ladder.
Perhaps a dedicated budget for a guideline implementation strategy would encourage adoption of at least some of the key recommendations? If Dermatologists in secondary care are not routinely recording PASI and DLQI then it seems unlikely that our primary care colleagues will be inclined, as suggested in SIGN 121 to check a DLQI annually.
References
1. Griffiths CE, Barker JN. Pathogenesis and clinical features of psoriasis. Lancet. 2007;370(9583):263-71
2. Diagnosis and management of psoriasis and psoriatic arthritis in adults: summary of SIGN guidance. BMJ 2010; 341:c5623
3. Ashcroft DM, Wan Po AL, Williams HC, Griffiths CE. Clinical measures of disease severity and outcome in psoriasis: a critical appraisal of their quality. Br J Dermatol 1999; 141(2):185-91
4. Basra MK, Fenech R, Gatt RM, Salek MS, Finlay AY. The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results. Br J Dermatol 2008; 159(5):997-1035
5. National Institute for Health and Clinical Excellence. Psoriasis: the management of psoriasis. NICE, 2012
6. National Institute for Clinical Excellence (NICE) Quality Standard (QS) 40: Psoriasis
Competing interests:
J A Leman was a member of the SIGN 121 guideline development group
Rapid Response:
Re: Diagnosis and management of psoriasis and psoriatic arthritis in adults: summary of SIGN guidance
Psoriasis is a common, chronic inflammatory skin disease that affects 1.5-3% of the UK population.1 Most patients have mild disease that can be managed with topical therapy in primary care. Patients with moderate-severe disease may require more intensive intervention in secondary care using phototherapy and/or methotrexate, ciclosporin or retinoids. Patients with severe disease unresponsive to systemic and phototherapy may be eligible for biological therapy using, for example a tumour necrosis factor inhibitor.
Clinical guidelines which provide recommendations based on current evidence for best practice are designed to help clinicians choose the most appropriate treatment. Such guidelines are costly, not only financially but also in terms of the time invested by the guideline development group. The Scottish Intercollegiate Guidelines Network (SIGN) budget circa £25000 (excludes SIGN staffing costs which makes up 70% of the total budget) for the development of a new guideline which takes around 29 months to complete (Personal communication, SIGN programme lead). The healthcare professionals involved in writing the guideline receive no payment.
The clinical guideline “SIGN 121: Diagnosis and management of psoriasis and psoriatic arthritis in adults” was published in October 2010, and summarised in the BMJ (BMJ 2010; 341:c5623)2. Amongst the recommendations is that a Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) be recorded in Dermatology secondary care at baseline, and then serially to aid assessment of efficacy of systemic and biologic interventions. The PASI is a clinical assessment tool used to monitor disease activity. A score (0-72) is calculated based on the surface area involved, erythema, induration (thickness) and desquamation (scaling). 3 Serial recordings of the PASI will highlight any change in severity of a patient’s disease, and crucially, gives objective measure as to whether or not a specific treatment is working. The DLQI questionnaire assesses the psychological burden of skin disease. It is a simple, reliable and sensitive tool that can detect any changes in a patient’s quality of life during treatment. 4
We audited the use of PASI and DLQI in a Scottish teaching hospital over a 3 month period between March and May 2013. Psoriasis patients referred from primary care are assessed in general dermatology clinics. Tertiary referrals are assessed in a dedicated psoriasis clinic.
Of 103 patients seen in the general clinics, only 6 patients (6%) had their PASI/DLQI recorded as per SIGN recommendations, with 63 (61%) never having these indices completed. In contrast, 80 of the 116 (68%) patients assessed in a dedicated psoriasis clinic had these measures recorded at baseline and serially thereafter.
On review of case records we noted 139 episodes where the prescribed systemic agent was continued with no apparent improvement in the patients’ psoriasis. In 75 (54%) of these episodes the patients continued with the medication for 6 months or longer. In the absence of more objective measures, the use of descriptive terms such as “worse”, “no improvement”, “static disease”, “and widespread disease” was assumed to mean that treatment was ineffective. The serial use of an objective assessment tool such as PASI may have prompted an earlier change in management.
Poor adherence with this part of the guideline may reflect a lack of awareness of the current SIGN recommendations. Some clinicians question the utility of using PASI to assess response to treatment as it has not been validated in a routine practice setting. In our experience, many clinicians cite time pressures as the main barrier to regular use of PASI and DLQI.
Given the significant resource allocated to guideline development, it is disappointing that such a key recommendation has not been implemented more widely. This is particularly pertinent when one considers that NICE guidance for the eligibility for biological therapies is dependent on fulfilling disease severity criteria based on PASI and DLQI.5 Recently published NICE Quality standards state that people with psoriasis should be offered an assessment of their disease activity and its impact on their physical, psychological and social wellbeing.6 The PASI/DLQI would facilitate this with serial measurement helping to encourage timely escalation along the therapeutic ladder.
Perhaps a dedicated budget for a guideline implementation strategy would encourage adoption of at least some of the key recommendations? If Dermatologists in secondary care are not routinely recording PASI and DLQI then it seems unlikely that our primary care colleagues will be inclined, as suggested in SIGN 121 to check a DLQI annually.
References
1. Griffiths CE, Barker JN. Pathogenesis and clinical features of psoriasis. Lancet. 2007;370(9583):263-71
2. Diagnosis and management of psoriasis and psoriatic arthritis in adults: summary of SIGN guidance. BMJ 2010; 341:c5623
3. Ashcroft DM, Wan Po AL, Williams HC, Griffiths CE. Clinical measures of disease severity and outcome in psoriasis: a critical appraisal of their quality. Br J Dermatol 1999; 141(2):185-91
4. Basra MK, Fenech R, Gatt RM, Salek MS, Finlay AY. The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results. Br J Dermatol 2008; 159(5):997-1035
5. National Institute for Health and Clinical Excellence. Psoriasis: the management of psoriasis. NICE, 2012
6. National Institute for Clinical Excellence (NICE) Quality Standard (QS) 40: Psoriasis
Competing interests: J A Leman was a member of the SIGN 121 guideline development group