Practice Guidelines

Assessment and management of psoriasis: summary of NICE guidance

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6712 (Published 24 October 2012) Cite this as: BMJ 2012;345:e6712
  1. Eleanor Samarasekera, research fellow1,
  2. Laura Sawyer, senior health economist1,
  3. Jill Parnham, operations director1,
  4. Catherine H Smith, consultant dermatologist and senior lecturer2
  5. on behalf of the Guideline Development Group
  1. 1National Clinical Guideline Centre, Royal College of Physicians of London, London NW1 4LE, UK
  2. 2St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
  1. Correspondence to: C H Smith catherine.smith{at}kcl.ac.uk

Psoriasis is a common inflammatory skin condition affecting about 1.3–2.2% of the UK population1 and may be associated with psoriatic arthritis.2 People with psoriasis, especially those with severe disease, are also at increased risk of cardiovascular disease,3 diabetes,4 and depression.5 Psoriasis may result in functional, psychological, and social morbidity, even in people with minimal involvement (less than the equivalent of three palm areas). However, doctors, including dermatologists, often fail to appreciate the extent of this disability,6 and many people with psoriasis are dissatisfied with their treatment.6 Yet, highly effective and cost effective treatments are available, and improving outcomes therefore requires better assessment and management of psoriasis, including its impact on a patient’s wellbeing, by healthcare professionals. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of psoriasis.7

Recommendations

NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Principles of care

  • Provide a single point of contact for people with all types of psoriasis (and their families or carers) to aid access to appropriate information and advice about the condition and the services available at each stage of the care pathway.

[Based on the experience and opinion of the Guideline Development Group (GDG)]

Assessment of disease severity and impact, and when to refer for specialist care

  • Assess the severity and impact of any type of psoriasis:

    • -At first presentation

    • -Before referral for specialist advice and at each referral point in the treatment pathway

    • -To evaluate the efficacy of interventions.

[Based on the experience and opinion of the GDG]

  • When assessing the disease severity in any healthcare setting, record:

    • -The results of a static Physician’s Global Assessment (the physician’s assessment of disease severity, which uses the descriptions “clear,” “nearly clear,” “mild,” “moderate,” “severe,” or “very severe”)8

    • -The patient’s assessment of current disease severity, for example, with the static Patient’s Global Assessment (also using the descriptions “clear,” “nearly clear,” “mild,” “moderate,” “severe,” or “very severe”)8

    • -The body surface area affected

    • -Any involvement of nails and of high impact or difficult to treat sites (such as the face, scalp, palms, soles, flexures, and genitals)

    • -Any systemic upset, such as fever and malaise, which are common in unstable forms of psoriasis such as erythroderma or generalised pustular psoriasis.

[Based on evidence of low to high quality from validity and reliability studies in a small number of patients for each method of assessment, indirect evidence from intervention studies for Physician’s Global Assessment in a large number of patients, and the experience and opinion of the GDG]

  • Assess the impact of any type of psoriasis on physical, psychological, and social wellbeing by asking:

    • -What aspects of the patient’s daily living are affected by the psoriasis

    • -How the person is coping with the skin condition and if any treatments are being used

    • -If the person needs further advice or support

    • -If the psoriasis has an impact on mood or causes distress

    • -If the condition has any impact on family or carers.

Ask children and young people age-appropriate questions.

[Based on evidence of low to high quality from validity and reliability studies in a large number of patients and the experience and opinion of the GDG]

  • Box 1 outlines the indications for specialist referral.

Box 1: Indications for specialist referral

Adults
  • Diagnostic uncertainty

  • Any type of psoriasis that is severe or extensive, for example if it affects more than 10% of the body surface area

  • Any type of psoriasis that cannot be controlled with topical therapy

  • Acute guttate psoriasis requiring phototherapy

  • Nail disease with a major functional or cosmetic impact

  • Any type of psoriasis with a major impact on a person’s physical, psychological, or social wellbeing

Children and young people
  • Any type of psoriasis

Urgent referral for same day assessment
  • Generalised pustular psoriasis or erythroderma

Assessment and referral for psoriatic arthritis

  • Use a validated tool to assess adults for psoriatic arthritis in primary care and specialist settings; for example, the Psoriasis Epidemiological Screening Tool (PEST, see box 2). Be aware that PEST does not detect axial arthritis or inflammatory back pain.9

[Based on evidence of very low to low quality from diagnostic studies and the experience and opinion of the GDG]

  • As soon as psoriatic arthritis is suspected, refer the person to a rheumatologist for assessment and advice about planning their care.

[Based on evidence of high quality from a prospective cohort study in a large number of patients and indirect evidence of very low to moderate quality from longitudinal studies in a large number of patients]

Box 2: Psoriasis Epidemiological Screening Tool (PEST)

Question
  • Have you ever had a swollen joint (or joints)?

  • Has a doctor ever told you that you have arthritis?

  • Do your finger nails or toenails have holes or pits?

  • Have you had pain in your heel?

  • Have you had a finger or toe that was completely swollen and painful for no apparent reason?

  • Score 1 point for each question answered in the affirmative. A total score of ≥3 is indicative of psoriatic arthritis

  • Reproduced with permission from Ibrahim et al Clin Exp Rheumatol 2009;27:469-74.9

Identification of comorbidities

  • Offer adults with severe psoriasis of any type a cardiovascular risk assessment at presentation with a validated risk estimation tool. Offer further assessment of cardiovascular risk every five years, or more frequently if indicated after assessment. For further information see NICE clinical guideline CG67 (Lipid modification).10

[Based on evidence of very low to moderate quality from population based cohort studies in a very large number of patients]

Topical therapy

Figure1

Algorithm for use of active topical treatments for psoriasis in adults. (Refer to British National Formulary (www.bnf.org) for guidance on use of emollients, which are not considered here)

  • Offer people with psoriasis topical therapy as first line treatment (see figure).

  • Offer second line treatment (phototherapy or systemic non-biological therapy) or third line treatment (systemic biological therapies) options at the same time when topical therapy alone is unlikely to adequately control psoriasis—such as in patients with

    • -Extensive disease (for example, >10% of body surface area affected)

    • -A score of at least “moderate” on the static Physician’s Global Assessment

    • -Conditions where topical therapy is ineffective, such as nail disease.

[Based on evidence of very low to low quality from randomised controlled trials in a small number of patients (for phototherapy only) and on the experience and opinion of the GDG]

  • Offer practical support and advice about the use and application of topical treatments (box 3). Advice should be provided by healthcare professionals who are trained and competent in the use of topical therapies. Support patients to adhere to treatment in line with NICE clinical guideline CG76 (Medicines adherence).11

[Based on the experience and opinion of the GDG]

  • Arrange a review appointment after starting a new topical treatment—after four weeks in adults, and after two weeks in children—to:

    • -Evaluate tolerability, toxicity, and initial response to treatment

    • -Reinforce the importance of adherence when appropriate

    • -Reinforce the importance of a four week break between courses of potent or very potent corticosteroids.

    • If there is little or no improvement at this review, discuss the next treatment option with the patient.

[Based on non-randomised data on time to maximum effect of topical treatments derived from evidence of very low to low quality from randomised controlled trials in a very large number of patients and on the experience and opinion of the GDG]

Box 3: Safe use of topical corticosteroids

Things to remember and explain to patients, along with discussion of how to avoid the risks
  • Continuous use of potent or very potent corticosteroids may cause:

    • -Irreversible skin atrophy and striae

    • -Psoriasis to become unstable

    • -Systemic side effects when applied continuously to extensive psoriasis (>10% of body surface area affected)

  • The face, flexures, and genitals are particularly vulnerable to steroid atrophy, and corticosteroids should be used only for short term treatment of psoriasis at these sites (for 1–2 weeks per month)

When prescribing topical corticosteroids (intermittent or short term courses)
  • Select the potency and formulation based on patient need

  • Do not use potent or very potent corticosteroids on the face, flexures, or genitals

  • Do not use very potent corticosteroids continuously at any site for longer than 4 weeks, or at all in patients aged <18 years

  • Do not use potent corticosteroids continuously at any site for longer than 8 weeks

  • Aim for a break of 4 weeks between courses of treatment with potent or very potent corticosteroids. During this break, consider topical treatments that are not steroid based as needed to maintain psoriasis control (such as vitamin D or vitamin D analogues, or coal tar)

  • Review annually:

    • -Patients aged ≥18 years using potent or very potent steroids

    • -Patients aged <18 years using any potency of steroid

Treatments available under specialist supervision

Phototherapy

  • Offer narrowband ultraviolet B phototherapy to people with plaque or guttate pattern psoriasis that cannot be controlled with topical treatments alone. Ensure that a permanent record of the person’s cumulative number of ultraviolet treatments is kept (for example, in a national record).

[Based on evidence of low to moderate quality from eight randomised controlled trials in a moderately small number of patients, cost effectiveness evidence, and on the experience and opinion of the GDG]

Systemic non-biological therapy

  • Box 4 outlines when to escalate to systemic non-biological therapy.

Box 4: Indications for systemic non-biological therapy

All of the following conditions must be met:

  • Psoriasis cannot be controlled with topical therapy

  • Psoriasis has a significant impact on physical, psychological or social wellbeing

  • Psoriasis is:

    • -Extensive (>10% of body surface area affected) or

    • -Localised and associated with significant functional impairment or high levels of distress (for example, severe nail disease or affecting high impact sites) or

    • -Not suitable for phototherapy because it has been ineffective, cannot be used, or has resulted in rapid relapse (return to >50% of baseline disease severity within 3 months)

Choice of drugs

  • Offer methotrexate as the first choice of systemic agent for people who fulfil the criteria for systemic therapy, except when contraindicated because of safety concerns or in those who meet the criteria for ciclosporin (see below).

[Based on evidence of very low to moderate quality from 13 randomised controlled trials in a large number of patients, cost effectiveness evidence, and on the experience and opinion of the GDG]

  • Offer ciclosporin as the first choice of systemic agent for people who fulfil the criteria for systemic therapy and who:

    • -Need rapid or short term disease control (for example, a psoriasis flare) or

    • -Have palmoplantar pustulosis or

    • -Are considering conception (both men and women) and systemic therapy cannot be avoided.

[Based on evidence of very low to moderate quality from 15 randomised controlled trials in a large number of patients, cost effectiveness evidence, and on the experience and opinion of the GDG]

Overcoming barriers

In primary care the main barrier to successful implementation of this guidance is likely to be insufficient training or understanding about psoriasis among healthcare professionals, since dermatology training is not compulsory.12 Formal assessment of psoriasis—including its impact on wellbeing and identification of psoriatic arthritis and cardiovascular risk—may represent a substantial shift in approach. Both patients and professionals alike will need to be knowledgeable about where, when, and how to use topical treatments, particularly corticosteroids, to achieve effective disease control and minimise risk of adverse effects. Increasing awareness of psoriasis-specific steroid safety issues (such as which preparations contain “hidden” steroids) is also necessary. The forthcoming quality standards and implementation tools to be developed will support this.

There is no nationally managed clinical network for phototherapy in England and Wales (in contrast to Scotland13), and thus no means of recording the cumulative phototherapy dose, a critical indicator of skin cancer risk, so this will require development.

Further information on the guidance

This guideline has particular emphasis on how to assess psoriasis, including identification of potentially destructive psoriatic arthritis, use of topical treatments, when to escalate therapy, and the options available for more difficult disease. The full guideline provides more detail for specialist care, including phototherapy, safety issues relating to phototherapy and skin cancer, and systemic therapy.

Evidence of inconsistent practice prompting this guideline

Few data are available on management of psoriasis in primary care, but a recent comprehensive audit of secondary care services indicates that the availability of day treatment centres, access to and use of phototherapies, and availability of funding for the use of biological therapies differ significantly across England and Wales.14 It is also known that in adults wide variations in practice exist regarding drug monitoring, specialist nurse support, and psychological services.14

Methods

The guideline was developed according to NICE guideline methodology (www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp). This involved systematic literature searches, critical appraisal, and summarising the clinical and cost effectiveness evidence. Original cost effectiveness modelling was also undertaken in the areas of topical therapy and use of a second systemic biological agent. The GDG responsible for considering the evidence was composed of dermatologists, general practitioners, nurse consultants or nurse practitioners, a pharmacist, and two people with psoriasis as well as experts in guideline methodology. Expert advisers in phototherapy, rheumatology, and psychology were co-opted. The draft guideline underwent rigorous stakeholder consultation. All of the comments received were carefully considered during the production of the final version of the guideline.

NICE has produced three different versions of the guideline: a full version including all of the evidence and methods as well as the recommendations; a version containing a list of all the recommendations known as the “NICE guideline”; and a version for patients and the public. All these versions are available from the NICE website (http://guidance.nice.org.uk/CG153). Future updates of this guidance will be published in line with the NICE guideline development programme.

Cost effectiveness analyses

An economic model was developed to compare the cost effectiveness of different sequences of topical therapies licensed to treat mild to moderate psoriasis of the trunk and limbs. Based on the mean costs and benefits of 122 compared sequences, once or twice daily application of potent corticosteroid or concurrent therapy with vitamin D and potent corticosteroid (applied separately in the morning and evening) was the most cost effective initial treatment depending on assumptions made. Twice daily vitamin D or vitamin D analogue was found to be likely to be cost effective second or third in a sequence. Twice daily coal tar was potentially cost effective if the other treatments failed to bring clearance or near clearance. The analysis found that a combined product containing calcipotriol monohydrate and betamethasone dipropionate, although most effective, was not cost effective: the modest additional benefits it produced were insufficient to justify the substantial extra cost compared with concurrent therapy or potent corticosteroids alone.

A similar economic model was developed to compare the cost effectiveness of different sequences of topical therapies licensed to treat severe scalp psoriasis. Based on the mean costs and benefits of 169 compared sequences, initial treatment with potent or very potent corticosteroids is likely to be most cost effective. The GDG was concerned that very potent corticosteroids, although most effective and cost effective, are an aggressive initial strategy and carry greater risk of steroid related adverse events, which were not captured in the economic model. Thus, they opted to recommend potent corticosteroids first. Vitamin D or vitamin D analogue was found to be a likely cost effective topical therapy after potent corticosteroids, particularly when continuous corticosteroids are to be avoided. Very potent corticosteroids are likely to be most cost effective after unsuccessful trials of potent corticosteroids and vitamin D or vitamin D analogues. A combined product containing calcipotriol monohydrate and betamethasone dipropionate may be cost effective, but only after potent and very potent corticosteroids have failed to bring about response.

Future research

The GDG identified five key areas for future research:

  • In children, young people, and adults with psoriasis, can tools be developed and/or existing ones further refined and validated to:

    • -Assess disease severity and impact in both non-specialist and specialist healthcare settings, to facilitate assessment, appropriate referral, treatment planning and measurement of outcomes

    • -Measure burden and cumulative effect of disease activity, severity, and impact for people with both psoriasis and psoriatic arthritis?

  • What is the impact of methotrexate compared with other approaches to care (for example other systemic non-biological or biological treatments) on risk of significant liver disease in people with psoriasis, and do risk factors such as obesity, alcohol use, or diabetes alter this risk?

  • Does early intervention with systemic treatments improve the long-term prognosis of psoriasis severity, comorbidities (including psoriatic arthritis), or treatment-related adverse effects? Are there any clinical (for example demographic or phenotypic) or laboratory (for example genetic or immune) biomarkers that may identify those most likely to benefit from such treatment?

  • Do structured psoriasis-focussed self-management programmes improve patient confidence, wellbeing, and disease control compared with standard care?

  • In people of all ages:

    • -How should topical therapies be used to maintain safe and effective disease control, and what are the health economic implications?

    • -What are the risks of “real life” long term corticosteroid use? Are particular people at risk, and what strategies can be used to modify or avoid risks?

Notes

Cite this as: BMJ 2012;345:e6712

Footnotes

  • This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

  • The members of the Guideline Development Group were David Chandler, Amelia Ch’ng (from May 2012), Jill Cobb, Paul Hepple, Bernard Higgins, Karina Jackson, Ruth Murphy, Jill Parnham, Jillian Peters, Nancy Pursey (February 2011–April 2012), Silvia Rabar (until February 2011), Eleanor Samarasekera, Laura Sawyer, Natasha Smeaton, Catherine Smith (chair), Claire Strudwicke, Roderick Tucker, Richard Warren, and David Wonderling. Expert advisers were Christine Bundy, James Ferguson, and Neil McHugh

  • Contributors: ES and CHS drafted the article. All authors revised it critically for important intellectual content and approved the final version to be published. All authors are guarantors of this article.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: CHS received financial support from the Department of Health via the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust; this work was undertaken by the National Clinical Guideline Centre, which received funding from NICE (the views expressed in this publication are those of the authors and not necessarily those of the Institute); no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References