Psoriasis

Short Text

The assessment and management of psoriasis

Introduction

This pathway covers the assessment and management of psoriasis in adults, young people and children.
Psoriasis is an inflammatory skin disease that typically follows a relapsing and remitting course. The prevalence of psoriasis is estimated to be around 1.3-2.2%Parisi R, Symmons D, Griffiths CEM and Ashcroft DM. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. Personal communication: 04/04/2012 in the UK. Psoriasis can occur at any age, although is uncommon in children (0.71%) and the majority of cases occur before 35 years. Psoriasis is associated with joint disease in a significant proportion of patients (reported in 1 study at 13.8%).Ibrahim G, Waxman R, Helliwell PS (2009). The prevalence of psoriatic arthritis in people with psoriasis. Arthritis and Rheumatism 15; 61(10):1373­–8
Plaque psoriasis is characterised by well-delineated red, scaly plaques that vary in extent from a few patches to generalised involvement. It is by far the most common form of the condition (about 90% of people with psoriasis). Other types of psoriasis include guttate psoriasis and pustular (localised or generalised) forms. Distinctive nail changes occur in around 50% of all those affected and are more common in people with psoriatic arthritis.
Healthcare professionals and patients using the term psoriasis are usually referring to plaque psoriasis, and unless stipulated otherwise, 'psoriasis' is used in this way in the pathway. Psoriasis for many people results in profound functional, psychological, and social morbidity, with consequent reduced levels of employment and income. Factors that contribute to this include symptoms related to the skin (for example, chronic itch, bleeding, scaling and nail involvement), problems related to treatments, psoriatic arthritis, and the effect of living with a highly visible, stigmatising skin disease. Even people with minimal involvement state that psoriasis has a major effect on their life. Several studies have also reported that people with psoriasis, particularly those with severe disease, may be at increased risk of cardiovascular disease, lymphoma and non-melanoma skin cancer.
A wide variety of treatment options are available. Some are expensive and some are accessed only in specialist care; all require monitoring. The treatment pathway in this NICE pathway begins with active topical therapies. The Guideline Development Group (GDG) acknowledged that the use of emollients in psoriasis was already widespread and hence the evidence review was limited to active topical therapies for psoriasis. Please refer to the BNF and cBNF for guidance on use of emollients.
NICE has published technology appraisals on the first-line use of biologic drugs, and this pathway incorporates recommendations from these appraisals where relevant (listed in alphabetical order). Biologic treatment is complicated by a poor response in a minority of people, and this pathway reviewed the literature for the use of a second biological drug.
For most people, psoriasis is managed in primary care, with specialist referral being needed at some point for up to 60% of people. Supra-specialist care (level 4)Level 4 care is defined as usually taking place entirely within an acute hospital and is carried out by consultant dermatologists and a range of other healthcare professionals with special skills in the management of complex and/or rare skin disorders – see Quality Standards for Dermatology: Providing the Right Care for People With Skin Conditions tertiary care is required in the very small minority with especially complex, treatment resistant and/or rare manifestations of psoriasis.
A recent UK audit in the adult population demonstrated wide variations in practice, and in particular, access to specialist treatments (including biological therapy), appropriate drug monitoring, specialist nurse support and psychological services.Eedy DJ, Griffiths CE, Chalmers RJ, Ormerod AD, Smith CH, Barker JN et al. (2009) Care of patients with psoriasis: an audit of U.K. services in secondary care. British Journal of Dermatology. 160 (3): 557-64
This pathway aims to provide clear recommendations on the management of all types of psoriasis in children, young people and adults (including the elderly). The term 'people' is used to encompass all ages. 'Children' refers to those up to 12 years, who become 'young people' thereafter, before merging with the adult population by 18 years of age. The GDG have focused on areas most likely to improve the management and delivery of care for a majority of people affected, where practice is very varied and/or where clear consensus or guidelines on treatments are lacking. It is hoped that this pathway will facilitate the delivery of high-quality health-care and improved outcomes for people with psoriasis.

Source guidance

The NICE guidance that was used to create the pathway.
Psoriasis: the assessment and management of psoriasis. NICE clinical guideline 153 (2012)
Ustekinumab for the treatment of adults with moderate to severe psoriasis. NICE technology appraisal guidance 180 (2009)
Adalimumab for the treatment of adults with psoriasis. NICE technology appraisal guidance 146 (2008)
Infliximab for the treatment of adults with psoriasis. NICE technology appraisal guidance 134 (2008)
Etanercept and efalizumab for the treatment of adults with psoriasis. NICE technology appraisal guidance 103 (2006)
Golimumab for the treatment of psoriatic arthritis. NICE technology appraisal guidance 220 (2011)
Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis. NICE technology appraisal guidance 199 (2010)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning guides

Commissioning guides provide information on key clinical and service-related issues to consider during the commissioning process. Each guide contains a commissioning and benchmarking tool, which is a resource that can be used to estimate and inform the level of service needed locally as well as the cost of local commissioning decisions.
Biologic drugs for the treatment of inflammatory disease in rheumatology, dermatology and gastroenterology

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Psoriasis
Adalimumab for psoriasis
Etanercept and efalizumab for the treatment of psoriasis
Infliximab for psoriasis
Ustekinumab stekinumab for the treatment of adults with moderate to severe psoriasis

Updates to this pathway

26 October 2012 Minor maintenance.

Supporting information

Assessment of severity and impact of psoriasis

Assess the severity and impact of psoriasis to evaluate the efficacy of interventions. part of 1.2.1.2
Assess whether people with any type of psoriasis are depressed when assessing disease severity and impact, and when escalating therapy. If appropriate offer information, advice and support in line with the pathway on depression. 1.2.3.5

Assessing severity

When assessing the disease severity, record:
  • the results of a static Physician's Global AssessmentSee Feldman SR, Krueger GG (2005) Psoriasis assessment tools in clinical trials. Ann Rheum Dis 64 (Suppl 2): ii65–ii68. (PGA) (classified as clear, nearly clear, mild, moderate, severe or very severe)
  • the patient's assessment of current disease severity, for example, using the static Patient's Global Assessment (classified as clear, nearly clear, mild, moderate, severe or very severe)
  • the body surface area affected
  • any involvement of nails and high-impact and difficult-to-treat sites (for example, 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. 1.2.1.3

Assessing impact

Assess the impact of any type of psoriasis on physical, psychological and social wellbeing by asking:
  • what aspects of daily living are affected by the person's psoriasis
  • how the person is coping with their skin condition and any treatments they are using
  • if they need further advice or support
  • if their psoriasis has an impact on their mood
  • if their psoriasis causes them distress (be aware the patient may have levels of distress and not be clinically depressed)
  • if their condition has any impact on their family or carers.
Ask children and young people age-appropriate questions. 1.2.1.6
Specialist settings
In specialist settings, use a validated tool to assess severity, for example the Psoriasis Area and Severity Index (PASI) in adults and for young children use the PGA. Be aware that:
  • PASI and body surface area are not validated for use in children and young people
  • erythema may be underestimated in people with darker skin types, such as skin types V and VI on the Fitzpatrick scaleFitzpatrick scale: type I: always burns, never tans; type II: usually burns, tans with difficulty, type III: sometimes mild burn, gradually tans; type IV: rarely burns, tans with ease; type V: very rarely burns, tans very easily; type VI: never burns, tans very easily. . 1.2.1.4
Use the Nail Psoriasis Severity IndexSee Rich P, Scher RK (2003) Nail Psoriasis Severity Index: A useful tool for evaluation of nail psoriasis. JAAD 49: 206–212. to assess nail disease in specialist settings:
  • if there is a major functional or cosmetic impact or
  • before and after treatment is initiated specifically for nail disease. 1.2.1.5
In specialist settings and if practical in non-specialist settings, use a validated tool to assess the impact of any type of psoriasis on physical, psychological and social wellbeing, for example the:
For more information on using the DLQI see using systemic biological therapy in this pathway. [1.2.1.7]

Glossary

First-line therapy describes traditional topical therapies (such as corticosteroids, vitamin D and vitamin D analogues, dithranol and tar preparations).
Second-line therapy includes the phototherapies (broad- or narrow-band ultraviolet B light and psoralen plus UVA light [PUVA]) and systemic non-biological agents such as ciclosporin, methotrexate and acitretin.
Third-line therapy refers to systemic biological therapies such as the tumour necrosis factor antagonists adalimumab, etanercept and infliximab, and the monoclonal antibody ustekinumab that targets interleukin-12 (IL-12) and IL-23.
Encompass the face, flexures, genitalia, scalp, palms and soles and are so-called because psoriasis at these sites may have especially high impact, may result in functional impairment, requires particular care when prescribing topical therapy and can be resistant to treatment.

Person with psoriasis

Person with psoriasis

Principles of care

Principles of care

Principles of care

Offer people with any type of psoriasis support and information tailored to suit their individual needs and circumstances, in a range of different formats, so they can confidently understand:
  • their diagnosis and treatment options
  • relevant lifestyle risk factors
  • when and how to treat their condition
  • how to use prescribed treatments safely and effectively (for example, how to apply topical treatments and how to minimise the risk of side effects through monitoring for safety of medicines)
  • when and how to seek further general or specialist review
  • strategies to deal with the impact of psoriasis on physical, psychological and social wellbeing.
When offering treatments to a person with any type of psoriasis:
  • ensure the treatment strategy is developed to meet the person's health goals so that the impact of their condition is minimised and use relevant assessment tools to ensure these goals are met
  • take into account the age and individual circumstances of the person, disease phenotype, severity and impact, co-existing psoriatic arthritis, comorbidities and previous treatment history
  • discuss the risks and benefits of treatment options with the person (and their families or carers where appropriate). Where possible include use of absolute risk and natural frequency see appendix B of the NICE guideline.
  • discuss the importance of adherence to treatment for optimising outcomes.
For more information about involving patients in decisions and supporting adherence see the medicines adherence pathway.
Assess whether support and information need updating or revising at every review or interaction with the person, in particular:
  • during transition from children's services to adult services
  • when new interventions become available
  • when the person's disease severity or circumstances (for example, in terms of comorbidities or lifestyle) change.
Provide a single point of contact to help people with all types of psoriasis (and their families or carers where appropriate) access appropriate information and advice about their condition and the services available at each stage of the care pathway.
NICE has produced guidance on the components of good patient experience in adult NHS services. Follow the recommendations in the pathway on patient experience in adult NHS services.

Source guidance

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CG153

Assessment

View the 'Assessment of psoriasis and comorbidities' path

Topical therapy

View the 'Topical therapy for psoriasis' path

Specialist referral

Specialist referral

Specialist referral

Refer children and young people with any type of psoriasis to a specialist at presentation.
Following assessment in a non-specialist setting, refer people for dermatology specialist advice if:
  • there is diagnostic uncertainty or
  • any type of psoriasis is severe (as defined on the static Physician's Global Assessment) or extensive, for example more than 10% of the body surface area is affected or
  • any type of psoriasis cannot be controlled with topical therapy or
  • acute guttate psoriasis requires phototherapy or
  • nail disease has a major functional or cosmetic impact or
  • any type of psoriasis is having a major impact on a person's physical, psychological or social wellbeing.
People with generalised pustular psoriasis or erythroderma should be referred immediately for same-day specialist assessment and treatment.
As soon as psoriatic arthritis is suspected, refer the person to a rheumatologist for assessment and advice about planning their care.

Source guidance

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CG153

Phototherapy

View the 'Phototherapy for psoriasis' path

Systemic therapy

View the 'Systemic therapy for psoriasis' path

Systemic biological therapy

View the 'Systemic biological therapy for psoriasis and psoriatic arthritis' path

Paths in this pathway

Pathway created: October 2012 Last updated: October 2012

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