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Psoriasis overview

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Psoriasis

About

What is covered

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% in the UK. Psoriasis can occur at any age, although is uncommon in children and the majority of cases occur before 35 years. Psoriasis is associated with joint disease in a significant proportion of patients.
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.
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 pathway focuses 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 healthcare and improved outcomes for people with psoriasis.

Updates

Updates to this pathway

24 November 2015 Apremilast for treating moderate to severe plaque psoriasis (NICE technology appraisal guidance 368) added to systemic therapy for psoriasis.
17 August 2015 Grenz rays therapy for inflammatory skin conditions (NICE interventional procedure guidance 236) added to when to consider second- or third-line treatment.
22 July 2015 Secukinumab for treating moderate to severe plaque psoriasis (NICE technology appraisal guidance 350) added to systemic biological therapy.
23 October 2013 Link to NICE pathway on obesity added.
5 August 2013 Psoriasis quality standard added.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on the assessment and management of psoriasis in an interactive flowchart.

What is covered

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% in the UK. Psoriasis can occur at any age, although is uncommon in children and the majority of cases occur before 35 years. Psoriasis is associated with joint disease in a significant proportion of patients.
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.
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 pathway focuses 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 healthcare and improved outcomes for people with psoriasis.

Updates

Updates to this pathway

24 November 2015 Apremilast for treating moderate to severe plaque psoriasis (NICE technology appraisal guidance 368) added to systemic therapy for psoriasis.
17 August 2015 Grenz rays therapy for inflammatory skin conditions (NICE interventional procedure guidance 236) added to when to consider second- or third-line treatment.
22 July 2015 Secukinumab for treating moderate to severe plaque psoriasis (NICE technology appraisal guidance 350) added to systemic biological therapy.
23 October 2013 Link to NICE pathway on obesity added.
5 August 2013 Psoriasis quality standard added.

Sources

NICE guidance and other sources used to create this pathway.
Psoriasis: assessment and management (2012) NICE guideline CG153
Apremilast for treating moderate to severe plaque psoriasis (2015) NICE technology appraisal guidance 368
Secukinumab for treating moderate to severe plaque psoriasis (2015) NICE technology appraisal guidance 350
Adalimumab for the treatment of adults with psoriasis (2008) NICE technology appraisal guidance 146
Infliximab for the treatment of adults with psoriasis (2008) NICE technology appraisal guidance 134
Etanercept and efalizumab for the treatment of adults with psoriasis (2006) NICE technology appraisal guidance 103
Grenz rays therapy for inflammatory skin conditions (2007) NICE interventional procedure guidance 236
Psoriasis (2013) NICE quality standard 40

Quality standards

Psoriasis quality standard

These quality statements are taken from the psoriasis quality standard. The quality standard defines clinical best practice for psoriasis and should be read in full.

Quality statements

Assessing disease severity

This quality statement is taken from the psoriasis quality standard. The quality standard defines clinical best practice for psoriasis and should be read in full.

Quality statement

People with psoriasis are offered an assessment of disease severity at diagnosis and when response to treatment is assessed.

Rationale

Assessing disease severity in people with psoriasis at diagnosis is important because it is the first step in treatment planning. It provides a benchmark for treatment efficacy to be measured against at all subsequent assessments, which are essential to monitor response to treatment. A holistic assessment needs to take place at diagnosis and when assessing response to treatment that includes reference to the severity and impact of the disease, to enable treatment to be optimised.

Quality measure

Structure
Evidence of local arrangements for people with psoriasis to receive an assessment of disease severity at diagnosis and when response to treatment is assessed.
Data source: Local data collection.
Process
a) Proportion of people with psoriasis who receive an assessment of disease severity at diagnosis.
Numerator – the number of people in the denominator who receive an assessment of disease severity at diagnosis.
Denominator – the number of people with psoriasis.
Data source: Local data collection. Contained in NICE clinical guideline 153 audit support for non-specialist services.
b) Proportion of people with psoriasis who receive an assessment of disease severity when response to treatment is assessed.
Numerator – the number of people in the denominator who receive an assessment of disease severity when response to treatment is assessed.
Denominator – the number of people with psoriasis receiving treatment.
Data source: Local data collection.
Outcomes
a) Women's satisfaction that they were supported in their choice for planned birthing option.
b) Rates of delivery modes for women who have had previous caesarean sections.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with psoriasis to be offered an assessment of disease severity at diagnosis and when response to treatment is assessed.
Healthcare practitioners ensure that people with psoriasis are offered an assessment of disease severity at diagnosis and when response to treatment is assessed.
Commissioners ensure that they commission services for people with psoriasis to be offered an assessment of disease severity at diagnosis and when response to treatment is assessed.

What the quality statement means for patients, service users and carers

People with psoriasis are offered an assessment of how severe their psoriasis is when they are diagnosed and when the response to the treatment is assessed.

Source guidance

Definitions

Assessment The severity of the disease should be assessed at first presentation and to evaluate the efficacy of interventions. It should also be assessed before referral for specialist advice and at each referral point in the treatment pathway.
The assessment includes recording the body surface area affected, any involvement of nails, high-impact and difficult-to-treat sites (for example, the face, scalp, palms, soles, flexures and genitals) and any systemic upset such as fever and malaise, which are common in unstable forms of psoriasis, such as erythroderma or generalised pustular psoriasis.
The Physician's Global Assessment and Patient's Global Assessment tools can be used to support assessment of disease severity. In specialist settings, the Psoriasis Area and Severity Index and Nail Psoriasis Severity Index can also be used.
Response to treatment Response to treatment should be evaluated by an assessment of disease severity at a time appropriate to the treatment. NICE guidance recommends the following timeframes:
  • Within 4 weeks of starting a new topical treatment in adults (within 2 weeks for a very potent corticosteroid in scalp psoriasis and corticosteroids for people with psoriasis of the face, flexures or genitals).
  • Within 2 weeks of starting a new topical treatment in children.
  • Within 3 months of starting phototherapy or systemic non-biological therapy.

Assessing impact of disease

This quality statement is taken from the psoriasis quality standard. The quality standard defines clinical best practice for psoriasis and should be read in full.

Quality statement

People with psoriasis are offered an assessment of the impact of the disease on physical, psychological and social wellbeing at diagnosis and when response to treatment is assessed.

Rationale

Assessing the impact of the disease on people with psoriasis at diagnosis helps identify those who may need specialist support. Psoriasis can be a stigmatising disease affecting quality of life, and its impact on wellbeing cannot be predicted from the severity of the disease. A holistic assessment needs to take place at diagnosis and when assessing response to treatment that includes reference to the impact and severity of the disease, to enable interventions to be tailored appropriately.

Quality measure

Structure
Evidence of local arrangements for people with psoriasis to have an assessment of the impact of the disease on physical, psychological and social wellbeing at diagnosis and when response to treatment is assessed.
Data source: Local data collection.
Process
a) Proportion of people with psoriasis who receive an assessment of the impact of the disease on physical, psychological and social wellbeing at diagnosis.
Numerator – the number of people in the denominator who receive an assessment of the impact of the disease on physical, psychological and social wellbeing at diagnosis.
Denominator – the number of people with psoriasis.
Data source: Local data collection. Contained in NICE clinical guideline 153 audit support for non-specialist services and audit support for specialist services.
b) Proportion of people with psoriasis who receive an assessment of the impact of the disease on physical, psychological and social wellbeing when response to treatment is assessed.
Numerator – the number of people in the denominator who receive an assessment of the impact of the disease on physical, psychological and social wellbeing when response to treatment is assessed.
Denominator – the number of people with psoriasis receiving treatment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with psoriasis to be offered an assessment of the impact of the disease on physical, psychological and social wellbeing at diagnosis and when response to treatment is assessed.
Healthcare practitioners ensure that people with psoriasis are offered an assessment of the impact of the disease on physical, psychological and social wellbeing at diagnosis and when response to treatment is assessed.
Commissioners ensure that they commission services for people with psoriasis to be offered an assessment of the impact of the disease on physical, psychological and social wellbeing at diagnosis and when response to treatment is assessed.

What the quality statement means for patients, service users and carers

People with psoriasis are offered an assessment of how their physical, psychological and social wellbeing is affected by having psoriasis when they are diagnosed and when their response to the treatment is assessed.

Source guidance

Definitions

Assessment The impact of the disease on physical, psychological and social wellbeing should be assessed at first presentation and to evaluate the efficacy of interventions. It should also be assessed before referral for specialist advice and at each referral point in the treatment pathway.
Assessing the impact of psoriasis on physical, psychological and social wellbeing includes asking:
  • what aspects of their 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 that the patient may have levels of distress and not be clinically depressed)
  • if their condition has any impact on their family or carers.
When assessing disease impact, people with psoriasis should be assessed for depression. Children and young people should be asked age-appropriate questions.
The Dermatology Life Quality Index or Children's Dermatology Life Quality Index can be used to support assessment of the impact of the disease on physical, psychological and social wellbeing.
Response to treatment Response to treatment should be evaluated by an assessment of disease severity at a time appropriate to the treatment. NICE guidance recommends the following timeframes:
  • Within 4 weeks of starting a new topical treatment in adults (within 2 weeks for a very potent corticosteroid in scalp psoriasis and corticosteroids for people with psoriasis of the face, flexures or genitals).
  • Within 2 weeks of starting a new topical treatment in children.
  • Within 3 months of starting phototherapy or systemic non-biological therapy.

Referring to specialist services

This quality statement is taken from the psoriasis quality standard. The quality standard defines clinical best practice for psoriasis and should be read in full.

Quality statement

People with psoriasis are referred for assessment by a dermatology specialist if indicated.

Rationale

Referral for assessment by a specialist when needed is important given that people with psoriasis may experience relapsing disease, and the fact that some treatments are only available in specialist care or suitable for intermittent use. Most people with psoriasis will need access to secondary care services at some point. Access to specialist advice and support can improve response to treatment and wellbeing.

Quality measure

Structure
Evidence of local arrangements for people with psoriasis to be referred for assessment by a dermatology specialist if indicated.
Data source: Local data collection.
Process
Proportion of people with psoriasis who are referred for assessment by a dermatology specialist if indicated.
Numerator – the number of people in the denominator who are referred for assessment by a dermatology specialist.
Denominator – the number of people with psoriasis who have an indication for referral for assessment by a dermatology specialist.
Data source: Local data collection. Contained in NICE clinical guideline 153 audit support for non-specialist services.
b) Proportion of people with psoriasis who receive an assessment of the impact of the disease on physical, psychological and social wellbeing when response to treatment is assessed.
Numerator – the number of people in the denominator who receive an assessment of the impact of the disease on physical, psychological and social wellbeing when response to treatment is assessed.
Denominator – the number of people with psoriasis receiving treatment.
Data source: Local data collection.
Outcome
Patient experience.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with psoriasis to be referred for assessment by a dermatology specialist if indicated.
Healthcare practitioners ensure that people with psoriasis are referred for assessment by a dermatology specialist if indicated.
Commissioners ensure that they commission services for people with psoriasis to be referred for assessment by a dermatology specialist if indicated.

What the quality statement means for patients, service users and carers

People with psoriasis are referred to a dermatology specialist for assessment if it is needed.

Source guidance

Definitions

Indications for referral
  • People with generalised pustular psoriasis or erythroderma should be referred immediately for same-day specialist assessment and treatment.
  • Children and young people with any type of psoriasis should be referred to a specialist at presentation.
  • People with psoriasis are indicated for referral for assessment by a dermatology specialist if:
    • there is diagnostic uncertainty or
    • any type of psoriasis is severe or extensive, for example, more than 10% of the body surface is affected or
    • any type of psoriasis cannot be controlled with topical therapy or
    • acute guttate psoriasis needs 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.
  • Any person whose skin condition cannot be managed by their GP will need to be referred for an assessment by a specialist. This could be a: consultant dermatologist, specialist registrar, staff and associate specialist doctor, trust grade doctor, clinical assistant, hospital practitioner, dermatology specialist nurse or accredited or trained GP with a special interest, in a hospital-based dermatology service or a community health facility suitable for specialist care.

Assessing cardiovascular risk

This quality statement is taken from the psoriasis quality standard. The quality standard defines clinical best practice for psoriasis and should be read in full.

Quality statement

Adults with severe psoriasis are offered a cardiovascular risk assessment at diagnosis and at least once every 5 years.

Rationale

Adults with severe psoriasis are at increased risk of cardiovascular disease. Assessing cardiovascular risk in this group allows appropriate intervention for modifiable risk factors such as smoking, alcohol use or high blood pressure to be offered.

Quality measure

Structure
Evidence of local arrangements for adults with severe psoriasis to receive a cardiovascular risk assessment at diagnosis and at least once every 5 years.
Data source: Local data collection.
Process
a) Proportion of adults with severe psoriasis who receive a cardiovascular risk assessment at diagnosis.
Numerator – the number of people in the denominator who receive a cardiovascular risk assessment at diagnosis.
Denominator – the number of adults diagnosed with severe psoriasis.
Data source: Local data collection. Contained in NICE clinical guideline 153 audit support for non-specialist services.
b) Proportion of adults with severe psoriasis diagnosed more than 5 years ago whose most recent cardiovascular risk assessment was within 5 years of diagnosis or the previous assessment.
Numerator – the number of people in the denominator whose most recent cardiovascular risk assessment was within 5 years of diagnosis or the previous cardiovascular risk assessment.
Denominator – the number of adults with severe psoriasis diagnosed more than 5 years ago.
Data source: Local data collection. Contained in NICE clinical guideline 153 audit support for non-specialist services.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for adults with severe psoriasis to be offered a cardiovascular risk assessment at diagnosis and at least once every 5 years.
Healthcare practitioners ensure that adults with severe psoriasis are offered a cardiovascular risk assessment at diagnosis and at least once every 5 years.
Commissioners ensure that they commission services for adults with severe psoriasis to be offered a cardiovascular risk assessment at diagnosis and at least once every 5 years.

What the quality statement means for patients, service users and carers

Adults with severe psoriasis are offered an assessment of their risk of having heart problems when they are diagnosed and at least once every 5 years.

Source guidance

Definitions

Severe psoriasis can be defined as psoriasis that needs, or is likely to need, treatment with phototherapy or systemic agents, or needs hospital admission.
Cardiovascular risk assessment Some validated cardiovascular risk estimation tools for use with adults exclude younger and older people.

Assessing for psoriatic arthritis

This quality statement is taken from the psoriasis quality standard. The quality standard defines clinical best practice for psoriasis and should be read in full.

Quality statement

People with psoriasis having treatment are offered an annual assessment for psoriatic arthritis.

Rationale

Psoriatic arthritis is a form of arthritis that is seen in people with psoriasis. This condition is often undiagnosed, leading to poorer long-term outcomes such as damage to joints and functional ability. Annual assessment for the condition (which may form part of a holistic review of response to treatment and disease severity and impact) could help to identify people with psoriatic arthritis earlier, so that treatment can be planned accordingly and before joint damage occurs.

Quality measure

Structure
Evidence of local arrangements for people with psoriasis having treatment to receive an annual assessment for psoriatic arthritis.
Data source: Local data collection.
Process
Proportion of people with psoriasis having treatment who receive an annual assessment for psoriatic arthritis.
Numerator – the number of people in the denominator who receive an annual assessment for psoriatic arthritis.
Denominator – the number of people with psoriasis having treatment.
Data source: Local data collection. Contained in NICE clinical guideline 153 audit support for non-specialist services and audit support for specialist services.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with psoriasis having treatment to be offered an annual assessment for psoriatic arthritis.
Healthcare practitioners ensure that people with psoriasis having treatment are offered an annual assessment for psoriatic arthritis.
Commissioners ensure that they commission services for people with psoriasis having treatment to be offered an annual assessment for psoriatic arthritis.

What the quality statement means for patients, service users and carers

People with psoriasis having treatment are offered an annual assessment for psoriatic arthritis (a type of joint disease).

Source guidance

Definitions

People with psoriasis having treatments such as active topical therapy (for example, corticosteroids), phototherapy or systemic therapy, should be offered an annual assessment for psoriatic arthritis.
The Psoriasis Epidemiological Screening Tool (PEST) can be used to help assess for psoriatic arthritis, although it does not detect axial arthritis or inflammatory back pain and is not validated in children. However, children should still be clinically assessed for psoriatic arthritis.

Monitoring systemic therapy

This quality statement is taken from the psoriasis quality standard. The quality standard defines clinical best practice for psoriasis and should be read in full.

Quality statement

People with psoriasis receiving systemic therapy are monitored in accordance with locally agreed protocols.

Rationale

Systemic therapy for psoriasis poses a risk of adverse events, for which careful monitoring is needed. It is essential that monitoring is in accordance with national drug guidelines to minimise this risk. Where shared care arrangements are in place, it is important that the roles and responsibilities of healthcare professionals involved in monitoring people with psoriasis receiving systemic therapy are clearly outlined in a formalised local agreement.

Quality measure

Structure
Evidence of local arrangements for people with psoriasis receiving systemic therapy to be monitored in accordance with locally agreed protocols.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with psoriasis receiving systemic therapy to be monitored in accordance with locally agreed protocols.
Healthcare practitioners ensure that people with psoriasis receiving systemic therapy are monitored in accordance with locally agreed protocols.
Commissioners ensure that they commission services for people with psoriasis receiving systemic therapy to be monitored in accordance with locally agreed protocols.

What the quality statement means for patients, service users and carers

People with psoriasis receiving drug treatment known as 'systemic therapy' are monitored according to a locally agreed procedure.

Source guidance

Definitions

Systemic therapy includes biological and non-biological therapies.
Responsibility for use of systemic therapy should be in specialist consultant-led settings only. Certain aspects of supervision and monitoring may be delegated to other healthcare professionals and completed in non-specialist settings. In such cases, the arrangements should be formalised.
Monitoring should be in accordance with locally agreed protocols that incorporate national accredited drug guidelines and policy.
Relevant national accredited drug guidelines include the following:

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

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.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

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.

Paths in this pathway

Pathway created: October 2011 Last updated: September 2016

© NICE 2016

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