A holistic approach is essential at all stages of psoriasis management

A holistic approach is essential at all stages of psoriasis management continued

Remit of the guideline

NICE CG153 considers the management of all people with psoriasis—from those with mild disease to individuals at the more severe end of the spectrum who require biologic treatments. The recommendations emphasise the importance of holistic assessment of patients at all stages.^6,7

It is important to note that the role of emollients was not specifically reviewed during the development of the NICE guideline and, in the absence of robust evidence to change this practice, the treatment pathway starts with the use of active topical therapies on the assumption that emollients have already been prescribed; emollients can help to soften plaques and improve cosmetic appearance and should be continued throughout treatment and alongside topical therapies and biologic agents.

The guideline does not cover the diagnosis of psoriasis as it is based on history, skin appearance, and presence of typical lesions, and there are no agreed diagnostic criteria or tests. Instead, NICE advises on other areas where there is wide variation in practice, and where the most significant improvements can be made in quality of care and availability of effective treatments.^6,7

This article highlights key points in the management of psoriasis that are relevant to GPs.

Initial assessment

It is recommended that a thorough examination of the whole patient is performed to estimate the total body surface area affected when a patient first presents with suspected psoriasis. The involvement of nails, high-impact and difficult-to-treat sites (for example the face, scalp, palms, and genitals), should be documented in particular. It is important to record:^6,7

• severity:
  • using the static Physician’s Global Assessment (classified as clear, nearly clear, mild, moderate, severe, or very severe)⁹
  • patient 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 impact of any type of psoriasis on physical, psychological, and social wellbeing, using a validated tool, such as the Dermatology Life Quality Index (DLQI; www.dermatology.org.uk/quality/dlqi/quality-dlqi.html)¹⁰ if practical (this tool can also be used in the assessment of other skin conditions such as eczema and acne)
  • any systemic upset such as fever and malaise, which are common in unstable forms of psoriasis such as erythroderma or generalised pustular psoriasis.

Disease severity and impact of psoriasis should be assessed before referral for specialist advice and at each referral point in the treatment pathway.^6,7

Psoriatic arthritis
Patients with any type of psoriasis should be assessed annually for psoriatic arthritis using a validated tool, such as the Psoriasis Epidemiological Screening Tool (PEST).¹¹ This is particularly important in the first 10 years of onset of psoriasis as this is the period during which the onset of psoriatic arthritis is most likely to occur (this was noted from the expertise of relevant GDG members).

Co-morbidities
The NICE guideline highlights that people with psoriasis, particularly those with severe disease, may be at higher risk of co-morbidities, such as cardiovascular disease. Where appropriate, individuals should be offered tailored lifestyle advice and support for behavioural change, for example, smoking cessation advice, cardiovascular risk modification, or psychological support.

A holistic approach is essential at all stages of psoriasis management continued

Initial treatment

It is important to discuss the following aspects with the patient as differences in cosmetic acceptability may improve adherence: the different formulations available for the treatment of psoriasis, practical aspects of application, and the sites to be treated. As a guide, healthcare professionals should advocate the use of:^6,7

• cream, lotion, or gel for widespread psoriasis
• lotion, solution, or gel for the scalp or hair-bearing areas
• ointment to treat areas with very adherent scale.

The full NICE guideline contains several algorithms—the algorithm on topical treatment strategies is shown in Figure 1.^7,12

First-line treatment

• Trunk or limb psoriasis:^6,7
  • adults—potent corticosteroid applied once daily plus vitamin D or a vitamin-D analogue applied once daily (but applied at separate times, for example, one in the morning and the other in the evening) for up to 4 weeks
  • children and young people—calcipotriol applied once daily (for those aged over 6 years) or a potent corticosteroid applied once daily (for those over 1 year of age) can be considered
• Scalp psoriasis—potent corticosteroid applied once daily for up to 4 weeks as initial treatment; a different formulation can be considered if this does not result in clearance, near clearance, or satisfactory control. Topical keratolytic agents can be used in addition or instead of a corticosteroid product to remove adherent scale (e.g. agents containing salicylic acid, emollients, and oils). Coal-tar-based shampoos alone should not be offered for severe scalp psoriasis
• Psoriasis affecting the face, flexures, or genitals—a short-term mild or moderate potency corticosteroid applied once or twice daily (for a maximum of 2 weeks). Healthcare professionals should ensure that patients understand that they must avoid prolonged continuous use as these areas are particularly vulnerable to steroid atrophy.

Review
Arrange a review appointment 4 weeks after starting topical therapy in adults and in 2 weeks for children.

Referral

Referral for psoriasis is indicated for adults if:^6,7

• there is diagnostic uncertainty
• the disease is severe or extensive (e.g. >10% body surface area is affected)
• the disease is not controlled by topical therapy
• the individual has acute guttate psoriasis requiring phototherapy
• the individual has nail disease that has a major functional or cosmetic impact
• the disease is having a major impact on the individual’s physical, psychological, or social wellbeing
• psoriatic arthritis is suspected (refer to a rheumatologist).

People with generalised pustular psoriasis or erythroderma should be referred urgently for same-day assessment. Children and young people should be referred for any type of psoriasis.^6,7

The use of systemic non-biologic and biologic therapy is discussed in the NICE guideline, which highlights that responsibility for the use of these interventions should be in specialist settings only.^6,7

A holistic approach is essential at all stages of psoriasis management continued

Implications for primary care

Skin complaints are the most common reason for patients presenting to their GP.¹³ Although more GP Speciality Training Schemes are recognising the importance of including dermatology placements, many GPs will have received no formal dermatology training. It is hoped that NICE CG153 on psoriasis will give GPs and trainees increased confidence on the management of psoriasis and when to refer to secondary care.

The key priorities for implementation of the guideline in primary care are to assess disease severity and the impact of psoriasis on wellbeing. Patient consultations are limited by time and some GPs may feel that the use of yet another screening tool can impede clinical judgment and ruin the flow of a consultation; to those with concerns, I would stress that the NICE guideline is intended to improve patient assessment and facilitate information flow between healthcare professionals and not to replace clinical skills. As with other questionnaires, patients can be given these items to complete at their leisure and to discuss at future appointments. In the new era of commissioning and collaboration, another way round this may be to look at pooling resources in order to cover a wider population (e.g. compiling a disease register such as those used for other chronic diseases or using a healthcare professional from one practice to screen patients from several practices). Pharmacists and voluntary organisations also have a role to play in providing advice and support for patients.

Figure 1: Topical treatment strategies for adults with psoriasis7,12
C

Conclusion

NICE CG153 provides clear guidance on the assessment and management of patients with psoriasis, and the identification of patients at risk of psoriatic arthritis. It is anticipated that improved management of psoriasis and early detection of potential co-morbidities will result in improved care, health, and quality of life outcomes for patients with this disease.

For further information, and to access the guideline, support tools, and advice for patients, please visit: www.nice.org.uk/CG153.

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Key points

A detailed examination of the patient’s skin should be performed when an individual presents with suspected psoriasis Take into account the patient’s perception of disease severity and psychological impact when discussing management as there can be a mismatch between the clinician’s assessment of severity and the effect that psoriasis has on the patient’s day-to-day life The aims and expectations of treatment should be discussed with the patient and this should be considered when prescribing or changing treatment Patients with severe psoriasis are potentially at increased risk of diabetes, cardiovascular disease, and depression, and should be offered risk assessment, using a validated tool where appropriate Screening for psoriatic arthritis should be performed at presentation and yearly for the first 10 years following diagnosis; a validated tool such as the PEST should be used A follow-up appointment should be arranged 4 weeks after initiating treatment or escalating treatment. PEST=Psoriasis Epidemiological Screening Tool

GP commissioning take home messages for England

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead CCGs should ensure that the easy to use algorithm is brought to the attention of primary care staff to guide management of psoriasis The advice on using separate preparations of potent corticosteroid and vitamin D/vitamin-D analogues applied at different times of day (unless compliance is an issue) rather than a combined preparation is worthy of special emphasis CCG formularies should identify cost-effective preparations of emollients, potent corticosteroids, and vitamin D analogues (most of which are available at low acquisition cost) CCGs may wish to explore the use of GPwSI or nurse-led community services to avoid fixed PbR tariff costs CCGs should agree with specialists a formulary and costing for non-PbR drugs, such as biologic agents, and also initiate shared-care schemes with primary care for monitoring of other drugs, including methotrexate Tariff costs for dermatology outpatients = £112 (new), £69 (follow up); phototherapy £74 (outpatient procedure).a CCG=clinical commissioning groups; PbR=Payment by Results awww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132654

Table 1: Psoriasis Epidemiological Screening Tool11
Question	Yes	No
Have you ever had a swollen joint (or joints)?
Has a doctor ever told you that you have arthritis?
Do your fingernails 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 ‘yes’. A total score of 3 or more is indicative of psoriatic arthritis (sensitivity 0.92, specificity 0.78, positive predictive value 0.61, negative predictive value 0.95)
Ibrahim G, Buch M, Lawson C et al. Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire. Clin Exp Rheumatol 2009; 27 (3): 469–474. Reproduced with kind permission from Clinical and Experimental Rheumatology

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NICE implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 153 (CG153) on Psoriasis: assessment and management of psoriasis. The tools are now available to download from the NICE website: www.nice.org.uk/CG153 NICE support for commissioners Commissioning guide: biologic drugs for the treatment of inflammatory disease in rheumatology, dermatology and gastroenterology  This guide focuses on commissioning biologic drugs for the treatment of inflammatory disease. Costing report  Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline. Costing template  Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets. NICE support for service improvement systems and audit Baseline assessment tool  The baseline assessment is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations. Clinical audit tools  Clinical audit tools are developed to help with clinical audit. They contain clinical audit standards, a data collection form, and an action plan template. Key to NICE implementation icons   NICE support for commissioners Support package for commissioners and others for quality standards NICE guide for commissioners NICE cost impact support for guidance (selection from national report/local template/costing statement, dependent on topic)   NICE support for service improvement systems and audit Forward planner 'How to' guides (generic advice on processes) Local government briefings (with Centre for Public Health Excellence) Baseline assessment tool for guidance Audit support including electronic data collection tools E-learning modules (commissioned)   NICE support for education and learning Clinical case scenarios Learning packages including slide sets Podcasts Shared learning and other local best practice examples

A holistic approach is essential at all stages of psoriasis management continued

Acknowledgments

The author would like to thank the work of all of the GDG members in developing the guideline and to Rod Tucker, Paul Hepple, Ellie Samarsekera, Amelia Ch’ng, and Jill Parnham for reviewing this article.

References

1. Parisi R, Symmons D, Griffiths C et al. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol 2012; doi: 10.1038/jid.2012.339.
2. The Health and Social Care Information Centre—Workforce Directorate. General and
   personal medical services 2001–2011. London: HSCIC, 2012.
3. Eedy D, Griffiths C, Chalmers R et al. Care of patients with psoriasis: an audit of UK services in secondary care. Br J Dermatol 2009; 160 (3): 557–564.
4. The King’s Fund. Improving the quality of care in general practice. Report of an independent inquiry commissioned by the King’s Fund. London: The King’s Fund, 2011. Available at: www.kingsfund.org.uk/publications/improving-quality-care-general-practice
5. The Patients Association. Primary care, patients and GPs—partners in care? Harrow: The Patients Association, 2012. Available at:
6. National Institute for Health and Care Excellence. Psoriasis: the assessment and management of psoriasis. Clinical Guideline 153. London: NICE, 2012. Available at: guidance.nice.org.uk/CG153  
7. National Clinical Guideline Centre. Psoriasis: assessment and management of psoriasis. London: NCGC, 2012. Available at: guidance.nice.org.uk/CG153  
8. Rapp S, Feldman S, Exum M et al. Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol 1999; 41 (3 Pt 1): 401–407.
9. Feldman S, Krueger G. Psoriasis assessment tools in clinical trials. Ann Rheum Dis 2005; 64 Suppl 2: ii65–68.
10. Finlay A, Khan G. Dermatology Life Quality Index (DLQI)— a simple measure for routine clinical use. Clin Exp Dermatol 1994; 19 (3): 210–216.
11. Ibrahim G, Buch M, Lawson C et al. Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire. Clin Exp Rheumatol 2009; 27 (3): 469–474.
12. Samarasekera E, Sawyer L, Parnham J, Smith C. Assessment and management of psoriasis: summary of NICE guidance. BMJ 2012; 345: e6712 doi: 10.1136/bmj.e6712
13. Schofield J, Grindlay D, Williams H. Skin conditions in the UK; a health needs assessment. Nottingham: Centre of Evidence Based Dermatology, 2009. Available at: G

Dr Natasha Smeaton
GP, London
Member of Guideline Development Group

View the eGuidelines.co.uk disease area hub on skin at: eguidelines.co.uk/hub/skin