Diagnosis and management of psoriasis and …

1 Diagnosis and management of psoriasis and psoriatic arthritis in adults A national clinical guidelineOctober 2010121 Scottish Intercollegiate Guidelines NetworkPart of NHS Quality Improvement ScotlandSIGNHelp us to improve SIGN guidelines -click here to complete our survey KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONSLEVELS OF EVIDENCE1++High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias1+Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias1 -Meta-analyses, systematic reviews, or RCTs with a high risk of bias2++ High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal2+Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal2 - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal3 Non-analytic studies, eg case reports, case series4 Expert opinionGRADES OF RECOMMENDATIONNote: The grade of recommendation relates to the strength of the evidence on which the recommendation is based.

2 It does not reflect the clinical importance of the At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of resultsBA body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; orExtrapolated evidence from studies rated as 1++ or 1+CA body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; orExtrapolated evidence from studies rated as 2++DEvidence level 3 or 4; orExtrapolated evidence from studies rated as 2+GOOD PRACTICE POINTS Recommended best practice based on the clinical experience of the guideline development groupNHS Evidence has accredited the process used by Scottish Intercollegiate Guidelines Network to produce guidelines.

3 Accreditation is valid for three years from 2009 and is applicable to guidance produced using the processes described in SIGN 50: a guideline developer s handbook, 2008 edition ( ). More information on accreditation can be viewed at Quality Improvement Scotland (NHS QIS) is committed to equality and diversity and assesses all its publications for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality aims are addressed in every guideline. This methodology is set out in the current version of SIGN 50, our guideline manual, which can be found at The EQIA assessment of the manual can be seen at The full report in paper form and/or alternative format is available on request from the NHS QIS Equality and Diversity care is taken to ensure that this publication is correct in every detail at the time of publication.

4 However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site This document is produced from elemental chlorine-free material and is sourced from sustainable Intercollegiate Guidelines NetworkDiagnosis and management of psoriasis and psoriatic arthritis in adults A national clinical guidelineOctober 2010 Diagnosis anD management of psoriasis anD Psoriatic arthritis in aDultsISBN 978 1 905813 67 4 Published October 2010citation textScottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults. Edinburgh: SIGN; 2010. (SIGN publication no.)

5 121). [cited 12 Oct 2010]. Available from URL: consents to the photocopying of this guideline for the purpose of implementation in NHSS cotlandscottish intercollegiate guidelines network elliott house, 8 -10 hillside crescent edinburgh eh7 5ea introduction .. The need for a guideline .. Remit of the guideline .. Definitions .. Statement of intent ..22 Key recommendations ..43 care pathway ..64 Diagnosis , assessment and Diagnosis .. Comorbidities .. Monitoring disease activity and response to treatment ..125 treatment in primary care .. Topical therapy .. Scalp, nail, facial and flexural Concordance-related issues .. Other interventions .. Referral to secondary care .. Annual review ..196 treatment of psoriatic arthritis in secondary care.

6 Organisation of care.. Pharmacological treatment ..207 treatment of psoriasis in secondary care .. Organisation of care .. Phototherapy and photochemotherapy .. Pharmacological treatment ..288 Provision of information .. Provision of information and patient education .. Checklist for provision of information .. Sources of further information ..359 implementing the guideline .. Resource implications of key recommendations .. Auditing current practice .. Implementation strategy .. Additional advice to NHSS cotland from NHS Quality Improvement Scotland and the Scottish Medicines Consortium ..39 Diagnosis anD management of psoriasis anD Psoriatic arthritis in aDults10 the evidence base .. Systematic literature review .. Recommendations for research.

7 Review and updating ..4211 Development of the guideline .. Introduction .. The guideline development group .. Acknowledgments .. Consultation and peer review ..44abbreviations ..47annexes ..49references ..61 Diagnosis anD management of psoriasis anD Psoriatic arthritis in aDults11 introDuction1 the neeD for a guiDelinePsoriasis is a common chronic inflammatory, immune-mediated disease that predominantly affects the skin and Given the estimated population prevalence of psoriasis of to 3%, over 100,000 people are affected in Approximately 20% of people with psoriasis may also have psoriatic arthritis (PsA), ie 20,000 people in Onset may occur at any age but peaks in the second and third decades of life. The course of the disease is characterised by relapses and remissions but the condition tends to persist throughout life.

8 Over the past 20 years there have been many developments in the understanding of the genetic, molecular and cellular mechanisms that underlie these inflammatory processes and many new and effective treatments have been negative impact of these diseases on health-related quality of life (QoL) is comparable to that of ischaemic heart disease, diabetes, depression and In many instances this disability can be reduced by effective treatment. In addition, severe psoriasis and PsA are associated with an increase in the standardised mortality ratio (SMR). In a study comparing patients with and without psoriasis in the United Kingdom General Practice Research Database, men with severe psoriasis died on average years younger (95% CI to years, p< ) than controls and women with severe psoriasis years younger (95% CI to years, p< ) than The visible nature of psoriasis can create a sense of stigmatisation amongst those Swollen joints, joint deformity, and physical disability in patients with PsA can lead to experiences of and PsA vary widely in their severity.

9 In mild psoriasis , topical treatment in primary care can be effective if used appropriately. Severe forms need prompt and intensive treatment, usually in secondary care, with phototherapy, systemic treatment, biologic treatment or inpatient treatment. The varied manifestations of PsA may be difficult to recognise, particularly in the absence of an acute phase response. General practitioners (GPs) may be uncertain when to refer patients to secondary care and may be unaware of the treatments available to their patients In both primary and secondary care, the biological severity of the disease and the resulting disability are not always fully explored and The management of patients with the combination of severe psoriasis and PsA may be particularly challenging and require close collaboration between several specialties.

10 Despite the availability of a variety of treatments, effective and safe control of disease activity is not always easy to achieve and there is no standard therapeutic approach. For these and other reasons there is considerable dissatisfaction amongst patients concerning psoriasis and its reMit of the OvERALL OBjECTIvESThis guideline provides recommendations based on current evidence for best practice in the Diagnosis and management of psoriasis and PsA in adults. It covers early Diagnosis of PsA, screening for comorbidities, assessment of disease severity, non-pharmacological treatment, psychological interventions, occupational health, topical treatment, phototherapy, systemic therapy, biologic treatment, referral pathways and the provision of patient information.