Excerpt

Psoriasis is a common, chronic disease, which for many people, is associated with profound functional, psychological and social morbidity and important comorbidities. Effective treatments are available. Some treatments are expensive; all require appropriate monitoring and some may only be accessed in specialist care settings. Evidence indicates that a substantial proportion of people with psoriasis are currently dissatisfied with their treatment.

This guideline aims to provide clear recommendations on the assessment and management of psoriasis for all people with psoriasis. The diagnosis of psoriasis has not been included within the scope, partly for pragmatic reasons given that to cover psoriasis management itself is a considerable task, but also because there are no agreed diagnostic criteria or tests available and accurate diagnosis remains primarily a clinical one. In considering which specific aspects of psoriasis management to address, the guideline development group have focussed 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. We have therefore addressed how to holistically assess people with psoriasis at all stages in the treatment pathway, the use of first, second and third line interventions and when to escalate therapy, and the role of psychological interventions and self-management strategies. We have avoided categorical description of what constitutes particular levels of disease severity, for example ‘mild’ or ‘moderate and severe’ excepting disease severity criteria for plaque psoriasis already described by NICE in order to qualify for biological therapy. There are no widely accepted definitions that are applicable to all situations and it is a contentious subject. Instead we emphasise the importance of measuring disease severity and impact to individualise care, and plan and evaluate management. There are also a number of key areas that we have not addressed for a variety of reasons. First, we have not evaluated the role of emollients in the treatment of psoriasis. These are widely prescribed and clinical experience suggests that they are used with benefit by patients. In the absence of robust RCT or high quality studies to inform recommendations to change this practice, and the fact that all placebo controlled trials involving topicals use a vehicle (which will have emollient properties) in the placebo arm, the treatment pathway starts on the assumption that when appropriate, emollients have already been prescribed. Secondly, we have not included fumaric acid esters in our evaluation of second line therapies. This intervention is not licensed for any indication in the UK and therefore cannot be included.

Contents

• Guideline development group members
• Acknowledgments
• 1. Introduction
  • 1.1. Epidemiology
  • 1.2. Clinical features
  • 1.3. Disease impact
  • 1.4. Comorbidities
  • 1.5. Approach to Management
  • 1.6. Service configuration and pathways of care
  • 1.7. Psoriasis in children and young people
  • 1.8. Aims of the Guideline
• 2. Patient experience of living with psoriasis
• 3. Development of the guideline
  • 3.1. What is a NICE clinical guideline?
  • 3.2. Remit
  • 3.3. Who developed this guideline?
  • 3.4. What this guideline covers
  • 3.5. What this guideline does not cover
  • 3.6. Relationships between the guideline and other NICE guidance
• 4. Methods
  • 4.1. Developing the review questions and outcomes
  • 4.2. Searching for evidence
  • 4.3. Evidence of effectiveness
  • 4.4. Evidence of cost-effectiveness
  • 4.5. Developing recommendations
• 5. Guideline summary
  • 5.1. Key priorities for implementation
  • 5.2. Full list of recommendations
  • 5.3. Key future research recommendations
  • 5.4. Algorithms
• 6. Principles of care
  • 6.1. Methodological introduction
  • 6.2. Self-management support (provided by a nurse specialist/trained practice nurse) vs. standard care
  • 6.3. Additional application information vs. standard information for use of dithranol
  • 6.4. Decision board aid vs. standard consultation
  • 6.5. Cost effectiveness evidence
  • 6.6. Recommendations and link to evidence
• 7. Assessment and referral
  • 7.1. Assessment tools for disease severity and impact and referral for specialist care
  • 7.2. Assessment and referral for psoriatic arthritis
  • 7.3. Specialist referral for psoriatic arthritis
  • 7.4. Identification of comorbidities
• 8. Topical therapy
  • 8.1. Topical therapies for trunk and limb psoriasis
  • 8.2. Topical therapies for high impact or difficult sites
• 9. Phototherapy
  • 9.1. UVB (broadband and narrowband) and PUVA
  • 9.2. Phototherapy combined with acitretin
  • 9.3. Dithranol, coal tar and vitamin D or vitamin D analogues combined with UVB
  • 9.4. Phototherapy, systemic therapy (biological and non-biological), tar and risk of skin cancer
• 10. Systemic non-biological therapy
  • 10.1. Methodological introduction
  • 10.2. Methotrexate vs placebo for induction of remission
  • 10.3. Methotrexate vs ciclosporin for induction of remission
  • 10.4. Acitretin vs placebo for induction of remission
  • 10.5. Increasing vs decreasing acitretin dosing schedule for induction of remission
  • 10.6. Increasing vs constant acitretin dosing schedule for induction of remission
  • 10.7. Ciclosporin vs placebo for induction of remission
  • 10.8. Ciclosporin dosage comparisons for induction of remission
  • 10.9. Ciclosporin vs placebo for maintenance of remission
  • 10.10. Intermittent (abrupt cessation) vs continuous ciclosporin for maintenance of remission
  • 10.11. Intermittent (taper to withdraw) vs continuous (taper to minimum dose) ciclosporin for the maintenance of remission
  • 10.12. Ciclosporin dosage comparisons for maintenance
  • 10.13. Ciclosporin vs placebo for induction of remission in palmoplantar pustulosis
  • 10.14. Time to maximum effect
  • 10.15. Recommendations and link to evidence
• 11. Methotrexate and risk of hepatotoxicity
  • 11.1. Methodological introduction
  • 11.2. Adults
  • 11.3. Children
  • 11.4. Recommendations and link to evidence
• 12. Methotrexate and monitoring for hepatotoxicity
  • 12.1. Methodological introduction
  • 12.2. Non-invasive liver tests vs. liver biopsy
  • 12.3. Economic evidence
  • 12.4. Recommendations and link to evidence
• 13. Systemic biological therapy
  • 13.1. Methodological introduction
  • 13.2. Previous biological therapy vs. no previous biological therapy
  • 13.3. Adalimumab as a first TNF antagonist vs adalimumab following discontinuation of a previous TNF antagonist
  • 13.4. Infliximab vs. placebo in those with prior exposure to biological therapy
  • 13.5. Ustekinumab vs placebo in those with prior exposure to biological therapy
  • 13.6. Ustekinumab vs etanercept in those with prior exposure to biological therapy
  • 13.7. Economic evidence
  • 13.8. Recommendations and link to evidence
• 14. Cognitive behavioural therapy
  • 14.1. Methodological introduction
  • 14.2. Cognitive behavioural therapy vs. standard care
  • 14.3. Economic evidence
  • 14.4. Recommendations and link to evidence
• 15. Glossary and abbreviations
• 16. Bibliography
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Review protocols
  • Appendix D. Literature search strategies
  • Appendix E. Study selection flow charts
  • Appendix F. Excluded studies list (clinical)
  • Appendix G. Excluded studies list (cost effectiveness)
  • Appendix H. Evidence tables – clinical studies
  • Appendix I. Evidence tables – economic studies
  • Appendix J. Forest plots
  • Appendix K. Network meta-analysis topicals trunk and limbs
  • Appendix L. Network meta-analysis topicals scalp
  • Appendix M. Cost-effectiveness analysis trunk and limbs
  • Appendix N. Cost-effectiveness analysis topicals scalp
  • Appendix O. Cost-effectiveness analysis second-line biologics
  • Appendix P. Review to define ‘best supportive care’
  • Appendix Q. Additional data (appendices from evidence reports)
  • Appendix R. Future research recommendations
  • Appendix S. Risks and benefits of treatments for psoriasis
  • Appendix T. Psoriasis Epidemiology Screening Tool (PEST)
  • Appendix U. References for appendices J – S