Psoriasis: assessment and management

Introduction

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% to 2.2% in the UK. Psoriasis can occur at any age, although is uncommon in children (0.71%) and most cases occur before 35 years. Psoriasis is associated with joint disease in a significant proportion of patients (reported in 1 study at 13.8%).

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 guideline. The phrase 'difficult-to-treat sites' encompasses 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.

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 guideline 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. See the BNF and BNF for children for guidance on use of emollients.

In this guideline, 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 narrowband 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. NICE has published technology appraisals on the use of biological drugs, and this guideline 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 guideline 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 (level 4) tertiary care is required in the very small minority with especially complex, treatment resistant and/or rare manifestations of psoriasis. 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 specialist skills in managing complex and/or rare skin disorders – see Quality Standards for Dermatology: providing the right care for people with skin conditions.

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 et al. 2009).

This guideline covers people of all ages and aims to provide clear recommendations on the management of all types of psoriasis. 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 most people affected, where practice is very varied and/or where clear consensus or guidelines on treatments are lacking. It is hoped that this guideline will facilitate the delivery of high-quality healthcare and improved outcomes for people with psoriasis.