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GPs should proactively assess the impact that psoriasis may be having on the daily lives of their patients, advises the National Institute for Health and Clinical Excellence (NICE) in new guidance out today (Wednesday 24 October).
Psoriasis is a skin condition characterised by red, flaky, crusty patches of skin covered with silvery scales. It is believed to affect up to 2.2% of the UK population (i.e. over 1.3 million people) with most cases seen in young people and adults under the age of 35. The disease can contribute to low self-esteem, anxiety, embarrassment and depression, much like other chronic conditions but this may be overlooked by healthcare professionals. For example, over a third of people who have psoriasis report clinically significant anxiety and depression. The condition can also affect a person's participation in social and physical activities, employment and education.
In its first clinical guideline on the assessment and management of the condition, NICE advises GPs and other healthcare professionals to assess the impact that psoriasis has on the physical, psychological and social wellbeing of their patients. They should do this when they first see their patients, before they refer them to specialists, and when they monitor how they are responding to treatments.
Dr Catherine Smith, a consultant dermatologist who chaired the development of the NICE guideline, said: "Psoriasis is much more than a skin irritation. The condition can have profound functional, psychological and social effects on a person's life. It is vital that GPs and other healthcare professionals recognise these possible consequences when they first see their patients, and that they routinely assess the impact that the disease is having on their daily lives. Early and proactive identification will allow patients to receive the support and effective treatment they need in a timely manner. Importantly, accurate assessment of people with psoriasis will ensure they can access the right treatment as early as possible whether in primary or specialist care."
Also in its new clinical guideline, NICE advises that everyone with psoriasis should be assessed for psoriatic arthritis on an annual basis, particularly during the first ten years as this is when the condition is most likely to develop.
Around one in seven people who have psoriasis will develop psoriatic arthritis, a progressive condition, which can cause pain, stiffness and swelling in and around the joints. Early diagnosis is crucial and so annual assessments will allow those with actual or suspected psoriatic arthritis to be referred to specialists sooner.
Dr Natasha Smeaton, a GP who helped develop the NICE guideline, said: "Psoriatic arthritis is rarely seen by GPs and so there may be confusion regarding how it should be diagnosed when compared to other joint problems, such as 'wear-and-tear' arthritis and gout. Early diagnosis is important because the condition is aggressive and associated with progressive joint damage. There are effective treatments available and so patients should receive these as soon as possible.
"The NICE guideline advises healthcare professionals to offer annual assessments for psoriatic arthritis to all of their patients who have psoriasis. They should use a validated tool in these assessments, such as the Psoriasis Epidemiological Screening Tool. This will facilitate more timely referrals to rheumatologists so that patients can receive the treatments they need."
Today's guideline is the first to be produced by NICE to help GPs and other healthcare professionals assess and treat their patients with this condition.
Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "Whilst there is no cure for psoriasis, treatments are effective and can include topical therapies, phototherapy and systemic medication, depending on the severity and extent of the disease.
"Clinical practice for the treatment of psoriasis is variable across the NHS. This guideline provides clear advice for the NHS on the assessment and management of psoriasis in order to improve comfort and minimise the effects of living with the condition."
Source: nice.org.uk
And here is the clinical guideline on the assessment and management of psoriasis for GPs
Source: nice.org.uk
Psoriasis is a skin condition characterised by red, flaky, crusty patches of skin covered with silvery scales. It is believed to affect up to 2.2% of the UK population (i.e. over 1.3 million people) with most cases seen in young people and adults under the age of 35. The disease can contribute to low self-esteem, anxiety, embarrassment and depression, much like other chronic conditions but this may be overlooked by healthcare professionals. For example, over a third of people who have psoriasis report clinically significant anxiety and depression. The condition can also affect a person's participation in social and physical activities, employment and education.
In its first clinical guideline on the assessment and management of the condition, NICE advises GPs and other healthcare professionals to assess the impact that psoriasis has on the physical, psychological and social wellbeing of their patients. They should do this when they first see their patients, before they refer them to specialists, and when they monitor how they are responding to treatments.
Dr Catherine Smith, a consultant dermatologist who chaired the development of the NICE guideline, said: "Psoriasis is much more than a skin irritation. The condition can have profound functional, psychological and social effects on a person's life. It is vital that GPs and other healthcare professionals recognise these possible consequences when they first see their patients, and that they routinely assess the impact that the disease is having on their daily lives. Early and proactive identification will allow patients to receive the support and effective treatment they need in a timely manner. Importantly, accurate assessment of people with psoriasis will ensure they can access the right treatment as early as possible whether in primary or specialist care."
Also in its new clinical guideline, NICE advises that everyone with psoriasis should be assessed for psoriatic arthritis on an annual basis, particularly during the first ten years as this is when the condition is most likely to develop.
Around one in seven people who have psoriasis will develop psoriatic arthritis, a progressive condition, which can cause pain, stiffness and swelling in and around the joints. Early diagnosis is crucial and so annual assessments will allow those with actual or suspected psoriatic arthritis to be referred to specialists sooner.
Dr Natasha Smeaton, a GP who helped develop the NICE guideline, said: "Psoriatic arthritis is rarely seen by GPs and so there may be confusion regarding how it should be diagnosed when compared to other joint problems, such as 'wear-and-tear' arthritis and gout. Early diagnosis is important because the condition is aggressive and associated with progressive joint damage. There are effective treatments available and so patients should receive these as soon as possible.
"The NICE guideline advises healthcare professionals to offer annual assessments for psoriatic arthritis to all of their patients who have psoriasis. They should use a validated tool in these assessments, such as the Psoriasis Epidemiological Screening Tool. This will facilitate more timely referrals to rheumatologists so that patients can receive the treatments they need."
Today's guideline is the first to be produced by NICE to help GPs and other healthcare professionals assess and treat their patients with this condition.
Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "Whilst there is no cure for psoriasis, treatments are effective and can include topical therapies, phototherapy and systemic medication, depending on the severity and extent of the disease.
"Clinical practice for the treatment of psoriasis is variable across the NHS. This guideline provides clear advice for the NHS on the assessment and management of psoriasis in order to improve comfort and minimise the effects of living with the condition."
Source: nice.org.uk
And here is the clinical guideline on the assessment and management of psoriasis for GPs
Quote:
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 (0.71%) and the majority of cases occur before 35 years. Psoriasis is associated with joint disease in a significant proportion of patients (reported in one 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.
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 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. 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.
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.
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 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 guideline will facilitate the delivery of high-quality healthcare and improved outcomes for people with psoriasis.
Source: nice.org.uk