1.2.1. Assessment tools for disease severity and impact and when to refer for specialist care

1.2.1.1.

For people with any type of psoriasis assess:

• disease severity
• the impact of disease on physical, psychological and social wellbeing
• whether they have psoriatic arthritis
• the presence of comorbidities.

1.2.1.2.

Assess the severity and impact of any type of psoriasis:

• at first presentation
• before referral for specialist advice and at each referral point in the treatment pathway
• to evaluate the efficacy of interventions.

1.2.1.3.

When assessing the disease severity in any healthcare setting, record:

• the results of a static Physician’s Global Assessment (classified as clear, nearly clear, mild, moderate, severe or very severe)^[10]
• the patient’s 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 body surface area affected
• any involvement of nails, high-impact and difficult-to-treat sites (for example, the face, scalp, palms, soles, flexures and genitals)
• any systemic upset such as fever and malaise, which are common in unstable forms of psoriasis such as erythroderma or generalised pustular psoriasis.

1.2.1.4.

In specialist settings, use a validated tool to assess severity of psoriasis, for example the Psoriasis Area and Severity Index (PASI)^[11] (in addition to the assessments indicated in recommendation 1.2.1.3).

1.2.1.5.

Be aware that:

• PASI and body surface area are not validated for use in children and young people
• erythema may be underestimated in people with darker skin types, such as skin types V and VI on the Fitzpatrick scale^[12].

1.2.1.6.

Use the Nail Psoriasis Severity Index^[13] to assess nail disease in specialist settings:

• if there is a major functional or cosmetic impact or
• before and after treatment is initiated specifically for nail disease.

1.2.1.7.

Assess the impact of any type of psoriasis on physical, psychological and social wellbeing by asking:

• what aspects of their daily living are affected by the person’s psoriasis
• how the person is coping with their skin condition and any treatments they are using
• if they need further advice or support
• if their psoriasis has an impact on their mood
• if their psoriasis causes them distress (be aware the patient may have levels of distress and not be clinically depressed)
• if their condition has any impact on their family or carers.

Ask children and young people age-appropriate questions.

1.2.1.8.

In specialist settings, and if practical in non-specialist settings, use a validated tool to assess the impact of any type of psoriasis on physical, psychological and social wellbeing, for example the:

• Dermatology Life Quality Index (DLQI)^[14],[15] for adults or
• Children’s Dermatology Life Quality Index (CDLQI)^[16] for children and young people.

1.2.1.9.

When using an assessment tool for a person with any type of psoriasis:

• take account of their age, any disabilities (such as physical, visual or cognitive impairment), and any language or other communication difficulties, and provide help and support if needed^[14]
• ensure that the chosen assessment tool continues to be a sufficiently accurate measure.

1.2.1.10.

Following assessment in a non-specialist setting, refer people for dermatology specialist advice if:

• there is diagnostic uncertainty or
• any type of psoriasis is severe or extensive, for example more than 10% of the body surface area is affected or
• any type of psoriasis cannot be controlled with topical therapy or
• acute guttate psoriasis requires phototherapy (see recommendation 1.4.1.1) or
• nail disease has a major functional or cosmetic impact or
• any type of psoriasis is having a major impact on a person’s physical, psychological or social wellbeing.

1.2.1.11.

People with generalised pustular psoriasis or erythroderma should be referred immediately for same-day specialist assessment and treatment.

1.2.1.12.

Refer children and young people with any type of psoriasis to a specialist at presentation.

1.2.2. Assessment and referral for psoriatic arthritis

1.2.2.1.

Offer annual assessment for psoriatic arthritis to people with any type of psoriasis. Assessment is especially important within the first 10 years of onset of psoriasis.

1.2.2.2.

Use a validated tool to assess adults for psoriatic arthritis in primary care and specialist settings, for example the Psoriasis Epidemiological Screening Tool (PEST)^[17]. Be aware that the PEST does not detect axial arthritis or inflammatory back pain.

1.2.2.3.

As soon as psoriatic arthritis is suspected, refer the person to a rheumatologist for assessment and advice about planning their care. Also see the NICE guideline on spondyloarthritis in over 16s.

1.2.3. Identification of comorbidities

1.2.3.1.

Offer adults with severe psoriasis^[18] of any type a cardiovascular risk assessment at presentation using a validated risk estimation tool. Offer further assessment of cardiovascular risk every 5 years, or more frequently if indicated following assessment. For further information see the NICE guideline on cardiovascular disease: risk assessment and reduction, including lipid modification.

1.2.3.2.

Discuss risk factors for cardiovascular comorbidities with people who have any type of psoriasis (and their families or carers where appropriate). Where appropriate offer preventative advice, healthy lifestyle information and support for behavioural change tailored to meet the needs of the individual in line with the following NICE guidance:

• Cardiovascular disease: risk assessment and reduction, including lipid modification
• Obesity prevention
• Type 2 diabetes prevention: population and community-level interventions
• Cardiovascular disease prevention
• Alcohol-use disorders: prevention
• Stop smoking interventions and services
• Physical activity: brief advice for adults in primary care
• Physical activity in the workplace
• Physical activity for children and young people

1.2.3.3.

For people with multiple comorbidities and/or multimorbidities and any type of psoriasis needing second- or third-line therapy, ensure multidisciplinary working and communication between specialties and, if needed, interdisciplinary team working (for example when both skin and joints are significantly affected).

1.2.3.4.

Be aware that psoriasis of any type, especially if severe^[19], is a risk factor for venous thromboembolism in adults, and:

• explain this risk to adults with any type of psoriasis
• offer advice on how to minimise the risk (for example, during hospital admission, surgery, or periods of immobility)
• manage the risk in line with the NICE guideline on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism.

1.2.3.5.

Assess whether people with any type of psoriasis are depressed when assessing disease severity and impact, and when escalating therapy. If appropriate offer information, advice and support in line with the NICE guidelines on depression in adults with a chronic physical health problem and depression in children and young people.

1.3.1. General recommendations

1.3.1.1.

Offer people with psoriasis topical therapy as first-line treatment.

1.3.1.2.

Offer second- or third-line treatment options (phototherapy or systemic therapy) at the same time when topical therapy alone is unlikely to adequately control psoriasis, such as:

• extensive disease (for example more than 10% of body surface area affected) or
• at least ‘moderate’ on the static Physician’s Global Assessment or
• where topical therapy is ineffective, such as nail disease.

See also recommendations 1.2.1.9; 1.4.1.1; 1.5.2.1; 1.5.3.4; 1.5.3.6; 1.5.3.8 and 1.5.3.10.

1.3.1.3.

Offer practical support and advice about the use and application of topical treatments. Advice should be provided by healthcare professionals who are trained and competent in the use of topical therapies. Support people to adhere to treatment in line with the NICE guideline on medicines adherence. Also see the NICE guideline on medicines optimisation.

1.3.1.4.

When offering topical agents:

• take into account patient preference, cosmetic acceptability, practical aspects of application and the site(s) and extent of psoriasis to be treated
• discuss the variety of formulations available and, depending on the person’s preference, use:

  –

  cream, lotion or gel for widespread psoriasis

  –

  lotion, solution or gel for the scalp or hair-bearing areas

  –

  ointment to treat areas with thick adherent scale

• be aware that topical treatment alone may not provide satisfactory disease control, especially in people with psoriasis that is extensive (for example more than 10% of body surface area affected) or at least ‘moderate’ on the static Physician’s Global Assessment.

1.3.1.5.

If a person of any age with psoriasis requiring topical therapy has a physical disability, or cognitive or visual impairment offer advice and practical support that take into account the person’s individual needs.

1.3.1.6.

Arrange a review appointment 4 weeks after starting a new topical treatment in adults, and 2 weeks after starting a new topical treatment in children, to:

• evaluate tolerability, toxicity, and initial response to treatment (including measures of severity and impact described in recommendations 1.2.1.3, 1.2.1.6 and 1.2.1.7)
• reinforce the importance of adherence when appropriate
• reinforce the importance of a 4 week break between courses of potent/very potent corticosteroids (see recommendation 1.3.1.10).

If there is little or no improvement at this review, discuss the next treatment option with the person.

1.3.1.7.

Discuss with people whose psoriasis is responding to topical treatment (and their families or carers where appropriate):

• the importance of continuing treatment until a satisfactory outcome is achieved (for example clear or nearly clear) or up to the recommended maximum treatment period for corticosteroids (see sections 1.3.2, 1.3.3 and 1.3.4)
• that relapse occurs in most people after treatment is stopped
• that after the initial treatment period topical treatments can be used when needed to maintain satisfactory disease control.

1.3.1.8.

Offer people with psoriasis a supply of their topical treatment to keep at home for the self-management of their condition.

1.3.1.9.

In people whose psoriasis has not responded satisfactorily to a topical treatment strategy, before changing to an alternative treatment:

• discuss with the person whether they have any difficulties with application, cosmetic acceptability or tolerability and where relevant offer an alternative formulation consider other possible reasons for non-adherence in line with the NICE guideline on medicines adherence.
• Also see the NICE guideline on medicines optimisation.

1.3.2. Topical treatment of psoriasis affecting the trunk and limbs

1.3.2.1.

Offer a potent corticosteroid applied once daily plus vitamin D or a vitamin D analogue applied once daily (applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment for adults with trunk or limb psoriasis.

1.3.2.2.

If once-daily application of a potent corticosteroid plus once-daily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance or satisfactory control of trunk or limb psoriasis in adults after a maximum of 8 weeks^[22], offer vitamin D or a vitamin D analogue alone applied twice daily.

1.3.2.3.

If twice-daily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance or satisfactory control of trunk or limb psoriasis in adults after 8–12 weeks, offer either:

• a potent corticosteroid applied twice daily for up to 4 weeks or
• a coal tar preparation applied once or twice daily.^[22]

1.3.2.4.

If a twice-daily potent corticosteroid or coal tar preparation cannot be used or a once-daily preparation would improve adherence in adults offer a combined product containing calcipotriol monohydrate and betamethasone dipropionate applied once daily for up to 4 weeks.

1.3.2.5.

Offer treatment with very potent corticosteroids in adults with trunk or limb psoriasis only:

• in specialist settings under careful supervision
• when other topical treatment strategies have failed
• for a maximum period of 4 weeks.

1.3.2.6.

Consider short-contact dithranol for treatment-resistant psoriasis of the trunk or limbs and either:

• give educational support for self-use or
• ensure treatment is given in a specialist setting.

1.3.2.7.

For children and young people with trunk or limb psoriasis consider^[23] either:

• calcipotriol applied once daily (only for those over 6 years of age) or
• a potent corticosteroid applied once daily (only for those over 1 year of age).

1.3.3. Topical treatment of psoriasis affecting the scalp

1.3.3.1.

Offer a potent corticosteroid^[24] applied once daily for up to 4 weeks^[25] as initial treatment for people with scalp psoriasis.

1.3.3.2.

Show people with scalp psoriasis (and their families or carers where appropriate) how to safely apply corticosteroid topical treatment.

1.3.3.3.

If treatment with a potent corticosteroid^[24] does not result in clearance, near clearance or satisfactory control of scalp psoriasis after 4 weeks^[25] consider:

• a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or
• topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid.

1.3.3.4.

If the response to treatment with a potent corticosteroid^[24] for scalp psoriasis remains unsatisfactory after a further 4 weeks^[22],[25] of treatment offer:

• a combined product containing calcipotriol monohydrate and betamethasone dipropionate^[26] applied once daily for up to 4 weeks or
• vitamin D or a vitamin D analogue^[27] applied once daily (only in those who cannot use steroids and with mild to moderate scalp psoriasis).

1.3.3.5.

If continuous treatment with either a combined product containing calcipotriol monohydrate and betamethasone dipropionate^[26] applied once daily or vitamin D or a vitamin D analogue applied once daily for up to 8 weeks^[25] does not result in clearance, near clearance or satisfactory control of scalp psoriasis offer:

• a very potent corticosteroid applied up to twice daily for 2 weeks for adults only or
• coal tar applied once or twice daily or
• referral to a specialist for additional support with topical applications and/or advice on other treatment options.

1.3.3.6.

Consider topical vitamin D or a vitamin D analogue^[27],[28] alone for the treatment of scalp psoriasis only in people who:

• are intolerant of or cannot use topical corticosteroids at this site or
• have mild to moderate scalp psoriasis.

1.3.3.7.

Do not offer coal tar-based shampoos alone for the treatment of severe scalp psoriasis.

1.3.4. Topical treatment of psoriasis affecting the face, flexures and genitals

1.3.4.1.

Offer a short-term mild or moderate potency corticosteroid^[29] applied once or twice daily (for a maximum of 2 weeks^[25]) to people with psoriasis of the face, flexures or genitals.

1.3.4.2.

Be aware that the face, flexures and genitals are particularly vulnerable to steroid atrophy and that corticosteroids should only be used for short-term treatment of psoriasis (1–2 weeks per month). Explain the risks to people undergoing this treatment (and their families or carers where appropriate) and how to minimise them.

1.3.4.3.

For adults with psoriasis of the face, flexures or genitals if the response to short-term moderate potency corticosteroids is unsatisfactory, or they require continuous treatment to maintain control and there is serious risk of local corticosteroid-induced side effects, offer a calcineurin inhibitor^[30] applied twice daily for up to 4 weeks. Calcineurin inhibitors should be initiated by healthcare professionals with expertise in treating psoriasis.

1.3.4.4.

Do not use potent or very potent corticosteroids on the face, flexures or genitals.

1.3.4.5.

When prescribing topical agents at facial, flexural and genital sites take into account that they may cause irritation and inform people undergoing treatment (and their families and carers where appropriate) of these risks and how to minimise them. See also recommendation 1.3.4.2.

1.4.2. Risk of skin cancer and how to minimise risk

1.4.2.1.

Do not use PUVA in people with psoriasis of any type and a genetic predisposition to skin cancer for example, xeroderma pigmentosum or familial melanoma.

1.4.2.2.

Do not use PUVA when other appropriate treatments are available in:

• people with a personal history of skin cancer or
• people who have already received 150 PUVA treatments or
• children.

1.4.2.3.

Use PUVA with caution or consider other treatment options in:

• people at risk of skin cancer (melanoma and non-melanoma type) (see ‘Improving outcomes for people with skin tumours including melanoma’ [NICE cancer service guidance])
• people with lighter skin types, such as skin types I or II on the Fitzpatrick scale^[12]
• people who are likely to require ciclosporin or long-term methotrexate
• young people.

1.4.2.4.

Offer lifetime skin cancer surveillance to people treated with PUVA who have:

• had more than 150 PUVA treatments or
• developed skin cancer.

1.4.2.5.

Ensure that a permanent record of the person’s cumulative number of UV treatments is kept (for example, in a national record).

1.5.1. General recommendations

1.5.1.1.

Responsibility for use of systemic therapy should be in specialist settings only. Certain aspects of supervision and monitoring may be delegated to other healthcare professionals and completed in non-specialist settings, in which case, such arrangements should be formalised.

1.5.1.2.

When offering systemic therapy, tailor the choice of agent and dosing schedule to the needs of the individual and include consideration of:

• the person’s age
• disease phenotype, pattern of activity and previous treatment history
• disease severity and impact
• the presence of psoriatic arthritis (in consultation with a rheumatologist)
• conception plans
• comorbidities
• the person’s views.

1.5.1.3.

Be aware of the benefits of, contraindications to and adverse effects associated with systemic treatments. Explain the risks and benefits to people undergoing this treatment (and their families or carers where appropriate), using absolute risks and natural frequencies when possible^[9]. Support and advice should be provided by healthcare professionals who are trained and competent in the use of systemic therapies.

1.5.1.4.

When reviewing response to systemic therapy, take into account:

• disease severity compared with baseline (for example, PASI baseline to endpoint score)
• control of psoriatic arthritis disease activity (in consultation with a rheumatologist if necessary)
• the impact of the disease on the person’s physical, psychological and social wellbeing
• the benefits versus the risks of continued treatment
• the views of the person undergoing treatment (and their family or carers where appropriate).

1.5.1.5.

Monitor people using systemic treatment for all types of psoriasis in accordance with national and local drug guidelines and policy. Take appropriate action in the event of laboratory abnormalities or adverse events.

1.5.1.6.

Offer adjunctive topical therapy to people with psoriasis using systemic therapy to optimise treatment outcomes.

1.5.1.7.

Offer people with psoriasis who are starting treatment with a systemic non-biological or biological drug the opportunity to participate in long-term safety registries (for example the British Association of Dermatologists Biologic Interventions Register).

1.5.2. Systemic non-biological therapy

1.5.2.1.

Offer systemic non-biological therapy to people with any type of psoriasis if:

• it cannot be controlled with topical therapy and
• it has a significant impact on physical, psychological or social wellbeing and
• one or more of the following apply:

  –

  psoriasis is extensive (for example, more than 10% of body surface area affected or a PASI score of more than 10) or

  –

  psoriasis is localised and associated with significant functional impairment and/or high levels of distress (for example severe nail disease or involvement at high-impact sites) or

  –

  phototherapy has been ineffective, cannot be used or has resulted in rapid relapse (rapid relapse is defined as greater than 50% of baseline disease severity within 3 months).

1.5.3. Systemic biological therapy

The GDG did not review evidence for any aspect of the use of a first biological agent because guidance on this is already available in the existing NICE technology appraisals^[36].

1.5.3.1.

Biological agents for psoriasis should be initiated and supervised only by specialist physicians experienced in the diagnosis and treatment of psoriasis.

1.5.3.2.

If a person has both psoriasis and psoriatic arthritis, take into account both conditions before initiating or making changes to biological therapy and manage their treatment in consultation with a rheumatologist (see also the NICE technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis^[37], ustekinumab for treating active psoriatic arthritis^[38], certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs^[37] and golimumab for the treatment of psoriatic arthritis^[37], and the NICE guideline on spondyloarthritis in over 16s).

1.5.3.3.

When using the DLQI, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the responses to the DLQI and make any adjustments they consider appropriate.

Why this is important

Assessment of disease severity and impact is fundamental to delivering high-quality health care and measuring outcomes. The evidence review indicates that the existing tools have important limitations, and have not been validated in relevant healthcare settings or in children or young people. Future research should ensure that tools are developed that capture information on site of involvement as well as extent and the impact of previous treatments. Tools should capture all aspects of impact on life including physical, psychological and social wellbeing and factors that may influence this impact, such as distress and beliefs about psoriasis. Tools that can be used by patients (as well as healthcare professionals) to assess disease severity and that encompass new technologies should be evaluated to facilitate, when appropriate, modern healthcare delivery models (for example, remote monitoring of disease activity).

In addition, understanding the true burden and effect of disease activity, severity and impact for both psoriasis and psoriatic arthritis has not previously been comprehensively studied. Capturing this information and distilling out significant factors for focused investigation will lead to better understanding of the needs of this particular group of people and the impact of treatments that benefit both disease compartments (skin and joints).

Why this is important

The evidence review indicates that people with psoriasis may be at risk of liver disease, and there is great uncertainty about the contributing role of methotrexate. Clinician and patient concerns about this side effect are a common cause of treatment discontinuation. However, existing studies are poorly controlled for important confounders and many are very old. Methotrexate is a low cost intervention that is effective in an important proportion of patients. Research in this area will properly delineate the size of risk and how to minimise it. Future research should be adequately powered to detect clinically relevant liver disease, use relevant tools to do so, and properly control for relevant confounders.

Why this is important

At present the treatment pathway for people with psoriasis follows clinical need as no studies have been conducted to evaluate whether early intervention with systemic treatments alters prognosis. Consequently, patients with more severe disease sequence through all therapies in the treatment pathway, with a proportion requiring high-cost biological interventions to maintain disease control. The evidence indicates that there are very few treatment options for people with chronic disease, all of them are associated with side effects, many are co-dependent (for example escalated risk of skin cancer in people treated with the phototherapy and ciclosporin sequence), and loss of response to biological therapies is a significant clinical issue. If early intervention with systemic treatments was shown to alter the prognosis, particularly if there were markers that could stratify those likely to benefit, this would be of major importance to patients, and likely to deliver much more cost-effective treatment strategies.

Why this is important

Virtually all patients self-manage their condition to a greater or lesser extent and this involves complex topical applications as well as systemic therapies to be used over many years in response to fluctuating disease severity. The evidence indicates that in contrast to many chronic disorders, there are no validated programmes to help patients achieve effective self-management. Establishing a focused programme that effectively improves outcomes for patients would be of clinical benefit and likely deliver healthcare savings.

Why this is important

Currently, topical therapies, in some form or another, are prescribed to virtually everyone with psoriasis, often as first line psoriasis treatment and they are also frequently used adjunctively with other interventions. There is a wide array of potential topical agents available and further research specifically targeting therapeutic strategies together with sequencing of topical agents for maintaining disease control in the long term continues to deserve focused attention. In addition exploration of the risks associated with long term corticosteroid use and strategies aimed at modifying risk would be a critical element of this research to fill the current gap in the literature.