Psoriasis - New NICE Guidelines

The BMJ this week includes an article on summary of the new NICE Guidelines on assessment and management of Psoriasis. This common inflammatory skin condition affects 1.3-2.2% of the UK population and can be associated with psoriatic arthritis. It can have a serious impact on social, functional and psychological morbidity which is often under-recognised. This often occurs despite very effective treatments available to help improve outcomes.

Recommendations:

• A single point of contact for people with all types of psoriasis to aid access to appropriate information. 
• Assessment should include a 'physician's global assessment' and a 'patient's global assessment', body surface area affected, involvement of nails or difficult to treat areas eg. scalp, any systemic upset. Ask about how a patient's daily living is affected, how they are coping with their skin condition, and if any treatments are being used. 
• Indications for referral: diagnostic uncertainty, a severe or extensive type of psoriasis eg >10% body surface area, cannot be controlled by topical therapy, acute guttate psoriasis requiring phototherapy, nail disease with functional/cosmetic impact, psoriasis with major impact on social/psychological/physical well-being. Also any type of psoriasis in children and urgent/same day assessment for generalised pustular psoriasis/erythroderma.
• NICE recommend the Psoriasis Epidemiological Screening Tool for assessment of psoriatic arthritis.
• Cardiovascular risk assessment at presentation for adults with severe psoriasis of any type.
• Offer topical treatments as first line, followed by 2nd/3rd line if these do not succeed. Offer practical support and advice about the use and application of topical treatments delivered by trained healthcare professionals. 
• Arrange a review appointment after starting a new topical treatment (4 weeks in adults, 2 weeks in children).
• Phototherapy - offer narrowband UVB to patients with plaque or guttate psoriasis that cannot be controlled with topical treatments alone.
• For systemic, non-biological therapy the following conditions must be met: psoriasis cannot be controlled with topical therapy, it has a significant impact on physical, psychological or social wellbeing, is extensive (>10% body surface area affected) or localised and associated with significant functional impairment, or not suitable for phototherapy.
• Methotrexate should be offered as first line systemic treatment except if contra-indicated or the patients meet the criteria for ciclosporin (rapid or short term disease control, palmo-plantar pustulosis, considering conception and systemic therapy cannot be avoided).

I'll be presenting a summary of the new NICE Guidelines on Psoriasis and comparing them with the recent SIGN guidelines on psoriasis at a the dermatology journal club meeting on the 22nd November.