Diagnosis and management of psoriasis and psoriatic arthritis in adults: summary of SIGN guidance
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5623 (Published 29 October 2010) Cite this as: BMJ 2010;341:c5623
- A D Burden, consultant dermatologist1,
- M Hilton Boon, programme manager2,
- J Leman, consultant dermatologist3,
- H Wilson, consultant rheumatologist4,
- R Richmond, consultant in rheumatology5,
- A D Ormerod, reader in dermatology6, honorary consultant dermatologist7
- on behalf of the Guideline Development Group
- on behalf of the Guideline Development Group
- 1Alan Lyell Centre for Dermatology, Western Infirmary, Glasgow, UK
- 2Scottish Intercollegiate Guidelines Network (SIGN), Glasgow
- 3Western Infirmary, Glasgow
- 4Stobhill Hospital, Glasgow
- 5Borders General Hospital, Melrose, UK
- 6Department of Applied Medicine, University of Aberdeen, Aberdeen, UK
- 7Aberdeen Royal Infirmary, Aberdeen
- Correspondence to: M Hilton Boon michele.hiltonboon{at}nhs.net
The degree of disability and negative impact on quality of life caused by psoriasis and psoriatic arthritis are comparable to those of ischaemic heart disease, diabetes, depression, and cancer.1 Severe psoriasis and psoriatic arthritis are associated with an increased risk of conditions such as cardiovascular disease, diabetes, and depression.2 3 4 5 Psoriatic arthritis is underdiagnosed; about a fifth of patients with psoriasis also have psoriatic arthritis.6 The management of patients with both conditions may be particularly challenging and require close collaboration among several specialties. This article summarises the most recent recommendations from the Scottish Intercollegiate Guidelines Network (SIGN) on the diagnosis and management of psoriasis and psoriatic arthritis in adults.7
Recommendations
SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (fig 1⇓), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”), based on the clinical experience of the guideline development group, is also indicated (as GPP).
Fig 1 Explanation of SIGN grades of recommendations
Diagnosis and assessment in primary care
Diagnose chronic plaque psoriasis (psoriasis vulgaris) on the basis of well demarcated bright red plaques covered by adherent silvery white scales affecting any body site, often symmetrically, especially the scalp and extensor surfaces of limbs. The differential diagnosis includes eczema, tinea, lichen planus, and lupus erythematosus (GPP).
Diagnose guttate psoriasis (fig 2⇓) on the basis of the development over a period of one to seven days of multiple small papules of psoriasis over wide areas of the body. The differential diagnosis includes pityriasis rosea, viral exanthems, and drug eruptions (GPP).
Generalised pustular psoriasis (fig 3⇓) is rare and is characterised by the development of numerous sterile non-follicular pustules within plaques of psoriasis or on red tender skin. This may occur acutely and be associated with fever. The differential diagnosis includes pyogenic infection, vasculitis, and drug eruptions (GPP).
Consider patient administered screening questionnaires such as the psoriasis epidemiology screening tool (PEST) for early detection of psoriatic arthritis in patients with articular symptoms (C).8
Suspect psoriatic arthritis in patients with psoriasis who develop early morning stiffness lasting more than 30 minutes, spinal stiffness that improves with exercise, joint swelling, joint tenderness, or dactylitis (diffusely swollen or “sausage” digit) (GPP).
Review patients annually (GPP). As part of the review:
-Optimise topical treatment (see later recommendations) (GPP)
-Document disease severity using the dermatology life quality index (see box outlining online assessment tools) (D)
-Assess for symptoms of arthritis (D)
-Screen for depression (D)
-In patients with severe disease, measure body mass index, blood pressure, and lipid profile, and screen for diabetes mellitus (D).
Online assessment tools for psoriasis and psoriatic arthritis
Dermatology life quality index (DLQI)—www.dermatology.org.uk/quality/quality-dlqi.html
Psoriasis area severity index (PASI) calculator—http://pasi.corti.li/
Psoriasis epidemiology screening tool (PEST) questionnaire—www.arthritisresearchuk.org/arthritis_information/information_for_medical_profes/hands_on/summer_2009.aspx#non
Bath ankylosing spondylitis disease activity index (BASDAI)—http://basdai.com/BASDAI.php
Bath ankylosing spondylitis functional index (BASFI)—http://basdai.com/BASFI.php
Referral
Offer dermatology referral for patients who fail to respond to topical treatment and who score >5 on the dermatology life quality index (D).
Refer patients with erythrodermic psoriasis (fig 4⇓) or generalised pustular psoriasis to a dermatology department as an emergency (D).
Refer all patients suspected as having psoriatic arthritis to a rheumatologist for an early diagnosis and appropriate escalation from treatment with disease modifying antirheumatic drugs to treatment with anti-tumour necrosis factor, if required, thereby reducing joint damage (B).
For guttate psoriasis, consider early referral for consideration of phototherapy in those who fail to respond to topical treatment (GPP).
Figure 5⇓ describes a care pathway for the referral and management of psoriasis and psoriatic arthritis.
Fig 5 Care pathway for the referral and management of psoriasis and psoriatic arthritis
Treatment
Encourage a healthy lifestyle with regular exercise, weight management, cessation of smoking, and moderation of alcohol consumption (D).
Encourage patients to be actively involved in their care management (D). Discuss treatment options, risks, and benefits with the patient, allowing them more opportunity to be involved in decision making (D).
To improve concordance, keep the number of treatments a day to a minimum (D).
Topical treatments
Consider regular application of emollient to reduce scaling and to help with other symptoms, including itch (GPP).
In plaque psoriasis, offer short term, intermittent, potent topical corticosteroids or a combined potent corticosteroid plus calcipotriol ointment for rapid improvement (A). Avoid regular use of potent to very potent topical corticosteroids for prolonged periods because of the risk of long term adverse effects, such as cutaneous atrophy (D). For long term use, a vitamin D analogue is appropriate. Choose calcipotriol first, but if this causes troublesome local irritation, switch to an alternative vitamin D analogue (A). If a vitamin D analogue is ineffective or not tolerated then consider coal tar (solution, cream, or lotion), tazarotene gel, or short contact dithranol (30 minute exposure in patients with a few relatively large plaques of psoriasis) (B).
In scalp psoriasis, offer short term intermittent use of potent topical corticosteroids or a combination of a potent corticosteroid and a vitamin D analogue (B).
For patients with thick scaling of the scalp, treat initially with overnight application of salicylic acid, tar preparations, or oil preparations (such as olive oil, coconut oil) to remove thick scale (GPP).
In nail psoriasis, consider topical corticosteroids, salicylic acid, calcipotriol, or tazarotene used alone or in combination (GPP).
In facial and flexural psoriasis, offer moderate potency topical corticosteroids for first line short term use (B). In patients who fail to respond to this, offer vitamin D analogues or tacrolimus ointment for intermittent use if tolerated (B). Avoid using treatments with irritant properties (dithranol, topical retinoids) in flexural sites (GPP).
Secondary care—psoriatic arthritis
Dermatology and rheumatology teams should work closely together to manage patients with severe joint and skin disease (GPP). Aim for monotherapy that treats both skin and joint disease rather than multiple therapies (GPP).
Offer methotrexate to treat psoriatic arthritis (C), especially when associated with severe cutaneous psoriasis (GPP).
For patients with peripheral psoriatic arthritis, offer the disease modifying antirheumatic drug leflunomide (A), or sulfasalazine as an alternative (C).
Offer treatment with a biologic drug (adalimumab, etanercept, or infliximab) to patients with active psoriatic arthritis who have failed to respond to, are intolerant of, or have had contraindications to at least two disease modifying drugs (A).
Insufficient evidence exists to support a recommendation on the use of ciclosporin in psoriatic arthritis. Patients should not be expected to have failed to respond to ciclosporin before being eligible for treatment with a biologic drug (GPP).
Secondary care—psoriasis
For patients with psoriasis who do not respond to topical treatment, offer narrow band ultraviolet B phototherapy (B). For patients who fail this phototherapy, consider psoralen plus ultraviolet A photochemotherapy (B). Advise patients against the use of a sunbed as a source of ultraviolet light for treatment (GPP).
For patients with severe or refractory psoriasis, consider systemic treatment with ciclosporin, methotrexate, or acitretin after discussion of benefits and risks (B):
-Offer methotrexate for longer term use and where there is concomitant psoriatic arthritis (B)
-Offer ciclosporin for short term intermittent use (A)
-Consider acitretin as an alternative (B) except in women of childbearing potential (GPP).
For patients who are not suitable for the above systemic treatments, consider fumaric acid esters as an alternative maintenance treatment (B).
Offer biologic drugs (adalimumab, etanercept, infliximab or ustekinumab) to patients with severe psoriasis who fail to respond to, who have a contraindication to, or are intolerant of phototherapy and other systemic treatments including ciclosporin and methotrexate (A).
Offer those who have started or switched systemic treatments or biologic drugs the opportunity to enrol on the British Association of Dermatologists Biologics Intervention Register (BADBIR) for assessment of long term relative safety (GPP).
Ensure that inpatient treatment on a dermatology ward is available for patients with severe psoriasis (D).
Consider nurse led clinics to deliver services such as follow-up of specialist caseload, repeat access for patients with recurrent disease, and monitoring of systemic treatments (D).
Overcoming barriers
Resources are needed in primary care for an annual review of patients that fully evaluates the impact of these diseases on quality of life, identifies those patients with more severe disease who require specialist services, and assesses comorbid conditions such as depression and vascular disease. In secondary care, clinical time needs to be made available for multidisciplinary care that optimises patient outcomes over the longer term, in the face of pressures to prioritise new patients. The increased resources required for phototherapy, systemic treatments, biologic treatments, and inpatient treatments are substantial.
Undergraduate and postgraduate medical education needs to reflect the prevalence and importance of psoriasis and psoriatic arthritis in the population. General practitioners may not have received specific rheumatology or dermatology training and consequently may need training in diagnosing, assessing, and managing these conditions. Specialists need to embrace the new concepts around understanding and treating comorbidities of psoriasis and psoriatic arthritis and remain conversant with a rapidly developing therapeutic area.
Further information on the guidance
Guideline development
Membership of this Guideline Development Group included representatives from dermatology, rheumatology, primary care, pharmacy, nursing, health psychology, photobiology, and patient representatives. The development of the guideline used established SIGN methodology to base recommendations on a systematic review of the evidence (www.sign.ac.uk/methodology/index.html). A national open meeting attended by 157 people was held on 1 October 2009 to consult with stakeholders on the draft guidance. The guideline was also reviewed in draft form by 25 independent expert referees. The guideline will be considered for review after three years. Any updates to the guideline in the interim period will be noted on the SIGN website (www.sign.ac.uk).
Areas for future research
Psoriasis, psoriatic arthritis, and cardiovascular disease
Cost effectiveness of measurement of cardiovascular disease risk factors for all patients with psoriasis (of any severity)
Long term follow-up of cardiovascular safety of non-steroidal anti-inflammatory drugs in psoriasis and psoriatic arthritis
Topical treatment
The effect of non-medical consultation on disease severity and further healthcare resource use (such as medical consultations) of patients who use topical treatments
Long term follow-up of patients treated with potent to very potent topical corticosteroids, recording adverse effects, including exacerbations of psoriasis
Phototherapy
Long term follow-up of risk of skin cancer in patients having phototherapy
Investigation of effective models of home phototherapy
Systemic and biologic treatments
Effect of early intervention in psoriasis and psoriatic arthritis with systemic treatments on the incidence of comorbidity, joint damage, and disability, compared with late intervention
Comparative efficacy and safety of leflunomide, sulfasalazine, and methotrexate for psoriatic arthritis, in doses regularly used in current practice
Concordance
Qualitative study to investigate patient beliefs on concordance with prescribed treatments and complementary therapies
Psychosocial interventions and support
Effectiveness of psychological therapies and peer support groups in psoriasis and psoriatic arthritis
Qualitative and quantitative studies to determine the impact of psychological distress including depression and anxiety on disease severity and flare-ups
Patient information and quality of life
Needs of patients with psoriatic arthritis in terms of information and education, quality of life, psychosocial support, involvement in care, satisfaction with their care, healthcare preferences, and unmet needs
Identification of the effects of psoriatic arthritis on activities of daily living
Notes
Cite this as: BMJ 2010;341:c5623
Footnotes
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the Guideline Development Group are David Burden (chair), consultant dermatologist, Alan Lyell Centre for Dermatology, Western Infirmary, Glasgow; Rosemary Beaton, patient representative, Glasgow; David Bilsland, consultant dermatologist, Southern General Hospital, Glasgow; Stewart Campbell, patient representative, Psoriasis Association; Robert Dawe, consultant dermatologist, Ninewells Hospital, Dundee; Diane Dixon, psychologist, Department of Psychology, University of Stirling; Linda Grimmond, consultant in occupational medicine, Occupational Health and Safety Advisory Services, Dundee; Sandra Hanlon, dermatology liaison sister, Inverclyde Royal Hospital, Greenock; Iain Henderson, general practitioner, Kingsway Medical Practice, Glasgow; Michele Hilton Boon, programme manager, Scottish Intercollegiate Guidelines Network (SIGN), Glasgow; Janice Johnson, patient representative and director of Psoriasis Scotland Arthritis Link Volunteers, Edinburgh; Alan Jones, general practitioner, Newton Stewart; Danny Kemmett, consultant dermatologist, Royal Infirmary of Edinburgh; Joyce Leman, consultant dermatologist, Western Infirmary, Glasgow; Ayyakkannu Manivannan, laser protection adviser and clinical scientist, NHS Grampian and University of Aberdeen; Lorna McHattie, research fellow, School of Pharmacy, Robert Gordon University, Aberdeen; David McKay, consultant dermatologist, Royal Infirmary of Edinburgh; Harry Moseley, head of scientific services, Photobiology Unit, Ninewells Hospital and Medical School, Dundee; Tony Ormerod, reader in dermatology, University of Aberdeen, and honorary consultant dermatologist, Aberdeen Royal Infimary; Gozde Ozakinci, lecturer in health psychology, University of St Andrews; Ruth Richmond, consultant in rheumatology, Borders General Hospital, Melrose; Lynne Smith, information officer, SIGN; Derek Stewart, reader in pharmacy practice, Robert Gordon University, Aberdeen; Anne Thorrat, psoriasis/research nurse, Western Infirmary, Glasgow; Hilary Wilson, consultant rheumatologist, Stobhill Hospital, Glasgow.
Contributors: ADB and ADO drafted the article. All authors were involved in the design, appraisal of evidence, analysis of results, revision, and final approval of the article. ADB is the guarantor.
Funding: No funding was received for writing this summary.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no funding from any organisation for the submitted work; ADB has been paid for consultancy and delivering lectures for Abbott, Pfizer, MSD, Janssen-Cilag, Leo, and Basilea and does consultancy for Merck and Novartis; MHB is employed by SIGN; JL was paid to attend one Abbott Advisory Board meeting and to deliver postgraduate education by Leo, has received meeting expenses from Pfizer, and has undertaken trials funded by Janssen-Cilag, Merck, Serono, Schering-Plough, Abbott, and Pfizer; HW has been paid to provide expert testimony to the Psoriatic Arthritis Advisory Panel and to develop and deliver a Wyeth educational presentation, and has received expenses from Abbott to attend one conference; HW’s institution will receive payment for participating in a study of the validity of the PEST questionnaire; RR received travel costs and a conference registration fee from Wyeth; ADO was paid to attend one Abbott advisory board meeting, one Schering-Plough advisory board meeting, and to deliver lectures for Wyeth and Abbott, and received expenses to attend one conference from Wyeth and one conference from Janssen-Cilag; ADO’s institution has received grants to conduct clinical trials of biologics for Abbott, Wyeth, Schering-Plough, and Janssen-Cilag; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.
Patient consent not required (patient anonymised, dead, or hypothetical).