Psoriasis : It s not just skin de eep NICE Guidelines and Quality Standards: a collaboration to deliver quality care GP Symposium Dermatology y p gy Dr Seow Hoong Foo Dr Shireen Velangi March 6th 2014
Introduction ti October 2012: NICE CG153 Psoriasis theas ssessment and managementof psoriasis August 2013: NICE QS40 Psoriasis Quality Standard
Oct 2012: NICE CG153 Psoriasis the assessment and management of psoriasis Key priorities for implementation Assessment for disease severity and impact Referral for psoriatic arthritis Identification of comorbidities Recommendation for management in a step wise manner
Aug 2013: NICE QS40 Psoriasis Quality Standard Statement 1. People with psoriasis are offered an assessment of disease severity at diagnosis and when response to treatment is assessed Statement 2. People with psoriasis are offered an assessment of the impact of the disease on physical, psychological land socia al wellbeing at diagnosis i and when response to treatment is assessed Statement 3. People withpsoriasis arerefe refe rred for assessment by a dermatology specialist if indicated Statement 4. Adults withsevere psoriasis a re offered a cardiovascular risk assessment at diagnosis and at least once every 5 years Statement 5. People with psoriasis having treatment are offered an annual assessment for psoriatic arthritis Statement 6. People with psoriasis receiving systemic therapy are monitored in accordance with locally agreed protocols
ement 1. People with psoriasis are offered an assessment of disease severity a nosis and when response to treatment is assessed. hen to assess at first presentation before referral for specialist advice hat to assess body surface area affected involvement of nails high impact and difficult to treat sites systemic upset ow to assess Physician's Global Assessment and Patient's Global Assessment tools PASI and NAPSI Score esponse to treatment assessment
PGA: inactive, mild, moderate, severe
Statement 2. People with psoriasis are offered an assessment of the impact of the disease on phys sical, psychological and social wellbeing at diagnosis and when response to treatment is assessed. people withpsoriasis should be asse ssed for depression Children and young people should be asked age appropriate appropriate questions The Dermatology Life Quality Index or Children's Dermatology Life Quality Index
Psychological burden of psoriasis and impact on quality of life iasis has been associated with: ychological land social ilproblems Depression 1 3 and anxiety 3 Stress 1,3 Anger 3 Feelings of stigmatisation 1,3 Suicidal ideation 1 3 Alcohol abuse 1,3 Smoking 3 Effects on social interactions at home 1,2 and in the workplace 2 educed qualityoflife life Compared with individuals without chronic conditions 4 Compared with other chronic conditions 5 1. Kimball AB et al. Am J Clin Dermatol. 2005;6:383 392. 2. Krueger G. et al. Arch Dermatol. 2001;137:280 4. 3. van de Kerkhof Textbook of Psoriasis. 2nd ed. Oxford: Blackwell Publishing; 2003. p. 45 47. 4. Weiss SC, et al. J Am Acad Dermatol. 2002;47:512 5. Rapp SR et al. J Am Acad Dermatol. 1999;41(3);401 7.
Statement 3. People with psoriasis are referred for assessment by a dermatology specialist if indicated. Indications for referral Children and young people with any type of psoriasis Ifthere isdiagnosticuncertainty any type of psoriasis is severe or extensive any type of psoriasis cannot be contr rolled withtopicaltopical therapy acute guttate psoriasis needs phototherapy nail disease has a major functional or cosmetic impact major impact on a person's physical, psychological or social wellbeing Same day specialist assessment if: generalised pustular psoriasis erythroderma.
atement 4. Adults with severe psoriasis are offered a rdiovascular risk assessment at diagnosis and at least once ery 5 years. Severe psoriasis can be defined as psoriasis that needs, or is likely to need, treatment with phototherap py or systemic agents, or needs hospital admission. Some validated cardiovascular risk estimation tools for use with adults exclude younger and older people.
Psoriasis is associated factors with CVD and CV risk Psoriasis has been associated with an increased risk of 1 5 : CVD Atherosclerosis/coronary heart disease Heart failure Myocardial infarction Ischaemic heart disease Cerebrovascular disease Peripheral vascular disease CV risk factors Diabetes Obesity Metabolic syndrome Insulin resistance Hypertension Dyslipidaemia Coronary artery calcification 1. Wu Y, et al. J Drugs Dermatol. 2008;7(4):373 7. 2. Mrowietz U, et al. Arch Dermatol Res. 2006;298(7):309 19. 3. Gottlieb AB, et al. J Dermatolog Treat. 2008;19(1):5 21. 4. Han C, et al. J Rheumatol. 2006 Nov;33(11):2167 72. 5. Ludwig RJ, et al. Br J Dermatol. 2007;156(2):271 6.
The epsoriatic march ac and the development eop e of comorbidities Cardiovascular diseases Metabolic syndrome Diabetes Genes Environmental ti triggers Obesity NAFLD Hypertension Dyslipidemia Smoking Psoriasis Psoriatic arthritis Gisondi P, Girolomoni G. Actas Dermosifiliogr. 2009;100 Suppl 2:14 21.
Statement 5. People with psoriasis having treatment are offered an annual assessment for psoriatic arthritis. People with psoriasis having treatments such as active topical therapy (for example, corticosteroids), pho ototherapy or systemic therapy, should be offered an annual assessment for psoriatic arthritis. The Psoriasis Epidemiological Screening Tool (PEST) can be used to help assess for psoriatic arthritis, although it does not detect axial arthritis or inflammatory back pain and is not validated in children. However, children should still be clinically assessed for psoriatic arthritis.
Presence of PsO at Presentation ti of PsA Pre existing PsA Simultaneous onset 15% 15% 70% Pre existing PsO Psoriatic skin lesions precede onset of by an average of 10 years in approxim 70% of patients stimated prevalence of PsA in le with active psoriasis is 25% (6 42%), gh the true prevalence is unknown Onset typically occurs in patients 30 50 years of Males and females equally affected Anandarajah AP, Ritchlin C. Nat. Rev. Rheumatol. 200
Statement 6. People with psoriasis receiving systemic therapy are monitored in acco ordance with locally agreed protocols. Responsibility for use of systemic therapy should be in specialist consultant led settings only Monitoring should be in accordance with locally agreed protocols that incorporate national accredited dr ug guidelines and policy Non Biological Therapy Methotrexate Ciclosporin Acitretin Fumaderm Biological Therapy Adalimumab Etanercept Ustekinumab Infliximab
Summary NICE CG153 Psoriasis the assessment and management of psoriasis ( October 2012) NICE QS40 Psoriasis Quality Standard (August 2013) The psoriatic march and the development of comorbidities
Any Que estions?