The assessment and management of psoriasis
NICE guidance indicates that health professionals should regularly assess people with psoriasis, and know when to refer them on to specialist care
In this article…
- Prevalence and management of psoriasis
- Assessments and ongoing checks required
- Treatment for psoriasis
Karina Jackson is nurse consultant at Guy’s and St Thomas’ Foundation Trust, London.
Jackson K (2013) The assessment and management of psoriasis. Nursing Times; 109: 28, 18-19.
Psoriasis is a long-term, inflammatory skin condition that affects around 1.3-2.2% of the UK population. Nurses involved in the assessment and treatment of people with psoriasis should take into account not only the condition’s physical effects but also the increased risk of health problems linked to it and its psychological effects. This article highlights National Institute for Health and Clinical Excellence guidance, primarily for non-specialist practitioners.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- Psoriasis is an inflammatory skin condition that affects around 1.3-2.2% of the UK population
- Patients have a higher risk of cardiovascular disease, diabetes and depression, especially those with severe disease
- Assessment for psoriatic arthritis should be undertaken annually and referral to a rheumatologist made promptly if suspected
- Adults with severe psoriasis should be offered a cardiovascular risk assessment every five years
- First-line treatment is topical therapy, with phototherapy or systemic drug therapy offered as second-line treatments
Psoriasis is a common inflammatory skin condition that affects approximately 1.3-2.2% of the UK population (Parisi et al, 2012). Up to 13% of this group may also develop psoriatic arthritis (Ibrahim et al, 2009a). Recent studies have found people with psoriasis have an increased risk of cardiovascular disease, diabetes and depression, especially those with severe disease (Ahlehoff, 2011; Kurd et al, 2010; Qureshi et al, 2009).
The National Institute for Health and Clinical Excellence published its first clinical guideline on the assessment and management of psoriasis last year (NICE, 2012). In most cases, psoriasis is managed in primary care, with specialist referral being needed at some point for up to 60% of people (Schofield et al, 2009). The new guideline makes recommendations for the holistic assessment of affected patients.
Psoriasis is a long-term condition and self-management requires the support of clinicians as a single point of contact to help patients (and families/carers) access information and advice about the condition and services at each stage of the care pathway. Clinicians should be trained and competent to offer support and advice about the use of topical treatments.
When seeing a patient with psoriasis in primary care, the following assessments should be undertaken as standard:
- Disease severity;
- Presence of psoriatic arthritis;
- Impact on physical, psychological and social wellbeing;
- Cardiovascular risk factors (in severe disease).
This holistic assessment will help determine whether the patient should be referred to a specialist (Box 1).
Various assessment tools are recommended. Disease severity can be estimated by both patient and clinician using a static global assessment score (clear, nearly clear, mild, moderate, severe or very severe). The clinician can estimate the body surface area (BSA) affected and should record if nails, high-impact sites and difficult-to-treat sites (for example the face, scalp, palms, soles, flexures and genitals) are affected. Any systemic upset, such as fever and malaise, should be noted and acted upon as these are common in unstable forms of psoriasis, such as erythroderma or generalised pustular disease. Specialists will use a psoriasis area and severity index (PASI) score to measure severity objectively.
Assessment for psoriatic arthritis should be undertaken annually and referral to a rheumatologist made promptly if suspected. The validated Psoriasis Epidemiology Screening Tool (PEST) questionnaire (Table 1) can be used; however, it does not detect axial arthritis or inflammatory back pain. Adults with severe psoriasis (>10% BSA) should be offered a cardiovascular risk assessment using a validated risk estimation tool; this should be repeated every five years or more frequently if indicated. All patients should be offered advice on healthy lifestyles.
The impact of psoriasis on physical, psychological and social wellbeing should be assessed by asking about a range of matters including:
- The aspects of daily living affected by psoriasis;
- How the patient is coping;
- Further advice or support is needed;
- If psoriasis affects mood or causes distress.
If depression is suspected, information, advice and support should be offered in line with NICE guidance (2009; 2005). A dermatology-specific questionnaire can be used to gauge the impact on quality of life (Lewis-Jones and Finlay, 1995; Finlay and Khan, 1994).
Topical therapy is the first-line treatment for psoriasis. Second-line treatments, for example phototherapy or systemic drug therapy, such as methotrexate, must be specialist-led. Treatment algorithms have been developed based on clinical and cost effectiveness analyses and are available to download from the NICE website (tinyurl.com/NICEpathways-Psoriasis).
Different sites require different topical therapies as some are more susceptible to side-effects. The face, flexures and genitals are particularly vulnerable to steroid atrophy, so corticosteroids should only be used for short-term treatment of psoriasis at these sites (1-2 weeks per month). All adult patients should be reviewed four weeks (for children, two weeks) after starting a new topical therapy to evaluate tolerability, toxicity and initial response.
Psoriasis lesions should be responding to treatment within four weeks but may require a further 2-4 weeks to clear fully. If there is no response after four weeks, treatment should be changed following the appropriate treatment algorithm. Prescribers need a good knowledge of the different strengths of topical corticosteroids and ensure patients are fully informed about their safe use (Box 2).
All clinicians assessing and treating psoriasis should reflect on their knowledge and skills to ensure they are delivering the care NICE sets out. Forthcoming quality standards and tools will provide support.
Ahlehoff O (2011) Psoriasis and cardiovascular disease. Danish Medical Bulletin; 58: 11, B4347.
Finlay AY, Khan GK (1994) Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clinical and Experimental Dermatology; 19, 210-216.
Ibrahim G et al (2009a) The prevalence of psoriatic arthritis in people with psoriasis. Arthritis and Rheumatism; 61: 10, 1373-1378.
Ibrahim GH et al (2009b) Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire. Clinical and Experimental Rheumatology; 27: 3, 469-474.
Kurd SK et al (2010) The risk of depression, anxiety, and suicidality in patients with psoriasis: a population-based cohort study. Archives of Dermatology; 146: 8, 891-895.
Lewis-Jones MS, Finlay AY (1995) The Children’s Dermatology Life Quality Index (CDLQI): initial validation and practical use. British Journal of Dermatology; 132: 942-949.
National Institute for Health and Clinical Excellence (2012) Psoriasis: the Assessment and Management of Psoriasis. London: NICE.
National Institute for Health and Clinical Excellence (2009) Depression in Adults with a Chronic Physical Health Problem: Treatment and Management. London: NICE.
National Institute for Health and Clinical Excellence (2005) Depression in Children and Young People: Identification and Management in Primary, Community and Secondary Care. London: NICE.
Parisi R et al (2012) Global epidemiology of psoriasis: a systematic review of incidence and prevalence. Journal of Investigative Dermatology; 133: 2, 377-385.
Qureshi AA et al (2009) Psoriasis and the risk of diabetes and hypertension: a prospective study of US female nurses. Archives of Dermatology; 145: 4, 379-382.
Schofield J et al (2009) Skin Conditions in the UK: a Health Needs Assessment. Nottingham: Centre of Evidence Based Dermatology.