Guideline Summary NGC-8256

Guideline Title
Diagnosis and management of psoriasis and psoriatic arthritis in adults. A national clinical
guideline.
Bibliographic Source(s)
Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and
psoriatic arthritis in adults. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate
Guidelines Network (SIGN); 2010 Oct. 65 p. (SIGN publication; no. 121). [217 references]
Guideline Status
This is the current release of the guideline.
Any amendments to the guideline in the interim period will be noted on Scottish Intercollegiate
Guidelines Network (SIGN) Web site .
FDA Warning/Regulatory Alert
Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which
important revised regulatory and/or warning information has been released.
September 7, 2011 Tumor Necrosis Factor-alpha : The U.S. Food and Drug Administration
(FDA) notified healthcare professionals that the Boxed Warning for the entire class of Tumor
Necrosis Factor-alpha (TNF) blockers has been updated to include the risk of infection from
two bacterial pathogens, Legionella and Listeria. In addition, the Boxed Warning and Warnings
and Precautions sections of the labels for all of the TNF blockers have been revised so that
they contain consistent information about the risk for serious infections and the associated
disease-causing pathogens.
Scope
Disease/Condition(s)
Psoriasis
Psoriatic arthritis (PsA)

Guideline Category
Counseling
Diagnosis
Management
Screening
Treatment
Clinical Specialty
Dermatology
Family Practice
Internal Medicine
Nursing
Psychology
Radiology
Rheumatology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Nurses
Occupational Therapists
Other
Patients
Pharmacists
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)
To provide recommendations based on current evidence for best practice in the diagnosis and
management of psoriasis and psoriatic arthritis (PsA) in adults
Target Population
Adults with psoriasis and psoriatic arthritis (PsA)
Note: The guideline excludes psoriasis and PsA in children. Pregnancy and pre-conception care (e.g., for patients
on systemic therapies) are not addressed. Other inflammatory conditions sometimes associated with psoriasis such
as palmoplantar pustulosis are not addressed. The management of chronic pain associated with PsA is also outside
the scope of this guideline. A minority of patients with PsA develop inflammatory joint disease prior to the
development of cutaneous disease. In most cases such patients will be managed as having an undifferentiated
inflammatory arthritis and will follow the care pathway appropriate to such conditions.


Interventions and Practices Considered
Diagnosis/Evaluation/Screening
1. Rheumatology referral when psoriatic arthritis (PsA) is suspected
2. Annual reassessment of arthritis symptoms in patients with psoriasis
3. Use of patient-administered questionnaires
4. Education of health care professionals on association between psoriasis and PsA
5. Assessment for comorbid conditions (e.g., obesity, diabetes, alcohol abuse, smoking,
cardiovascular disease, psychiatric morbidity)
6. Monitoring disease and response to treatment using clinical assessment tools: Psoriasis Area
and Severity Index (PASI), Dermatology Life Quality Index (DLQI), Bath Ankylosing Spondylitis
Disease Activity Index (BASDAI), PsA Response Criteria (PsARC)
Note: Measurement of serum anticyclic citrullinated peptide antibodies to screen for psoriatic arthritis was
considered but not recommended.
Management/Treatment
Treatment in Primary Care
1. Potent topical corticosteroid or a combined potent corticosteroid plus calcipotriol ointment
2. Vitamin D analogue therapy
3. Moderate potency topical steroids
4. Topical tacrolimus
5. Emollients and other topical therapy
6. Ensuring patient adherence
7. Empathetic communication with patients
8. Referral to secondary care (rheumatology, dermatology, occupational health services)
Treatment in Secondary Care (Rheumatology or Dermatology)
1. Nurse-led triage clinics
2. Pharmacological treatment
Non-steroidal anti-inflammatory drugs (NSAIDS)
Intra-articular corticosteroids (not recommended routinely)
Disease-modifying anti-rheumatic drugs (DMARDs) (leflunomide, sulfasalazine,
methotrexate, ciclosporin, acitretin, hydroxycarbamide, fumaric acid esters) (gold salts
are considered but not recommended routinely)
Biologic therapy (adalimumab, etanercept, infliximab, ustekinumab)
Phototherapy and photochemotherapy
3. Inpatient treatment
4. Provision of information and patient education

Major Outcomes Considered
Sensitivity, specificity, and reliability of diagnostic and assessment tools
Risk for comorbid conditions
Efficacy and tolerability of treatment
Patient adherence to treatment
Dermatology Life Quality Index (DLQI)
Psoriasis Area and Severity Index (PASI) 75
Psoriasis clearance
American College of Radiology (ACR) 20, 50, 70 response to treatment
Radiologic progression of disease
Number of tender or swollen joints
Quality of life
Methodology
Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
Systematic Literature Review
The evidence base for this guideline was synthesised in accordance with Scottish Intercollegiate
Guidelines Network (SIGN) methodology. A systematic review of the literature was carried out using an
explicit search strategy devised by a SIGN Information Officer. Databases searched include Medline,
Embase, CINAHL, PsycINFO and the Cochrane Library. Full details of the searches, including date
ranges and search strategies, are available on the SIGN website. Internet searches were carried out on
various websites including the US National Guideline Clearinghouse and Guidelines International
Network. The main searches were supplemented by material identified by individual members of the
development group. Each of the selected papers was critically appraised by two members of the group
using standard SIGN methodological checklists before conclusions were considered as evidence.
Literature Search for Patient Issues
At the start of the guideline development process, a SIGN Information Officer conducted a literature
search for qualitative and quantitative studies that addressed patient issues of relevance. Databases
searched include Medline, Embase, CINAHL and PsycINFO. The results were summarised and
presented to the guideline development group. A copy of the Medline version of the patient search
strategy is available on the SIGN website.

Number of Source Documents
19,447
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs
with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high
probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a
moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the
relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
Once papers have been selected as potential sources of evidence, the methodology used in each study
is assessed to ensure its validity. The result of this assessment will affect the level of evidence
allocated to the paper, which will in turn influence the grade of recommendation that it supports.
The methodological assessment is based on a number of key questions that focus on those aspects of
the study design that research has shown to have a significant influence on the validity of the results
reported and conclusions drawn. These key questions differ between study types, and a range of
checklists is used to bring a degree of consistency to the assessment process. The Scottish
Intercollegiate Guidelines Network (SIGN) has based its assessments on the MERGE (Method for
Evaluating Research and Guideline Evidence) checklists developed by the New South Wales
Department of Health, which have been subjected to wide consultation and evaluation. These
checklists were subjected to detailed evaluation and adaptation to meet SIGN's requirements for a
balance between methodological rigour and practicality of use.
The assessment process inevitably involves a degree of subjective judgment. The extent to which a
study meets a particular criterione.g., an acceptable level of loss to follow upand, more
importantly, the likely impact of this on the reported results from the study will depend on the clinical
context. To minimise any potential bias resulting from this, each study must be evaluated
independently by at least two group members. Any differences in assessment should then be discussed
by the full group. Where differences cannot be resolved, an independent reviewer or an experienced
member of SIGN Executive staff will arbitrate to reach an agreed quality assessment.
Evidence Tables
Evidence tables are compiled by SIGN Executive staff based on the quality assessments of individual
studies provided by guideline development group members. The tables summarise all the validated
studies identified from the systematic literature review relating to each key question. They are
presented in a standard format to make it easier to compare results across studies, and will present
separately the evidence for each outcome measure used in the published studies. These evidence
tables form an essential part of the guideline development record and ensure that the basis of the
guideline development group's recommendations is transparent.
Additional details can be found in the companion document titled "SIGN 50: A Guideline Developers'
Handbook." (Edinburgh [UK]: Scottish Intercollegiate Guidelines Network. [SIGN publication; no. 50]),
available from the SIGN Web site .
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Synthesising the Evidence
Guideline recommendations are graded to differentiate between those based on strong evidence and
those based on weak evidence. This judgement is made on the basis of an (objective) assessment of
the design and quality of each study and a (perhaps more subjective) judgement on the consistency,
clinical relevance and external validity of the whole body of evidence. The aim is to produce a
recommendation that is evidence-based, but which is relevant to the way in which health care is
delivered in Scotland and is therefore implementable.
It is important to emphasise that the grading does not relate to the importance of the
recommendation, but to the strength of the supporting evidence and, in particular, to the predictive
power of the study designs from which that data was obtained. Thus, the grading assigned to a
recommendation indicates to users the likelihood that, if that recommendation is implemented, the
predicted outcome will be achieved.
Considered Judgement
It is rare for the evidence to show clearly and unambiguously what course of action should be
recommended for any given question. Consequently, it is not always clear to those who were not
involved in the decision making process how guideline developers were able to arrive at their
recommendations, given the evidence they had to base them on. In order to address this problem,
SIGN has introduced the concept of considered judgement.
Under the heading of considered judgement, guideline development groups summarise their view of
the total body of evidence covered by each evidence table. This summary view is expected to cover the
following aspects:
Quantity, quality, and consistency of evidence
External validity (generalisability) of study findings
Directness of application to the target population for the guideline
Any evidence of potential harms associated with implementation of a recommendation
Clinical impact (i.e., the extent of the impact on the target patient population, and the
resources needed to treat them in accordance with the recommendation)
Whether, and to what extent, any equality groups may be particularly advantaged or
disadvantaged by the recommendations mad
Implementability (i.e., how practical it would be for the NHS in Scotland to implement the
recommendation.)
The group are finally asked to summarise its view on all of these issues, both the quality of the
evidence and its potential impact, before making a graded recommendation. This summary should be
succinct, and taken together with its views of the level of evidence represent the first draft of the text
that will appear in the guideline immediately before a graded recommendation.
Additional detail about SIGN's process for formulating guideline recommendations is provided in
Section 6 of the companion document titled "SIGN 50: A Guideline Developers' Handbook." (Edinburgh
[UK]: Scottish Intercollegiate Guidelines Network. [SIGN publication; no. 50], available from the SIGN
Web site .
Rating Scheme for the Strength of the Recommendations
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++,
and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target
population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and
demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and
demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline
development group
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
National Open Meeting
A national open meeting is the main consultative phase of Scottish Intercollegiate Guidelines Network
(SIGN) guideline development, at which the guideline development group presents its draft
recommendations for the first time. The national open meeting for this guideline was held on 1 October
2009 and was attended by 157 representatives of all the key specialties relevant to the guideline and
members of the public.
The draft guideline was also available on the SIGN website for a limited period at this stage to allow
those unable to attend the meeting to contribute to the development of the guideline.
Specialist Review
This guideline was also reviewed in draft form by independent expert referees, who were asked to
comment primarily on the comprehensiveness and accuracy of interpretation of the evidence base
supporting the recommendations in the guideline. The guideline group addresses every comment made
by an external reviewer, and must justify any disagreement with the reviewers' comments (see
Section 11 of the original guideline document for a listing of the independent reviewers).
SIGN Editorial Group
As a final quality control check, the guideline is reviewed by an editorial group comprising the relevant
specialty representatives on SIGN Council to ensure that the specialist reviewers' comments have been
addressed adequately and that any risk of bias in the guideline development proc ess as a whole has
been minimised.



































Recommendations
Major Recommendations
Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline
Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline
development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (AD) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are
defined at the end of the "Major Recommendations" field.
Diagnosis, Assessment and Monitoring
Diagnosis
Early Diagnosis
B - All patients suspected as having psoriatic arthritis should be assessed by a rheumatologist so that
an early diagnosis can be made and joint damage can be reduced.
B - Patients with inflammatory joint disease should be classified as having psoriatic arthritis based on
ClASsification criteria for Psoriatic ARthritis (CASPAR) criteria.
Screening for Psoriatic Arthritis
D - Healthcare professionals who treat patients with psoriasis should be aware of the association
between psoriasis and psoriatic arthritis.
C - The use of patient-administered screening questionnaires such as the Psoriasis Epidemiology
Screening Tool (PEST) should be considered for early detection of psoriatic arthritis in primary care and
dermatology clinics.
B - The measurement of serum anticyclic citrullinated peptide antibodies in patients with psoriasis
should not be used to screen for psoriatic arthrit is.
Comorbidities
D - Healthcare professionals should be aware of the need to consider comorbid conditions in patients
with psoriasis and psoriatic arthritis. Where necessary, detailed assessment should be carried out to
accurately identify and manage comorbid conditions.
Cardiovascular Risk
D - Evaluation of patients with severe psoriasis or psoriatic arthritis should include annual body mass
index (BMI), diabetes mellitus (DM) screening, blood pressure measurement, and lipid profile.
D - Consider advising patients with severe psoriasis or psoriatic arthritis that they may be at increased
risk of cardiovascular disease and diabetes.
Alcohol Consumption
D - All patients with psoriasis or psoriatic arthritis should be encouraged to adopt a healthy lifestyle,
including:
Regular exercise
Weight management, aiming for BMI 18.5-24.9
Moderation of alcohol consumption
Cessation of smoking
Impact on Psychological Well-being
D - Assessment of patients with psoriasis or psoriatic arthritis should include psychosocial measures,
with referral to mental health services as appropriate.
Monitoring Disease Activity and Response to Treatment
Assessment Tools for Psoriasis
D - Healthcare professionals should be aware that the Psoriasis Area and Severity Index (PASI) and
Dermatology Life Quality Index (DLQI) are part of the eligibility criteria for biologic therapy in psoriasis
and must be used to assess the efficacy of these agents over t ime.
D - The DLQI should be measured as part of the global assessment of patients with psoriasis.
Assessment Tools for Psoriatic Arthritis
D - Psoriatic Arthritis Response Criteria (PsARC) should be used to monitor response to biologic agents
in patients with peripheral psoriatic arthritis.
D - Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and spinal pain visual analogue score
should be used to monitor response to biologic agents in patients with axial disease.












Treatment in Primary Care
Topical Therapy
A - Short term intermittent use of a potent topical corticosteroid or a combined potent corticosteroid
plus calcipotriol ointment is recommended to gain rapid improvement in plaque psoriasis.
D - Potent to very potent topical corticosteroids are not recommended for regular use over prolonged
periods because of concern over long term adverse effects.
A - For long term topical treatment of plaque psoriasis a vitamin D analogue is recommended.
B - If a vitamin D analogue is ineffective or not tolerat ed then short contact dithranol, coal tar solution,
cream or lotion or tazarotene gel should be considered in appropriate patients.
Scalp, Nail, Facial, and Flexural Psoriasis
Scalp
B - Short term intermittent use of potent topical corticosteroids or a combination of a potent
corticosteroid and a vitamin D analogue is recommended in scalp psoriasis.
Face and Flexures
B - Moderate potency topical corticosteroids are recommended for short term use in facial and flexural
psoriasis.
B - If moderate potency topical corticosteroids are ineffective in facial and flexural psoriasis, then
vitamin D analogues or tacrolimus ointment are recommended for intermittent use.
Concordance-Related Issues
D - Patients should be offered a follow-up appointment within six weeks of initiating or changing
topical therapy to assess treatment efficacy and acceptability.
D - To improve adherence, the number of treatments per day should be kept to a minimum.
Communication with Patients
D - Healthcare professionals should express empathy, acknowledge day to day difficulties, and
recognise and manage psychosocial needs related to having psoriasis.
D - Treatment options, risks and benefits should be discussed with the patient, allowing them to be
involved in decision making.
Referral to Secondary Care
Referral to Dermatology
D - Referral to a consultant dermatologist should be considered if any of the following apply:
Diagnostic uncertainty
Extensive disease
Occupational disability or excessive time lost from work or school
Involvement of sites which are difficult to treat, e.g., the face, palms or genitalia
Failure of appropriate topical treatment after two or three months' use
Adverse reactions to topical treatment
Severe or recalcitrant disease
D - Patients with erythrodermic or generalised pustular psoriasis must receive emergency referral to
dermatology.
D - Patients in primary care who do not respond to topical therapy and who score 6 or above on the
DLQI should be offered referral to dermatology.
D - Referral to a dermatology nurse specialist or nurse-led clinic should be considered in patients in
whom a diagnosis of psoriasis has previously been established in secondary care if any of the following
apply:
Relapse following topical therapy
Refractory scalp psoriasis
Request for further counselling and/or education, including demonstration of topical treatment
Topical therapy/phototherapy according to protocols, nurse competencies and local
arrangements





















Treatment of Psoriatic Arthritis in Secondary Care
Organisation of Care
D - Nurse-led triage clinics should be considered for psoriatic arthritis.
Pharmacological Treatment
C - Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for short term symptom relief
in patients with psoriatic arthritis where not contraindicated.
Disease-Modifying Anti-rheumatic Drugs
A - Leflunomide is recommended for the treatment of active peripheral psoriatic arthritis.
C - Sulfasalazine may be considered as an alternative in the treatment of peripheral psoriatic arthritis.
C - Methotrexate may be considered in the treatment of psoriatic arthritis.
D - The addition of ciclosporin to methotrexate in the treatment of psoriatic arthritis is not
recommended for routine therapy.
B - The use of intramuscular or oral gold in the treatment of psoriatic arthritis is not recommended
where less toxic treatments are an option.
Biologic Therapy
A - Adalimumab, etanercept or infliximab are recommended for treatment of active psoriatic arthritis in
patients who have failed to respond to, are intolerant of, or have had contraindications to at least two
disease-modifying therapies.
Treatment of Psoriasis in Secondary Care
Organisation of Care
D - Patients with erythrodermic or generalised pustular psoriasis must receive emergency referral to
dermatology.
Inpatient Care
D - Inpatient treatment on a dermatology ward should be available for patients with severe psoriasis.
Nurse-Led Clinics
C - Nurse-led clinics for psoriasis should be considered for delivery of services such as follow up of
specialist caseload, re-access for patients with recurrent disease, and monitoring of systemic therapies.
Phototherapy and Photochemotherapy
A - Broad band ultraviolet B phototherapy (BBUVB) is not recommended.
B - Patients with psoriasis who do not respond to topical therapy should be offered narrow band
ultraviolet B phototherapy (NBUVB).
B - Psoralen ultraviolet A photochemotherapy (PUVA) should be considered for those patients who do
not respond to NBUVB.
D - All patients who have received >200 whole-body PUVA treatments and/or >500 whole-body
ultraviolet B (UVB) treatments should be invited for annual skin cancer screening review.
B - Three times weekly NBUVB phototherapy is recommended where practicable.
B - Home NBUVB phototherapy under controlled supervision should be considered where practicable
for patients who are unable to attend hospital.
Pharmacological Treatment
Systemic Therapy
B - Patients with severe or refractory psoriasis should be considered for systemic therapy with
ciclosporin, methotrexate or acitretin, following discussion of benefits and risks.
B - Methotrexate is recommended for longer term use and where there is concomitant psoriatic
arthritis.
A - Ciclosporin is recommended for short term intermittent use.
B - Acitretin can be considered as an alternative.
B - Fumaric acid esters can be considered as an alternative maintenance therapy for patients who are
not suitable for other systemic therapies or have failed other therapies.
C - Hydroxycarbamide can be considered as an alternative maintenance therapy for patients who are
not suitable for other systemic therapies or have failed other therapies.
Biologic Therapy
A - Patients with severe psoriasis who fail to respond to, have a contraindication to, or are intolerant of
phototherapy and systemic therapies including ciclosporin and methotrexate should be offered biologic
therapy unless they have contraindications or are at increased risk of hazards from these therapies.
A - Adalimumab loading regimen followed by 40 mg every other week is recommended in the
treatment of severe psoriasis.
A - Etanercept 25 mg twice weekly or 50 mg weekly is recommended in the treatment of severe
psoriasis.
A - Infliximab 5 mg/kg at weeks 0, 2, 6 and repeated as maintenance treatment every two months is
recommended in the treatment of severe psoriasis, especially when rapid disease control is required.
A - Ustekinumab 45 mg for patients weighing under 100 kg and 90 mg for patients weighing over 100
kg given at weeks 0 and 4 then every 12 weeks as maintenance is recommended in the treatment of
severe psoriasis.

Provision of Information
Provision of Information and Patient Education
D - Active involvement of patients in managing their care should be encouraged.
D - Patients should receive information about their diagnosis, treatment options, and the correct
application of topical treatments.
Definitions:
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs
with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high
probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a
moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the
relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
Grades of Recommendations
Note: The grade of recommendation relates to the strength of the evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the
target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target
population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and
demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and
demonstrating overall consistency of results; or
Extrapolated evidence from studies rate as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+































Clinical Algorithm(s)
A care pathway for psoriasis and psoriatic arthritis in primary and secondary care is provided in the
original guideline document.
Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major
Recommendations").
Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
Appropriate diagnosis and treatment of psoriasis and psoriatic arthritis, including patient involvement
in care, results to greater patient satisfaction with care, reduction in pain and joint damage, and
improved quality of life
Potential Harms
Adverse Effects of Topical Treatments for Psoriasis
These adverse effects include development of striae, skin fragility and easy bruising; rebound,
persistent or unstable psoriasis; and systemic adverse effects. These adverse effects were
uncommon in the reported studies, but most studies were short term (none involving topical
corticosteroid use for more than one year). Because monitoring in studies is close, participants
will be less likely to continue to more serious side effects than in standard treatment outwith a
study. Rare but serious (sometimes fatal) side effects such as systemic hypothalamic-pituitary
axis suppression and generalised pustular psoriasis need to be considered.
Potent to very potent topical corticosteroids are not recommended for regular use over
prolonged periods because of concern over long term adverse effects.
Ultraviolet Radiation Risks
Exposure to ultraviolet (UV) radiation is a recognised risk factor for squamous cell carcinoma (SCC),
basal cell carcinoma (BCC) and malignant melanoma (MM).
Toxicity of Systemic Therapy
Methotrexate potentially causes hepatotoxicity and is less effective than ciclosporin.
Ciclosporin is potentially nephrotoxic and causes hypertension.
Hydroxycarbamide is teratogenic and can cause bone marrow suppression.
Acitretin is teratogenic.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are potentially cardiotoxic.

Adverse Effects of Biologic Therapy
The crude incidence of adverse events in the systematic reviews did not reveal any significant
differences in safety between agents although adverse effects differ. The choice of therapy will
depend on individual factors, comorbidity including the presence of psoriatic arthritis and
consideration of adverse effects.
The most common adverse effects with adalimumab therapy were upper respiratory tract
infection, nasopharyngitis, and injection site reactions.
Infusion reactions and antibody formation are the most common adverse effects of infliximab
although it is not clear whether these occur more frequently than with placebo.
Injection site reactions are the most common adverse effect with etanercept in published
studies.
Contraindications
Contraindications
Women who are or may be pregnant should not be treated with systemic or biologic agents.
Acitretin should be avoided in women of childbearing potential.
Qualifying Statements
Qualifying Statements
This guideline is not intended to be construed or to serve as a standard of care. Standards of care are
determined on the basis of all clinical data available for an individual case and are subject to change as
scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline
recommendations will not ensure a successful outcome in every case, nor should they be const rued as
including all proper methods of care or excluding other acceptable methods of care aimed at the same
results. The ultimate judgement must be made by the appropriate healthcare professional(s)
responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This
judgement should only be arrived at following discussion of the options with the patient, covering the
diagnostic and treatment choices available. It is, however, advised that significant departures from the
national guideline or any local guidelines derived from it should be fully documented in the patient's
case notes at the time the relevant decision is taken.
Every care is taken to ensure that this publication is correct in every detail at the time of publication.
However, in the event of errors or omissions corrections will be published in the web version of this
document, which is the definitive version at all times. This version can be found on www.sign.ac.uk .
Prescribing of Licensed Medicines outwith Their Marketing Authorisation
Recommendations within this guideline are based on the best clinical evidence. Some
recommendations may be for medicines prescribed outwith the marketing authorisation (product
licence). This is known as 'off label' use. It is not unusual for medicines to be prescribed outwith their
product licence and this can be necessary for a variety of reasons.
Generally the unlicensed use of medicines becomes necessary if the clinical need cannot be met by
licensed medicines; such use should be supported by appropriate evidence and experience.
Medicines may be prescribed outwith their product licence in the following circumstances:
For an indication not specified within the marketing authorisation
For administration via a different route
For administration of a different dose
Prescribing medicines outside the recommendations of their marketing authorisation alters (and
probably increases) the prescribers' professional responsibility and potential liability. The prescriber
should be able to justify and feel competent in using such medicines.
Any practitioner following a Scottish Intercollegiate Guidelines Network (SIGN) recommendation and
prescribing a licensed medicine outwith the product licence needs to be aware that they are
responsible for this decision, and in the event of adverse outcomes, may be required to justify the
actions that they have taken. Prior to prescribing, the licensing status of a medication should be
checked in the current version of the British National Formulary (BNF).
Implementation of the Guideline
Description of Implementation Strategy
Implementation of national clinical guidelines is the responsibility of each National Health Service
(NHS) Board and is an essential part of clinical governance. Mechanisms should be in place to review
care provided against the guideline recommendations. The reasons for any differences should be
assessed and addressed where appropriate. Local arrangements should then be made to implement
the national guideline in individual hospitals, units and practices.
Resource implications of key recommendations and key points to audit are available in section 9 of the
original guideline document.
Implementation of this guideline will be encouraged and supported by the Scottish Intercollegiate
Guidelines Network (SIGN), NHS Quality Improvement Scotland (QIS) and other stakeholder
organisations. The implementation strategy for this guideline encompasses dissemination, provision of
tools such as PowerPoint slide sets, education and awareness-raising activities. The detailed strategy is
available from www.sign.ac.uk .
Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
Clinical Algorithm
Patient Resources
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.
Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Identifying Information and Availability
Bibliographic Source(s)
Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and
psoriatic arthritis in adults. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate
Guidelines Network (SIGN); 2010 Oct. 65 p. (SIGN publication; no. 121). [217 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2010 Oct
Guideline Developer(s)
Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.]
Source(s) of Funding
Scottish Executive Health Department
Guideline Committee
Guideline Development Group
Composition of Group That Authored the Guideline
Guideline Development Group: Dr David Burden (Chair), Consultant Dermatologist, The Alan Lyell
Centre for Dermatology, Western Infirmary, Glasgow; Mrs Rosemary Beaton, Patient Representative,
Glasgow; Dr David Bilsland, Consultant Dermatologist, Southern General Hospital, Glasgow; Mr
Stewart Campbell, Patient Representative, Psoriasis Association; Dr Robert Dawe, Consultant
Dermatologist, Ninewells Hospital, Dundee; Dr Diane Dixon, Senior Lecturer, School of Psychological
Sciences and Health, University of Strathclyde; Dr Linda Grimmond, Consultant Occupational Physician,
Occupational Health and Safety Advisory Services, Dundee; Mrs Sandra Hanlon, Dermatology Liaison
Sister, Inverclyde Royal Hospital, Greenock; Dr Iain Henderson, General Practitioner, Kingsway Medical
Practice, Glasgow; Ms Michele Hilton Boon, Programme Manager, SIGN; Mrs Janice Johnson, Patient
Representative; Director, PSALV - Psoriasis Scotland, Arthritis Link Volunteers, Edinburgh; Dr Alan
Jones, General Practitioner, Newton Stewart; Dr Danny Kemmett, Consultant Dermatologist, Royal
Infirmary of Edinburgh; Dr Joyce Leman, Consultant Dermatologist, Western Infirmary, Glasgow; Dr
Ayyakkannu Manivannan, Laser Protection Advisor and Clinical Sc ientist, NHS Grampian and University
of Aberdeen; Dr Lorna McHattie, Lecturer, School of Pharmacy and Life Sciences, Robert Gordon
University, Aberdeen; Dr David McKay, Consultant Dermatologist, Royal Infirmary of Edinburgh;
Professor Harry Moseley, Consultant Clinical Scientist, Photobiology Unit, Ninewells Hospital and
Medical School, Dundee; Dr Tony Ormerod, Reader in Dermatology, Department of Applied Medicine,
University of Aberdeen and Honorary Consultant Dermatologist, Aberdeen Royal Infirmary; Dr Gozde
Ozakinci, Lecturer in Health Psychology, University of St Andrews; Dr Ruth Richmond, Consultant
Rheumatologist, Borders General Hospital, Melrose; Mrs Lynne Smith, Information Officer, SIGN; Dr
Derek Stewart, Reader in Pharmacy Practice, Robert Gordon University, Aberdeen; Anne Thorrat,
Psoriasis/Research Nurse, Western Infirmary, Glasgow; Dr Hilary Wilson, Consultant Rheumatologist,
Stobhill Hospital, Glasgow
Financial Disclosures/Conflicts of Interest
Declarations of interests were made by all members of the guideline development group. Further
details are available from the Scottish Intercollegiate Guidelines Network (SIGN) Executive.
Guideline Status
This is the current release of the guideline.
Any amendments to the guideline in the interim period will be noted on Scottish Intercollegiate
Guidelines Network (SIGN) Web site .
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the Scottish Intercollegiate
Guidelines Network (SIGN) Web site .
Availability of Companion Documents
The following are available:
Quick reference guide: Diagnosis and management of psoriasis and psoriatic arthritis in adults.
A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network;
2010. 72 p. Available in Portable Document Format (PDF) from the Scottish Intercollegiate
Guidelines Network (SIGN) Web site .
Summary of recommendations: Diagnosis and management of psoriasis and psoriatic arthritis
in adults. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines
Network; 2010. Available from the SIGN Web site .
SIGN 50: A guideline developer's handbook. Edinburgh (Scotland): Scottish Intercollegiate
Guidelines Network. (SIGN publication; no. 50). Available in PDF from the SIGN Web site .
Appraising the quality of clinical guidelines. The SIGN guide to the AGREE (Appraisal of
Guidelines Research & Evaluation) guideline appraisal instrument. Edinburgh (Scotland):
Scottish Intercollegiate Guidelines Network; 2001. Available in PDF from the SIGN Web site .
Implementation strategy: Diagnosis and management of psoriasis and psoriatic arthritis.
Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network; 2010. 1 p. Available in PDF
from the SIGN Web site .
Search narrative: Guideline topic: Management of psoriasis and psoriatic arthritis. Edinburgh
(Scotland): Scottish Intercollegiate Guidelines Network; 2010. 1 p. Available in PDF from the
SIGN Web site .
In addition, the annexes of the original guideline document include a number of screening and
assessment tools for psoriasis and psoriatic arthritis. Section 9 of the original guideline document also
contains key points to audit.
Patient Resources
The following is available:
Treating psoriasis and psoriatic arthritis. A booklet for patients and carers. Edinburgh (UK):
Scottish Intercollegiate Guidelines Network, 2011. 33 p. Available in Portable Document
Format (PDF) from the Scottish Intercollegiate Guidelines Network (SIGN) Web site .
Please note: This patient information is intended to provide health professionals with information to share with
their patients to help them better understand their health and their diagnosed disorders. By providing access to
this patient information, i t is not the intention of NGC to provide specific medical advice for particular patients.
Rather we urge patients and their representatives to review this material and then to consult wi th a licensed health
professional for evaluation of treatment options sui table for them as well as for diagnosis and answers to their
personal medical questions. This patient information has been derived and prepared from a guideline for health
care professionals included on NGC by the authors or publishers of that original guideline. The pa tient information
is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
NGC Status
This summary was completed by ECRI Institute on February 22, 2011. The information was verified by
the guideline developer on March 4, 2011. This summary was updated by ECRI Institute on October
12, 2011 following the U.S. Food and Drug Administration (FDA) advisory on Tumor Necrosis Factor-
alpha (TNF) Blockers.
Copyright Statement
Scottish Intercollegiate Guidelines Network (SIGN) guidelines are subject to copyright; however, SIGN
encourages the downloading and use of its guidelines for the purposes of implementation, education,
and audit.
Users wishing to use, reproduce, or republish SIGN material for commercial purposes must seek prior
approval for reproduction in any medium. To do this, please contact sara.twaddle@nhs.net.
Additional copyright information is available on the SIGN Web site .
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