bookshelf nbk247829 psoriasis
TRANSCRIPT
-
8/15/2019 Bookshelf NBK247829 Psoriasis
1/758
-
8/15/2019 Bookshelf NBK247829 Psoriasis
2/758
-
8/15/2019 Bookshelf NBK247829 Psoriasis
3/758
Poriai
Conen
Poriai fll gideline (Ocober 2012)
Poriai
Pblihed b he Naional Clinical Gideline Cenre a
The Roal College of Phician, 11 S Andre Place, Regen Park, London, NW1 4BT
Fir pblihed Ocober 2012
Naional Clinical Gideline Cenre Ocober 2012
Apar from an fair dealing for he prpoe of reearch or priae d, criicim or reie, a
permied nder he Coprigh, Deign and Paen Ac, 1988, no par of hi pblicaion ma be
reprodced, ored or ranmied in an form or b an mean, iho he prior rien permiion of
he pbliher or, in he cae of reprographic reprodcion, in accordance ih he erm of licence
ied b he Coprigh Licening Agenc in he UK. Enqirie concerning reprodcion oide he
erm aed here hold be en o he pbliher a he UK addre prined on hi page.
The e of regiered name, rademark, ec. in hi pblicaion doe no impl, een in he abence of
a pecific aemen, ha ch name are eemp from he relean la and reglaion and herefore
for general e.
The righ of Naional Clinical Gideline Cenre o be idenified a Ahor of hi ork hae been
aered b hem in accordance ih he Coprigh, Deign and Paen Ac, 1988.
Poriai fll gideline (Ocober 2012)
-
8/15/2019 Bookshelf NBK247829 Psoriasis
4/758
-
8/15/2019 Bookshelf NBK247829 Psoriasis
5/758
Poriai
Conen
Poriai fll gideline (Ocober 2012)
5
4.4 Eidence of coeffeciene ............................................................................................ 39
4.4.1 Lierare reie ................................................................................................. 39
4.4.2 Underaking ne healh economic anali ........................................................ 41
4.4.3 Coeffeciene crieria ................................................................................... 41
4.5 Deeloping recommendaion ............................................................................................ 42
4.5.1 Reearch recommendaion ................................................................................ 42
4.5.2 Validaion proce ............................................................................................... 42
4.5.3 Updaing he gideline ........................................................................................ 42
4.5.4 Diclaimer ............................................................................................................ 43
4.5.5 Fnding ................................................................................................................ 43
5 G .............................................................................................................. 44
5.1 Ke prioriie for implemenaion ....................................................................................... 44
5.2 Fll li of recommendaion .............................................................................................. 46
5.3 Ke fre reearch recommendaion .............................................................................. 62
5.4 Algorihm ........................................................................................................................... 63
6 P ................................................................................................................. 71
6.1 Mehodological inrodcion .............................................................................................. 71
6.2 Selfmanagemen ppor (proided b a nre peciali / rained pracice nre) .
andard care ...................................................................................................................... 75
6.2.1 Eidence profile ................................................................................................... 75
6.2.2 Eidence aemen ........................................................................................... 776.2.3 Sbgrop anali ................................................................................................ 78
6.3 Addiional applicaion informaion . andard informaion for e of dihranol ............ 78
6.3.1 Eidence profile ................................................................................................... 78
6.3.2 Eidence aemen ........................................................................................... 79
6.4 Deciion board aid . andard conlaion ..................................................................... 79
6.4.1 Eidence profile ................................................................................................... 79
6.4.2 Eidence aemen ........................................................................................... 81
6.5 Co effeciene eidence ................................................................................................ 81
6.5.1 Eidence aemen ........................................................................................... 82
6.6 Recommendaion and link o eidence ............................................................................. 82
7 A ...................................................................................................... 87
7.1 Aemen ool for dieae eeri and impac and referral for peciali care ............ 87
7.1.1 Mehodological inrodcion ............................................................................... 88
7.1.2 Clinical eidence for inernal conienc ........................................................... 94
7.1.3 Clinical eidence for eree or inraraer reliabili ..................................... 96
7.1.4 Clinical eidence for inerraer reliabili ........................................................... 98
7.1.5 Clinical eidence for conrc alidi conino cale.............................. 100
7.1.6 Clinical eidence for conrc alidi/agreemen dichoomo raing of
-
8/15/2019 Bookshelf NBK247829 Psoriasis
6/758
Poriai
Conen
Poriai fll gideline (Ocober 2012)
6
repone or eeri .......................................................................................... 107
7.1.7 Clinical eidence for eniii o change ......................................................... 108
7.1.8 Clinical eidence for pracicabili ..................................................................... 110
7.1.9 Economic Eidence ............................................................................................ 111
7.1.10 Recommendaion and link o eidence ........................................................... 111
7.2 Aemen and referral for poriaic arhrii ................................................................. 119
7.2.1 Mehodological inrodcion ............................................................................. 119
7.2.2 Sd deail mehod and rel.................................................................. 122
7.2.3 Eidence profile ................................................................................................. 127
7.2.4 Eidence Smmar ............................................................................................ 129
7.2.5 Eidence aemen ......................................................................................... 132
7.2.6 Economic Eidence ............................................................................................ 133
7.2.7 Recommendaion and link o eidence ........................................................... 133
7.3 Speciali referral for poriaic arhrii ............................................................................ 137
7.3.1 Mehodological inrodcion ............................................................................. 137
7.3.2 Direc eidence .................................................................................................. 142
7.3.3 Indirec eidence ............................................................................................... 143
7.3.4 Economic eidence ............................................................................................ 147
7.3.5 Recommendaion and link o eidence ........................................................... 147
7.4 Idenificaion of comorbidiie .......................................................................................... 150
7.4.1 Mehodological inrodcion ............................................................................. 150
7.4.2 Cardioaclar dieae ...................................................................................... 174
7.4.3 Cardioaclar dieae rik facor .................................................................... 184
7.4.4 Depreion ......................................................................................................... 187
7.4.5 Cancer ................................................................................................................ 188
7.4.6 Incidence of morali from ario cancer compared ih people iho
poriai ............................................................................................................. 193
7.4.7 Morali ............................................................................................................ 196
7.4.8 Economic eidence ............................................................................................ 198
7.4.9 Recommendaion and link o eidence ........................................................... 201
8 T .................................................................................................................. 210
8.1 Topical herapie for rnk and limb poriai .................................................................. 211
8.1.1 Mehodological inrodcion ............................................................................. 211
8.1.2 Viamin D and iamin D analoge . placebo ................................................. 225
8.1.3 Viamin D or iamin D analoge . placebo (children) ................................... 229
8.1.4 Poen coricoeroid . placebo ...................................................................... 230
8.1.5 Ver poen coricoeroid . placebo ............................................................. 232
8.1.6 Taaroene . placebo ...................................................................................... 236
8.1.7 Poen coricoeroid . placebo for mainenance of remiion ..................... 238
-
8/15/2019 Bookshelf NBK247829 Psoriasis
7/758
Poriai
Conen
Poriai fll gideline (Ocober 2012)
7
8.1.8 Viamin D or iamin D analoge . poen coricoeroid .............................. 239
8.1.9 Concrren iamin D or iamin D analoge and poen coricoeroid (one
in he morning and one in he eening) . iamin D or iamin D analoge
alone .................................................................................................................. 243
8.1.10 Combined prodc conaining iamin D or iamin D analoge and poen
coricoeroid (calciporiol pl beamehaone dipropionae) . iamin D
or iamin D analoge alone .............................................................................. 246
8.1.11 Combined prodc conaining iamin D or iamin D analoge and poen
coricoeroid (calciporiol pl beamehaone dipropionae) . poen
coricoeroid ..................................................................................................... 249
8.1.12 Combined prodc conaining iamin D or iamin D analoge and poen
coricoeroid (calciporiol pl beamehaone dipropionae) hen iamin
D or iamin D analoge . iamin D or iamin D analoge alone ................ 250
8.1.13 Combined prodc conaining iamin D or iamin D analoge and poen
coricoeroid (calciporiol pl beamehaone dipropionae) . iamin D
or iamin D analoge (52 eek mainenance) ............................................... 254
8.1.14 Viamin D or iamin D analoge . dihranol .................................................. 257
8.1.15 Viamin D or iamin D analoge . coal ar .................................................... 260
8.1.16 Viamin D or iamin D analoge once dail compared o iamin D or
iamin D ice dail ......................................................................................... 263
8.1.17 Time o remiion or maimm effec for rnk or limb poriai .................... 264
8.1.18 Neork meaanali for rnk or limb poriai ........................................... 283
8.1.19 Co effeciene eidence for rnk or limb poriai .................................... 288
8.1.20 Recommendaion and link o eidence ........................................................... 303
8.2 Topical herapie for high impac or difficl ie ........................................................... 317
8.2.1 Mehodological inrodcion ............................................................................. 317
8.2.2 Scalp poriai .................................................................................................... 322
8.2.3 Time o remiion or maimm effec for calp poriai ................................. 341
8.2.4 Neork meaanali calp poriai ........................................................... 352
8.2.5 Co effeciene eidence (calp poriai) .................................................... 354
8.2.6 Face, flere and genial................................................................................. 367
8.2.7 Time o remiion or maimm effec for face, flere and genial .............. 370
8.2.8 Co effeciene eidence face and flere (inclding genial) ................ 374
8.2.9 Recommendaion and link o eidence ........................................................... 374
9 P .................................................................................................................... 385
9.1 UVB (broadband and narroband) and PUVA .................................................................. 385
9.1.1 Mehodological inrodcion ............................................................................. 385
9.1.2 Narroband broadband UVB ........................................................................ 389
9.1.3 Narroband UVB PUVA................................................................................. 392
9.1.4 Differen NBUVB reamen freqencie ........................................................... 401
9.1.5 Economic eidence ............................................................................................ 416
-
8/15/2019 Bookshelf NBK247829 Psoriasis
8/758
Poriai
Conen
Poriai fll gideline (Ocober 2012)
8
9.1.6 Recommendaion and link o eidence ........................................................... 419
9.2 Phooherap combined ih acirein ............................................................................. 425
9.2.1 Mehodological inrodcion ............................................................................. 425
9.2.2 Acirein Acirein pl BBUVB ...................................................................... 426
9.2.3 Acirein pl BBUVB placebo pl BBUVB .................................................... 427
9.2.4 Acirein pl NBUVB acirein pl PUVA ..................................................... 428
9.2.5 Acirein pl PUVA placebo pl PUVA ........................................................ 430
9.2.6 Economic eidence ............................................................................................ 432
9.2.7 Recommendaion and link o eidence ........................................................... 433
9.3 Dihranol, coal ar and iamin D or iamin D analoge combined ih UVB ............... 436
9.3.1 Mehodological inrodcion ............................................................................. 436
9.3.2 Viamin D analoge pl NBUVB iamin D analoge alone ......................... 438
9.3.3 Calciporiol pl BBUVB calciporiol .............................................................. 440
9.3.4 Calciporiol pl NBUVB placebo pl NBUVB .............................................. 441
9.3.5 Viamin D or iamin D analoge pl BBUVB placebo pl BBUVB ............. 443
9.3.6 LCD (Liqor carboni diillae; eqi. 2.3% coal ar) pl NBUVB NBUVB ... 446
9.3.7 Tar oil pl berhemogenic BBVB placebo pl maimall
erhemogenic BBUVB....................................................................................... 448
9.3.8 Dihranol (Micanol) pl BBUVB Dihranol ................................................... 449
9.3.9 Dihranol (micanol) pl BBUVB placebo pl BBUVB .................................. 450
9.3.10 Economic eidence ............................................................................................ 4549.3.11 Recommendaion and link o eidence ........................................................... 456
9.4 Phooherap, emic herap (biological and nonbiological), ar and rik of kin
cancer ................................................................................................................................ 460
9.4.1 Clinical inrodcion ........................................................................................... 460
9.4.2 Mehodological inrodcion ............................................................................. 461
9.4.3 PUVA .................................................................................................................. 471
9.4.4 Biological drg, cicloporin, mehoreae, UVB, ar and reinoid ................ 487
9.4.5 Economic eidence ............................................................................................ 491
9.4.6 Recommendaion and link o eidence ........................................................... 491
10 S ......................................................................................... 498
10.1 Mehodological inrodcion ............................................................................................ 498
10.2 Mehoreae placebo for indcion of remiion ....................................................... 503
10.2.1 Eidence profile ................................................................................................. 503
10.2.2 Eidence aemen ......................................................................................... 505
10.3 Mehoreae cicloporin for indcion of remiion ................................................... 506
10.3.1 Eidence profile ................................................................................................. 506
10.3.2 Eidence aemen ......................................................................................... 511
10.3.3 Sbgrop and heerogenei ........................................................................... 512
-
8/15/2019 Bookshelf NBK247829 Psoriasis
9/758
Poriai
Conen
Poriai fll gideline (Ocober 2012)
9
10.4 Acirein placebo for indcion of remiion ................................................................ 513
10.4.1 Eidence profile ................................................................................................. 513
10.4.2 Eidence aemen ......................................................................................... 520
10.4.3 Sbgrop and heerogenei ........................................................................... 521
10.5 Increaing decreaing acirein doing chedle for indcion of remiion ............... 522
10.5.1 Eidence profile ................................................................................................. 522
10.5.2 Eidence aemen ......................................................................................... 524
10.6 Increaing conan acirein doing chedle for indcion of remiion ................... 525
10.6.1 Eidence profile ................................................................................................. 525
10.6.2 Eidence aemen ......................................................................................... 527
10.7 Cicloporin placebo for indcion of remiion ............................................................ 528
10.7.1 Eidence profile ................................................................................................. 528
10.7.2 Eidence aemen ......................................................................................... 531
10.7.3 Sbgrop and heerogenei ........................................................................... 531
10.8 Cicloporin doage comparion for indcion of remiion ............................................ 532
10.8.1 Eidence profile ................................................................................................. 532
10.8.2 Eidence aemen ......................................................................................... 535
10.9 Cicloporin placebo for mainenance of remiion ...................................................... 535
10.9.1 Eidence profile ................................................................................................. 537
10.9.2 Eidence aemen ......................................................................................... 540
10.9.3 Sbgrop and heerogenei ........................................................................... 540
10.10 Inermien (abrp ceaion) conino cicloporin for mainenance of
remiion ........................................................................................................................... 541
10.10.1 Eidence profile ................................................................................................. 541
10.10.2 Eidence aemen ......................................................................................... 543
10.11 Inermien (aper o ihdra) conino (aper o minimm doe) cicloporin
for he mainenance of remiion ..................................................................................... 544
10.11.1 Eidence profile ................................................................................................. 544
10.11.2 Eidence aemen ......................................................................................... 546
10.11.3 Sbgrop and heerogenei ........................................................................... 546
10.12 Cicloporin doage comparion for mainenance ........................................................... 547
10.12.1 Eidence profile ................................................................................................. 547
10.12.2 Eidence aemen ......................................................................................... 549
10.13 Cicloporin placebo for indcion of remiion in palmoplanar ploi ................ 550
10.13.1 Eidence profile ................................................................................................. 550
10.13.2 Eidence aemen ......................................................................................... 553
10.14 Time o maimm effec ................................................................................................... 554
10.14.1 Eidence profile ................................................................................................ 554
10.14.2 Daa mmar able .......................................................................................... 558
-
8/15/2019 Bookshelf NBK247829 Psoriasis
10/758
Poriai
Conen
Poriai fll gideline (Ocober 2012)
10
10.14.3 Eidence aemen ......................................................................................... 560
10.14.4 Economic eidence ............................................................................................ 561
10.15 Recommendaion and link o eidence ........................................................................... 565
11 M ............................................................................ 577
11.1 Mehodological inrodcion ............................................................................................ 577
11.2 Adl ................................................................................................................................ 585
11.2.1 Rik facor 1: Alcohol ......................................................................................... 585
11.2.2 Rik Facor 2: Obei ........................................................................................ 595
11.2.3 Rik facor 3: Diabee ....................................................................................... 599
11.2.4 Rik Facor 4: Hepaii ...................................................................................... 603
11.2.5 Rik Facor 5: Preeiing lier dieae ............................................................. 604
11.2.6 Rik Facor 6: Cmlaie doe of mehoreae .............................................. 607
11.3 Children ............................................................................................................................. 617
11.3.1 Rik Facor 1: Obei ........................................................................................ 617
11.3.2 Economic eidence ............................................................................................ 618
11.4 Recommendaion and link o eidence ........................................................................... 618
12 M ............................................................... 622
12.1 Mehodological inrodcion ............................................................................................ 622
12.1.1 Reie mehod ................................................................................................ 622
12.1.2 Sd deail mehod and rel.................................................................. 628
12.2 Noninaie lier e . lier biop ............................................................................ 635
12.2.1 Eidence profile ................................................................................................. 635
12.2.2 Eidence mmar ............................................................................................. 640
12.2.3 Eidence aemen ......................................................................................... 646
12.3 Economic eidence ........................................................................................................... 649
12.3.1 Uni co ........................................................................................................... 651
12.3.2 Eidence aemen ......................................................................................... 651
12.4 Recommendaion and link o eidence ........................................................................... 651
13 S ................................................................................................ 656
13.1 Mehodological inrodcion ............................................................................................ 656
13.2 Preio biological herap . no preio biological herap ........................................ 662
13.2.1 Eanercep in hoe ih and iho prior epore o biological herap .... 662
13.2.2 Adalimmab in hoe ih and iho prior epore o biological herap . 666
13.2.3 Infliimab in hoe ih and iho prior epore o biological herap ...... 669
13.2.4 Uekinmab in hoe ih and iho prior epore o biological herap 670
13.3 Adalimmab a a fir TNF anagoni adalimmab folloing diconinaion of a
preio TNF anagoni ................................................................................................... 681
13.3.1 Eidence profile ................................................................................................. 681
13.3.2 Eidence aemen ......................................................................................... 684
-
8/15/2019 Bookshelf NBK247829 Psoriasis
11/758
Poriai
Conen
Poriai fll gideline (Ocober 2012)
11
13.3.3 Eidence profile ................................................................................................. 685
13.3.4 Eidence aemen ......................................................................................... 687
13.4 Infliimab . placebo in hoe ih prior epore o biological herap ....................... 688
13.4.1 Eidence profile ................................................................................................. 688
13.4.2 Eidence aemen ........................................................................................... 688
13.5 Uekinmab placebo in hoe ih prior epore o biological herap .................. 688
13.5.1 Eidence profile ................................................................................................. 688
13.5.2 Eidence aemen ......................................................................................... 690
13.6 Uekinmab eanercep in hoe ih prior epore o biological herap ............. 691
13.6.1 Eidence profile ................................................................................................. 691
13.6.2 Eidence aemen ......................................................................................... 692
13.7 Economic eidence ........................................................................................................... 693
13.7.1 Lierare reie ............................................................................................... 693
13.7.2 Original economic anali ................................................................................ 693
13.7.3 Mehod ............................................................................................................. 693
13.7.4 Rel ................................................................................................................ 696
13.7.5 Limiaion ......................................................................................................... 697
13.8 Recommendaion and link o eidence ........................................................................... 699
14 C ........................................................................................... 707
14.1 Mehodological inrodcion ............................................................................................ 707
14.2 Cogniie behaioral herap . andard care ............................................................. 709
14.2.1 Eidence profile ................................................................................................. 709
14.2.2 Eidence aemen ......................................................................................... 712
14.3 Economic eidence ........................................................................................................... 712
14.4 Recommendaion and link o eidence ........................................................................... 712
15 G ................................................................................................ 715
15.1 Gloar ............................................................................................................................. 715
15.2 Abbreiaion .................................................................................................................... 724
16 B ...................................................................................................................... 726
17 L .............................................................................................................. 760
Appendi A: Scope ................................................................................................................. 760
Appendi B: Declaraion of inere ..................................................................................... 760
Appendi C: Reie proocol ............................................................................................... 760
Appendi D: Lierare earch raegie ............................................................................... 760
Appendi E: Sd elecion flo char ................................................................................ 760
Appendi F: Eclded die li (clinical) ............................................................................ 760
Appendi G: Eclded die li (co effeciene) .......................................................... 760Appendi H: Eidence able clinical die ....................................................................... 760
-
8/15/2019 Bookshelf NBK247829 Psoriasis
12/758
Poriai
Conen
Poriai fll gideline (Ocober 2012)
12
Appendi I: Eidence able economic die .................................................................. 760
Appendi J: Fore plo ........................................................................................................ 760
Appendi K: NMA opical rnk and limb ........................................................................... 760
Appendi L: NMA opical calp ............................................................................................ 760
Appendi M: CEA opical rnk and limb ............................................................................. 760
Appendi N: CEA opical calp .............................................................................................. 760
Appendi O: CEA econdline biologic .................................................................................. 760
Appendi P: Reie o define 'be pporie care' ............................................................ 760
Appendi Q: Addiional daa (appendice from eidence repor) ........................................ 760
Appendi R: Fre reearch recommendaion ................................................................... 760
Appendi S: Rik and benefi of reamen for poriai .................................................. 760
Appendi T: Poriai Epidemiolog Screening Tool (PEST) ................................................... 760
Appendi U: Reference for appendice JS .......................................................................... 760
-
8/15/2019 Bookshelf NBK247829 Psoriasis
13/758
-
8/15/2019 Bookshelf NBK247829 Psoriasis
14/758
Poriai
Acknoledgmen
Poriai fll gideline (Ocober 2012)
14
A
The deelopmen of hi gideline a greal aied b he folloing people:
• Amar Pal Dhillon, Conlan hiopahologi, Deparmen of Hiopaholog, Roal Free
Hopial, London
• Rober Dae, Conlan Dermaologi, PHOTONET Lead Clinician, NHS Taide
• Zarif JabbarLope, Reearch Fello, NCGC
• Tarn Krae, Senior Projec Manager and Reearch Fello, NCGC
• Faema Limbada, Projec Coordinaor, NCGC
• Anne Maon, Reearch Fello, Cenre for Healh Economic, Unieri of York
• Jlie Neilon, Senior Reearch Fello, NCGC
• Vicki Polli, Healh Economi, NCGC• Maggie Web, Clinical Effeciene Lead, NCGC
• Rachel Wheeler, Reearch Fello, NCGC
• Hel William, Coordinaing edior, Cochrane Skin Grop and profeor of dermao
epidemiolog and direcor of he cenre of eidence baed dermaolog, facl of medicine and
healh cience, Unieri of Noingham
• Dae Wonderling, Head of Healh Economic, NCGC
• Terr Wong, Conlan Hepaologi, G and S Thoma' Hopial Fondaion Tr, London
-
8/15/2019 Bookshelf NBK247829 Psoriasis
15/758
Poriai
Inrodcion
Poriai fll gideline (Ocober 2012)
15
1
I
Poriai i an inflammaor kin dieae ha picall follo a relaping and remiing core.
1.1
EThe prealence of poriai i eimaed o be arond 1.32.2%
306 in he UK, ih he greae
prealence being in hie people. Men and omen are eqall affeced. I can occr a an age
alhogh i ncommon in children (0.71%) and he majori of cae occr before he age of 35 ear.
Poriai i aociaed ih join dieae in a ignifican proporion of paien (repored in one d
a 13.8%)157
.
1.2 C
Plaqe poriai i b far he mo common form of he condiion (90% of people ih poriai) and
i characeried b ell delineaed red, cal plaqe306
. The een of inolemen i ariable,ranging from a fe localied pache a eenor ie, o generalied inolemen inoling an ie.
Rarel, poriai ma inole he hole bod, erhroderma. The appearance of plaqe poriai ma
be modified b ie. Fleral (alo knon a inere or inerrigino) poriai refer o plaqe
poriai a bmammar, groin, aillar, genial and naal clef ie, and i picall le cal.
Seborrhoeic poriai (eboporiai) i imilar in appearance and diribion o eborrhoeic
dermaii (hence he name) and ma occr in iolaion or aociaed ih plaqe poriai
elehere. Oher pe of poriai inclde gae poriai (an ace erpion of mall (< 1 cm)
paple of poriai hich appear oer a period of a monh or o and i preceded b a repococcal
infecion in arond 2/3rd of people), and plar poriai hich inclde generalied plar
poriai (GPP) and localied form (ie: palmoplanar ploi and acrodermaii conina of
Halopea). Diincie nail change occr in arond 50% of all hoe affeced and are more commonin hoe ih poriaic arhrii. Occaionall combinaion of he differen pe deelop
imlaneol or eqeniall oer ime in he ame peron. P poriai i all he pe
referred o b boh healhcare profeional and paien hen ing he erm poriai375
. Unle
iplaed oherie, he erm poriai refer o plaqe poriai in hi gideline. The phrae
' ' encompae he face, flere, genialia, calp, palm and ole and are o
called becae poriai a hee ie ma hae an epeciall high impac, ma rel in fncional
impairmen, reqire pariclar care hen precribing opical herap and can be reian o
reamen.
1.3 D
Deah direcl de o poriai i rare, b he chronic, incrable nare of poriai mean ha
aociaed morbidi i ignifican. People ih poriai, like hoe ih oher major medical
diorder, hae redced leel of emplomen and income a ell a a decreaed qali of life. The
impac of poriai encompae fncional, pchological, and ocial dimenion205
. Facor ha
conribe o hi inclde mpom pecificall relaed o he kin (for eample, chronic ich,
bleeding, caling and nail inolemen), problem relaed o reamen (me, odor, inconenience
and ime), poriaic arhrii, and he effec of liing ih a highl iible, difigring kin dieae
(difficlie ih relaionhip, difficlie ih ecring emplomen and poor elf eeem). Een
people ih minimal inolemen (le han he eqialen of hree palm area) ae ha poriai
ha a major effec on heir life. The combined co of longerm herap and ocial co of he
dieae hae a major impac on healhcare em and on ocie in general. Abo a hird of peopleih poriai eperience major pchological dire, and he een o hich he feel ociall
igmaied and eclded i banial332
. Healhcare profeional, inclding dermaologi, ofen
-
8/15/2019 Bookshelf NBK247829 Psoriasis
16/758
Poriai
Inrodcion
Poriai fll gideline (Ocober 2012)
16
fail o appreciae he een of hi diabili and een hen i i correcl idenified, ome eimae
gge ha le han a hird of people ih poriai receie appropriae pchological
inerenion.
1.4 C
Aide from he brden of poriaic arhrii, and pchological morbidi, a nmber of die hae
ggeed ha people ih poriai ma alo be a rik of cardioaclar dieae. I i nclear
heher hi increae direcl relae o he poriai ielf, or an increaed incidence of radiional
cardioaclar rik facor repored in people ih poriai180,322
. Rik facor inclde obei, pe 2
diabee melli, meabolic ndrome, ece alcohol inake or alcoholim, moking and
hperlipidaemia (hich ma be parl iarogenic de o agen ch a cicloporin and acirein).
Commni and hopialbaed die gge ha people ih poriai, pariclarl hoe ih
eere dieae, ma alo be a increaed rik of lmphoma and nonmelanoma kin cancer. The
relaie inflence of knon confonder ch a concomian herap ih immnopprean,
phooherap, moking, and alcohol i nclear.
1.5 A M
The ignifican impac of poriai on ellbeing ffered b affeced indiidal, nderline he need
for promp, effecie reamen, and longerm dieae conrol. Treamen aailable for poriai are
aried. For he prpoe of hi gideline, decribe he radiional opical
herapie (ch a coricoeroid, iamin D and analoge, dihranol and ar preparaion).
inclde phooherap, broad or narroband lraiole [UV] B ligh, ih or iho
peried applicaion of comple opical herapie ch a dihranol in Laar' pae or crde coal
ar and phoochemoherap, poralen pl UVA ligh [PUVA], and nonbiological emic agen
ch a cicloporin, mehoreae and acirein. refer o emic biological
herapie ha e molecle deigned o block pecific moleclar ep imporan in hedeelopmen of poriai ch a he TNF anagoni adalimmab, eanercep and infliimab, and
ekinmab, aniIL1223 monoclonal anibod266,267,269,273
. Thee agen are approed for e b
NICE, bjec o cerain dieae eeri crieria, and acqiiion co are high. All of hee
inerenion can be aociaed ih longerm oici and ome people ih poriai hae
reamenreian dieae. In common ih man long erm condiion, poor adherence o
precribed reamen can preen opimal ocome, and i inflenced b mliple facor inclding
hoe relaed o he reamen ielf (for eample comple, comeicall naccepable opical
regimen), qali of commnicaion beeen clinician and paien, a ell a belief and
percepion of he indiidal affeced.
The approach o herap i, o a large degree, goerned b he een and eeri of dieae. Ingeneral, people hoe dieae i localied o
-
8/15/2019 Bookshelf NBK247829 Psoriasis
17/758
Poriai
Inrodcion
Poriai fll gideline (Ocober 2012)
17
face or back of hand. Seing aide poriaic arhrii, here i no compelling eidence ha an of
he inerenion hae a dieae modifing effec or impac beond improemen of he poriai
ielf and o, ih he ecepion of he minori of paien ih nable and life hreaening form
of poriai, he approach o herap and rik/benefi aemen of he differen inerenion i
rongl inflenced b he impac he poriai i haing on he ellbeing of he indiidal affeced.
1.6 S
Mo people ih poriai are managed in primar care45
; one d fond ha peciali referral i
reqired in p o 60% a ome poin in heir dieae core277,355
. Thee daa are baed on adl
poplaion, b approach o care in children and ong adl i imilar. Commonl cied rigger for
referral for peciali opinion inclde: diagnoic ncerain; reqe for frher conelling or
edcaion inclding demonraion of opical reamen; failre o repond o appropriael ed
opical herap for hree monh; poriai a ie ha are difficl o rea and/or a high impac
ie; if nreponie o iniial herap; adere reacion o opical herapie; need for emic
herap, phooherap, da reamen, or inpaien admiion; diabili preening ork or
eceie ime off ork; ignifican pchoocial diabili; preence of poriaic arhrii and; lifehreaening form of poriai here rgen referral ma be jified.
Ongoing periion of hoe on emic herap occr in peciali eing, omeime ih
hared care arrangemen for drg monioring in primar care. Sprapeciali (leel 4, eriar)
cenre ih acce o mlidiciplinar eam ih eperience in comple inerenion and
aociaed mlimorbidiie proide peciali care for he minori of people. A recen UK adi in
he adl poplaion demonraed ide ariaion in pracice, and in pariclar, acce o peciali
reamen (inclding biologic), appropriae drg monioring, peciali nre ppor and
pchological erice82
. No comparable adi ha been carried o in children. Recommended
indicaion for referral from primar o peciali care hae been pblihed46
b here are no formal
andard/indicaion for prapeciali leel care (leel 4).
Delier of care in all peciali (leel 3 and 4) eing45
largel follo he radiional model of
opaien conlaion ih dacare/inpaien admiion for more eere dieae. People on
biological herap aend econdar or eriar care cenre for monioring hil he drg ielf i
deliered b commni baed companie.
Good commnicaion beeen healhcare profeional and paien i eenial. I hold be
ppored b eidencebaed rien informaion ailored o he paien need. Treamen and
care, and he informaion paien are gien abo i, hold be acceible o people ih addiional
need and clrall appropriae. Familie and carer hold alo be gien he informaion and
ppor he need.
1.7 P
Poriai in childhood i le common han adl. I end o preen in laer childhood ih a
median age of one beeen 7 and 10 ear and an eimaed UK prealence of 0.71%91,203,260,363
.
Since one hird of adl paien ih poriai preen before 20 ear of age he are an imporan
grop o conider in he oerall dieae managemen20
. A poiie famil hior of poriai i
aociaed ih a redced age of one of he dieae16,145
.
Paediaric pracice end o mirror ha in adl, and in hi gideline, recommendaion relae o
eerone ih poriai irrepecie of age, nle oherie aed. The erm children refer o
hoe p o 12 ear, ho become ong people hereafer, before merging ih he adlpoplaion b 18 ear of age. Wihin he recommendaion, he erm people i ed o encompa
all age. Adl and paediaric healhcare eam hold ork joinl o proide aemen and
erice o ong people ih poriai. Diagnoi and managemen hold be reieed hrogho
-
8/15/2019 Bookshelf NBK247829 Psoriasis
18/758
Poriai
Inrodcion
Poriai fll gideline (Ocober 2012)
18
he raniion proce, and here hold be clari abo ho i he lead clinician o enre conini
of care.
Poin of pariclar releance o he paediaric poplaion inclde he folloing:
• Plaqe pe poriai i alo he mo common form in he paediaric poplaion. Oher form are
gae poriai ih relape folloing infecion
326
and in er ong children, le han oear of age, napkin poriai. Thi picall affec he inginal fold and hen pread o inole
he rnk and limb62
.
• A ih an condiion occrring in children and ong people, poriai ma impac on he
peron' pchological and emoional deelopmen and edcaional need. Dring adolecence,
he impac of poriai can be epeciall challenging hen ie arond bod image and
appearance are pariclarl alien. All hee apec need o be conidered in cone of he
indiidal, famil and carer, and appropriae ppor proided. There i a lack of daa on
inerenion in children and ong people ih poriai. The GDG agreed o bae reamen
recommendaion on RCT ih erapolaion o children if no eparae paediaric eidence a
fond. An ecepion o hi principle are noed in he LETR able of he relean reie
qeion. Noe ha onl o die62,295
ha pecificall addreed poriai in children ereidenified and inclded in he gideline.
• Poriai in children and ong people i crrenl managed a par of he general paediaric
dermaolog cae mi b conlan dermaologi ho alo care for children. There are no
pecialied paediaric poriai clinic alhogh combined paediaric dermaolog and
rhemaolog clinic are in eience in ome cenre o manage poriai and poriaic arhrii in
children. De o he drg licening rericion, children ih relaiel mild dieae are ofen
referred o econdar care for reamen.
• Mo opical agen hae licening rericion from pecific age and emic herapie are
crrenl no licened for he reamen of poriai in children of le han 16 ear of age apar
from Eanercep (he onl biological herap crrenl licened for children of le han 16 ear
of age). Ulimael he precriber m ake reponibili for ing drg oide of heir licened
indicaion b i i imporan o inole he paren and, if poible he child, in a dicion
abo rik and poenial benefi, epeciall hen conidering inerenion ch a PUVA and
emic drg. In all dicion ih paien abo heir reamen he clinician hold eablih
ha he paien ha he capaci2 o make a fll informed deciion abo heir care, and he
abili o nderand he poenial benefi (and rik) of reamen.
• In he cae of children, clinician old normall inole hoe ih parenal reponibili in he
clinical deciionmaking proce. Clinician hold alo conider he mari and compeence of
he child o nderand and make deciion abo heir on care. Children can conen o
reamen hen he are able o nderand he rik and benefi b he canno legall refe
reamen again heir paren ihe nil he are 16 ear old. I i imporan o conider he
ong peron cogniie deelopmenal age hen dicing he dieae and reamen
opion. Uing appropriae erminolog ill help children and ong people paricipae aciel in
deciionmaking.
• A children mare ino ong people and adl he hold be encoraged o ake morereponibili for managing heir condiion. Arrangemen for raniion o adl care (e.g. join
clinic ih adl and paediaric dermaolog eam) hold be an inegral par of he erice. The
relean principle are conidered in a Deparmen of Healh pblicaion75
.
• When managing poriai in children and ong people, reamen choice hold be carefllconidered o aoid or minimie longerm eqelae. Thi apec i epeciall perinen in relaion
o phooherap.
-
8/15/2019 Bookshelf NBK247829 Psoriasis
19/758
Poriai
Inrodcion
Poriai fll gideline (Ocober 2012)
19
1.8 A G
Poriai i a common, chronic dieae, hich for man people, i aociaed ih profond
fncional, pchological and ocial morbidi and imporan comorbidiie. Effecie reamen are
aailable. Some reamen are epenie; all reqire appropriae monioring and ome ma onl be
acceed in peciali care eing. Eidence indicae ha a banial proporion of people ihporiai are crrenl diaified ih heir reamen.
Thi gideline aim o proide clear recommendaion on he aemen and managemen of
poriai for all people ih poriai. The diagnoi of poriai ha no been inclded ihin he
cope, parl for pragmaic reaon gien ha o coer poriai managemen ielf i a coniderable
ak, b alo becae here are no agreed diagnoic crieria or e aailable and accrae
diagnoi remain primaril a clinical one. In conidering hich pecific apec of poriai
managemen o addre, he gideline deelopmen grop hae foced on area mo likel o
improe he managemen and delier of care for a majori of people affeced, here pracice i
er aried and/or here clear conen or gideline on reamen are lacking. We hae
herefore addreed ho o holiicall ae people ih poriai a all age in he reamen
paha, he e of fir, econd and hird line inerenion and hen o ecalae herap, and he
role of pchological inerenion and elfmanagemen raegie. We hae aoided caegorical
decripion of ha conie pariclar leel of dieae eeri, for eample 'mild' or 'moderae
and eere' eceping dieae eeri crieria for plaqe poriai alread decribed b NICE in order
o qalif for biological herap. There are no idel acceped definiion ha are applicable o all
iaion and i i a conenio bjec. Inead e emphaie he imporance of mearing dieae
eeri and impac o indiidalie care, and plan and ealae managemen. There are alo a
nmber of ke area ha e hae no addreed for a arie of reaon. Fir, e hae no
ealaed he role of emollien in he reamen of poriai. Thee are idel precribed and
clinical eperience gge ha he are ed ih benefi b paien. In he abence of rob RCT
or high qali die o inform recommendaion o change hi pracice, and he fac ha all
placebo conrolled rial inoling opical e a ehicle (hich ill hae emollien properie) in he
placebo arm, he reamen paha ar on he ampion ha hen appropriae, emollien
hae alread been precribed. Secondl, e hae no inclded fmaric acid eer in or ealaion
of econd line herapie. Thi inerenion i no licened for an indicaion in he UK and herefore
canno be inclded.
We incerel hope ha hee gideline faciliae he delier of highqali healhcare and improe
ocome for people ih poriai.
-
8/15/2019 Bookshelf NBK247829 Psoriasis
20/758
Poriai
Paien eperience of liing ih poriai
Poriai fll gideline (Ocober 2012)
20
2
P T GDG
.
From a paien perpecie poriai doe no dicriminae. I i, a be, an inconenien dieae, aor, a liing nighmare. Poriai can be a relenle 24 hor a da, 7 da a eek, 365 da of he
ear problem. A bale beeen reaing flak, ich, ore kin and aemping o carr on a dail
roine of normal life of emplomen, famil, ocial een and general daoda aciiie ha
hoe ho do no hae poriai ake for graned. I i a relenle condiion hich ha a derimenal
impac on qali of life e for hich man people hae gien p eeking medical ppor318
.
The grinding proce of a kin hich i hedding and i reamen are j par of liing ih he
condiion. There are oher conideraion ha people ih poriai oon learn are par and parcel of
haing ch a iible dieae. The are hich linger j oo long and he look of relion are
qickl learn. Then here are he akard ilence in iaion hen poriai i fir enconered
b omeone ne ch a dring a roine ii o he hairdreer; he conan jificaion of i
no conagio or i j poriai are repone he peron liing ih i ill hae read o a on
eer occaion cloe crin appear imminen. And o, niingl, an ndermining habi of elf
jificaion i acqired.
The impac of poriai on an indiidal life arie enormol, heher nel diagnoed or afer
man ear of acie dieae. The nel diagnoed are ofen beildered b he aemen o hae
poriai a ha (for man) i ofen he ar of a qe o find aner o more qeion hich
canno poibl be anered in he fe mine of a fir conlaion. The ord and adice from a
medical profeional a ha iniial appoinmen ill remain ih he peron affeced for he re of
heir long life ih poriai.
Wha i aid, read or learn ill hae a grea impac and ma hape an indiidal approach o hohe lie heir lie in he fre. A fe carele ord a he rong ime or nrealiic adice ma
hae profond coneqence leaing an indiidal ih fale hope abo he effeciene of
reamen or deperaion a he hogh of a dieae ih hich he hae been brdened.
Dealing ih an indiidal poriai need rn mch deeper han proiding a precripion. Tha i
onl par of he olion. Effecie reamen i, of core, imporan b poriai impac can
haer elfconfidence. I i a lonel dieae a reamen are all elfadminiered and ime
conming. A lifeime of appling oinmen, alloing pill or injecing drg lie ahead. In a b
hoehold, reamen ime ma no ala be aailable. The peron ih poriai ma hae o fi
arond oher hich can cae fricion and irriaion. The me aociaed ih a hedding kin, he
odor of reamen and heir abili o ick o clohing can cae ace embarramen and
difficlie ihin relaionhip.
Poriai i an inidio condiion hich need o be aken eriol. The join ongoing managemen
of poriai beeen paien and healhcare proider on eer apec of hi dieae ill no remoe
i phical and emoional brden b migh improe he ocome.
-
8/15/2019 Bookshelf NBK247829 Psoriasis
21/758
-
8/15/2019 Bookshelf NBK247829 Psoriasis
22/758
Poriai
Deelopmen of he gideline
Poriai fll gideline (Ocober 2012)
22
3.3 W ?
A mlidiciplinar Gideline Deelopmen Grop (GDG) compriing profeional grop member and
conmer repreenaie of he main akeholder deeloped hi gideline (ee ecion on
Gideline Deelopmen Grop Memberhip and acknoledgemen).
The Naional Inie for Healh and Clinical Ecellence fnd he Naional Clinical Gideline Cenre
(NCGC) and h ppored he deelopmen of hi gideline. The GDG a conened b he NCGC
and chaired b Caherine Smih in accordance ih gidance from he Naional Inie for Healh
and Clinical Ecellence (NICE).
The grop me eer for eek dring he deelopmen of he gideline. A he ar of he
gideline deelopmen proce all GDG member declared inere inclding conlancie, feepaid
ork, hareholding, fellohip and ppor from he healhcare indr. A all beqen GDG
meeing, member declared ariing conflic of inere, hich ere alo recorded (Appendi B).
Member ere eiher reqired o ihdra compleel or for par of he dicion if heir declared
inere made i appropriae. The deail of declared inere and he acion aken are hon inAppendi B.
Saff from he NCGC proided mehodological ppor and gidance for he deelopmen proce.
The eam orking on he gideline inclded a projec manager, reearch fello, healh economi
and informaion cieni. The nderook emaic earche of he lierare, appraied he
eidence, condced meaanali and coeffeciene anali here appropriae and drafed
he gideline in collaboraion ih he GDG.
3.4 W
Grop coered in hi gideline are children and adl ih a diagnoi of poriai. Conideraion igien o he pecific need, if an, of people ih poriaic arhrii.
Ke clinical ie coered:
• Ealaion of dieae eeri and impac on people ih poriai.
• Idenificaion of poriaic arhrii.
• Managemen of poriai inclding, for eample:
o opical herap:
– coricoeroid
– iamin D analoge
– coal ar (ih or iho phooherap)
– dihranol (ih or iho phooherap)
o phooherap (narro band UVB)
o phoochemoherap (poralen and UVA)
o emic herap:
– cicloporin
– mehoreae
– acirein.
Noe ha gideline recommendaion ill normall fall ihin licened indicaion; ecepionall,
and onl if clearl ppored b eidence, e oide a licened indicaion ma be recommended.The gideline ill ame ha precriber ill e a drg mmar of prodc characeriic o
inform deciion made ih indiidal paien.
-
8/15/2019 Bookshelf NBK247829 Psoriasis
23/758
Poriai
Deelopmen of he gideline
Poriai fll gideline (Ocober 2012)
23
• Selfmanagemen.
• Managemen of he pchological impac of poriai.
• Combinaion and eqencing of reamen.
For frher deail pleae refer o he cope in Appendi A and reie qeion in ecion 4.1.
3.5 W
Grop no coered in hi gideline are children and adl ho do no hae a diagnoi of poriai.
Ke clinical ie no coered:
• Diagnoi.
• Managemen of poriaic arhrii.
• Complemenar and alernaie reamen.
• Fmaric acid eera.
3.6
R NICE
NICE T A :
• Uekinmab for he reamen of adl ih moderae o eere poriai. NICE echnolog
appraial gidance 180 (2009). Aailable from .nice.org.k/gidance/TA180
• Adalimmab for he reamen of adl ih poriai. NICE echnolog appraial gidance
146 (2008). Aailable from .nice.org.k/gidance/TA146
• Infliimab for he reamen of adl ih poriai. NICE echnolog appraial gidance 134
(2008). Aailable from .nice.org.k/gidance/TA134
• Eanercep and efalimab for he reamen of adl ih poriai. NICE echnolog
appraial gidance 103 (2006). Aailable from .nice.org.k/gidance/TA103
O NICE T A:
• Eanercep, infliimab and adalimmab for he reamen of poriaic arhrii. NICE echnolog
appraial gidance 199 (2010). Aailable from .nice.org.k/gidance/TA199
R NICE I P:
• Gren ra herap for inflammaor kin condiion. NICE inerenional procedre gidance 236(2007). Aailable from .nice.org.k/gidance/IPG236
R NICE C G:
• Alcohole diorder: phical complicaion. NICE clinical gideline 100 (2010). Aailable from.nice.org.k/gidance/CG100
• Medicine adherence. NICE clinical gideline 76 (2009). Aailable from
.nice.org.k/gidance/CG76
• Obei. NICE clinical gideline 43 (2006). Aailable from .nice.org.k/gidance/CG43
R NICE P H G:
• Alcohole diorder preening harmfl drinking. NICE pblic healh gidance 24 (2010).Aailable from .nice.org.k/gidance/PH24
• Smoking ceaion erice. NICE pblic healh gidance 10 (2008). Aailable from
.nice.org.k/gidance/PH10
aFmaric acid eer are no licened for an indicaion ihin he UK and herefore e are no able o conider hi
reamen ihin he gideline.
-
8/15/2019 Bookshelf NBK247829 Psoriasis
24/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
24
4
M
Thi gidance a deeloped in accordance ih he mehod olined in he NICE Gideline
Manal 2009272
.
4.1
D
Reie qeion ere deeloped in a PICO frameork (paien, inerenion, comparion and
ocome) for inerenion or eperimenal reie, and ih a frameork of poplaion, inde e,
reference andard and arge condiion for reie of diagnoic e accrac, and poplaion,
preence or abence of rik facor and li of ideal minimm confonding facor for reie of
prognoic facor. Thi a o gide he lierare earching proce and o faciliae he
deelopmen of recommendaion b he gideline deelopmen grop (GDG). The ere drafed b
he NCGC echnical eam and refined and alidaed b he GDG. The qeion ere baed on he
ke clinical area idenified in he cope (Appendi A). Frher informaion on he ocome meare
eamined follo hi ecion. For all inerenion ha ere reieed, abole rae of efficac and
oici ere alo ogh in order o proide informaion for people ih poriai and heir
healhcare proider in line ih he Paien Eperience gideline262
, hich recommend ha
informaion i proided a a naral freqenc ing he ame denominaor and ih inerenion
and conrol rae qoed eparael. For hi, efficac daa ere baed on he nmber achieing
eiher PASI75 or clear/nearl clear on he PGA, hicheer ocome a aailable or proided he
large ample ie. Similarl, for oici, hi a repored for ihdraal de o adere een
and he adere een pecified for ha inerenion.
C R O
Principle of
care
Wha raegie can be ppor people ih
poriai (all pe) o elfmanage he condiion
effeciel?
• Paien aifacion
• Concordance ih reamen
• Redced
dire/anie/depreion
(change in HADS)
• Redced dieae eeri (change
in PASI)
• Redced re (PLSI)
• Improed qali of life (change in
DLQI/PDI)
• Serice e
Aemenand referral
In people ih poriai (all pe), hich are hemo effecie ool o ae he (a) eeri and
(b) impac of dieae acro all leel of healhcare
proiion and a an age of he dieae jorne?
• Conrc alidi conergenand diergen
• Inerraer reliabili
• Inraraer reliabili
• Inernal conienc
• Repeaabili
• Pracicabili
• Seniii o change
Aemen
and referral
In people ih poriai (all pe), hich i he
mo accrae diagnoic ool compared ih
clinical diagnoi b a rhemaologi o help a
nonpeciali idenif poriaic arhrii?
• Seniii
• Specifici
• Poiie predicie ale• Negaie predicie ale
• Likelihood raio
-
8/15/2019 Bookshelf NBK247829 Psoriasis
25/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
25
C R O
Aemen
and referral
In people ih poriai (all pe) and peced
poriaic arhrii, ho qickl hold referral o a
peciali be made in order o minimie he impac
of dieae on mpom, join damage and qali
of life?
• Qali of life : HAQ, EQ5D
• Dieae mpom/ign: pain,
enderne, join elling (or
econdline herap a a rrogae)
• Join damage: clinical, radiological(e.g. Sharp, Laren, Seinbrocker)
• Biochemical marker : CRP and ESR
• Morali
• Cardioaclar een
Aemen
and referral
Are people ih poriai a higher rik han people
iho poriai for ignifican comorbidiie and
are here bgrop ihin he poriai
poplaion a a frher increaed rik?
• Incidence of comorbidiie
• Incidence of morali
Topical In people ih chronic plaqe poriai of he rnk
and/or limb, ha are he clinical effeciene,
afe, olerabili, and co effeciene of opicaliamin D and iamin D analoge, poen or er
poen coricoeroid, ar, dihranol and reinoid
compared ih placebo or iamin D and iamin D
analoge, and of combined or concrren iamin
D and iamin D analoge and poen
coricoeroid compared ih poen
coricoeroid or iamin D and iamin D
analoge alone?
• Clear/nearl clear or marked
improemen (a lea 75%
improemen on Ineigaor
aemen of oerall global
improemen (IAGI) or clear/nearl
clear/minimal (no mild) on
Phician Global Aemen
(PGA))
• Clear/nearl clear or marked
improemen (a lea 75%
improemen on Paien
aemen of oerall global
improemen (PAGI) or
clear/nearl clear/minimal (no
mild) on Paien Global
Aemen)
• Percenage change in PASI
• Change in DLQI
• Draion of remiion
• Timeoremiion or imeo
maimm effec
• Wihdraal de o oici
• Wihdraal de o lack of efficac
• Skin aroph
Topical In people ih poriai a high impac or difficlorea ie (calp, flere, face), ha are he
clinical effeciene, afe, olerabili and co
effeciene of iamin D and iamin D
analoge, mild o er poen coricoeroid,
combined or concrren iamin D or iamin D
analoge and poen coricoeroid, pimecrolim,
acrolim, ar, dihranol and reinoid compared
ih placebo, coricoeroid or iamin D or
iamin D analoge.
• Clear/nearl clear or markedimproemen (a lea 75%
improemen on Ineigaor
aemen of oerall global
improemen (IAGI) or clear/nearl
clear/minimal (no mild) on
Phician Global Aemen
(PGA))
• Clear/nearl clear or marked
improemen (a lea 75%
improemen on Paien
aemen of oerall global
improemen (PAGI) orclear/nearl clear/minimal (no
mild) on Paien Global
-
8/15/2019 Bookshelf NBK247829 Psoriasis
26/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
26
C R O
Aemen)
• Percenage change in PASI
• Change in DLQI
• Draion of remiion
• Timeoremiion or imeo
maimm effec
• Wihdraal de o oici
• Wihdraal de o lack of efficac
• Skin aroph
Phooherap In people ih poriai (all pe), ha are he
clinical effeciene, afe, olerabili and co
effeciene of BBUVB, NBUVB and PUVA
compared ih each oher or placebo/no
reamen?
• PASI75
• PASI50
• Change in PASI
• Clear or nearl clear (minimal
reidal acii/PASI>90/0 or 1 on
PGA)• Relape (imeoeen daa if
aailable oherie ordinal daa
acceped)
• Time (or nmber of reamen) o
remiion/ma repone
• Change in DLQI
• Brn (grade 3 erhema or grade 2
erhema ih >50% BSA inoled)
• Caarac
Phooherap In people ih poriai (all pe), ha are he
clinical effeciene, afe, olerabili and coeffeciene of acirein pl UVB (NBUVB and
BBUVB) and acirein pl PUVA compared ih
heir monoherapie and compared ih each
oher?
• PASI75
• PASI50
• Change in PASI
• Clear or nearl clear (minimal
reidal acii/PASI>90/0 or 1 on
PGA)
• Relape (imeoeen daa if
aailable oherie ordinal daa
acceped)
• Time o remiion/maimm
repone
• Change in DLQI
• Brn (grade 3 erhema or grade 2erhema ih >50% BSA inoled)
• Caarac
• Nmber of UV reamen (a a
rrogae for cmlaie doe)
Phooherap In people ih poriai (all pe), ha are he
clinical effeciene, afe, olerabili and co
effeciene of UVB (NBUVB or BBUVB) combined
ih dihranol, coal ar or iamin D and iamin D
analoge compared ih UVB alone or opical
herap alone?
• PASI75
• PASI50
• Change in PASI (mean
improemen);
• Clear or nearl clear (minimal
reidal acii/PASI>90/0 or 1 on
PGA);
• Relape (imeoeen daa if
aailable oherie ordinal daa
-
8/15/2019 Bookshelf NBK247829 Psoriasis
27/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
27
C R O
acceped)
• Time o remiion/ma repone;
• Change in DLQI
• Brn (grade 3 erhema or grade 2
erhema ih >50% BSAinoled);
• Caarac;
• Nmber of UV reamen (a a
rrogae for cmlaie doe)
Phooherap In people ih poriai (all pe) ho hae been
epoed o coal ar, phooherap (BBUVB, NBUVB
and PUVA) or emic herap (nonbiological and
biological herap), ha i he rik of kin cancer
compared ih people no epoed o hee
inerenion and hich indiidal are a
pariclar rik?
• Melanoma kin cancer
• Non melanoma kin cancer
(raified a qamo cell
carcinoma and baal cell
carcinoma)
Semic non
biological
herap
In people ih poriai (all pe), ha are he
clinical effeciene, afe, olerabili and co
effeciene of emic mehoreae, cicloporin
and acirein compared ih each oher or ih
placebo?
• PASI75
• PASI50
• Change in PASI
• Clear or nearl clear (minimal
reidal acii/PASI>90/0 or 1 on
PGA);
• Improemen (for PPP)
• Relape (imeoeen or relape
rae a a rrogae meare)
• Time o remiion/maimm
repone
• Change in DLQI
• Seere adere een:
Mehoreae (MTX): hepaooici,
marro ppreion and
pnemonii
Acirein: hperlipidaemia,
hepaooici, keleal AE and
cheilii
Cicloporin (CSA): renal impairmen,
hperenion, go and
hperricaemia• Wihdraal de o oici
Mehoreae
and rik of
hepaooici
In people ih poriai (all pe) ho are being
reaed ih mehoreae, are here pecific
grop ho are a high rik of hepaooici?
• Biop grade
• Biop grade progreion
• Periporal inflammaion
• Fa change
• Fibroi
• Cirrhoi
• Abnormal lier fncion e
Mehoreae
andmonioring for
hepaooici
In people ih poriai (all pe) ho are being
reaed ih mehoreae or ho are abo obegin reamen ih mehoreae, ha i he
opimm noninaie mehod of monioring
hepaooici (fibroi or cirrhoi) compared ih
• Seniii
• Specifici• Poiie predicie ale
• Negaie predicie ale
-
8/15/2019 Bookshelf NBK247829 Psoriasis
28/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
28
C R O
lier biop? • Likelihood raio
Semic
biological
herap
In people ih chronic plaqe poriai eligible o
receie biologic, if he fir biological fail, hich i
he ne effecie, afe and co effecie raeg?
• PASI75
• PASI50
• Change in PASI
• Clear or nearl clear (minimal
reidal acii/PASI>90/0 or 1 on
PGA);
• Relape (imeoeen daa if
aailable oherie ordinal daa
acceped)
• Time o remiion/maimm
repone
• Change in DLQI
• Seere adere een
• Wihdraal de o oici
Cogniie
behaioral
herap
In people ih poriai (all pe), ho effecie
are cogniie behaioral herap (grop and
indiidal) inerenion alone or a an adjnc o
andard care compared ih andard care alone
for managing pchological apec of he dieae
in redcing dire and improing qali of life?
• Redced
dire/anie/depreion
(change in Hopial Anie and
Depreion Scale (HADS)/Beck
Depreion Inenor
(BDI)/Speilberger Sae Trai
Anie Inenor (STAI))
• Redced re (change in Poriai
Life Sre Inenor (PLSI))
• Improed qali of life (change in
Dermaolog Life Qali Inde
(DLQI)/Poriai Diabili Inde(PDI))
• Redced poriai eeri (change
in PASI)
4.2 S
4.2.1 C
Semaic lierare earche ere nderaken o idenif eidence ihin pblihed lierare in
order o aner he reie qeion a per The Gideline Manal [2009]272. Clinical daabae
ere earched ing relean medical bjec heading, freee erm and d pe filer here
appropriae. Sdie pblihed in langage oher han Englih ere no reieed. Where poible,
earche ere rericed o aricle pblihed in Englih langage. All earche ere condced on
core daabae, MEDLINE, Embae, Cinahl and The Cochrane Librar. Addiional bjec pecific
daabae ere ed for ome qeion: e.g. PcInfo for paien ie. All earche ere pdaed
on 8h
March 2012. No paper afer hi dae ere conidered.
Search raegie ere checked b looking a reference li of relean ke paper, checking earch
raegie in oher emaic reie and aking he GDG for knon die. The qeion, he
d pe applied, he daabae earched and he ear coered can be fond in Appendi D.
Dring he coping age, a opicpecific earch a condced for gideline and repor on he
ebie lied belo and on organiaion relean o he opic. Searching for gre lierare or
npblihed lierare a no nderaken. All reference en b akeholder ere conidered.
-
8/15/2019 Bookshelf NBK247829 Psoriasis
29/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
29
• Gideline Inernaional Neork daabae (.gin.ne)
• Naional Gideline Clearing Hoe (.gideline.go/)
• Naional Inie for Healh and Clinical Ecellence (NICE) (.nice.org.k)
• Naional Inie of Healh Conen Deelopmen Program (conen.nih.go/)
• Naional Librar for Healh (.librar.nh.k/)
4.2.1.1 C
The GDG decided o iniiae a call for eidence for comparaie daa o addre he qeion of
heher biologic are afe and effecie in people ih chronic plaqe poriai ho hae preiol
receied anoher biological agen. The GDG belieed ha imporan eidence eied ha old no
be idenified b he andard earche. The NCGC conaced all regiered akeholder and aked
hem o bmi an relean pblihed or npblihed eidence. Eidence a receied and noed in
he relean chaper (Chaper 13).
4.2.2
H
Semaic lierare earche ere alo nderaken o idenif healh economic eidence ihin
pblihed lierare relean o he reie qeion. The eidence a idenified b condcing a
broad earch relaing o poriai in he NHS economic ealaion daabae (NHS EED), he Healh
Economic Ealaion Daabae (HEED) and healh echnolog aemen (HTA) daabae ih no
dae rericion. Addiionall, he earch a rn on MEDLINE and Embae, ih a pecific economic
filer, from 2008, o enre recen pblicaion ha had no e been indeed b hee daabae
ere idenified. Sdie pblihed in langage oher han Englih ere no reieed. Where
poible, earche ere rericed o aricle pblihed in Englih langage.
The earch raegie for healh economic are inclded in Appendi D. All earche ere pdaed on
8h March 2012. No paper pblihed afer hi dae ere conidered.
4.3 E
The Reearch Fello:
• Idenified poeniall relean die for each reie qeion from he relean earch relb reieing ile and abrac fll paper ere hen obained.
• Reieed fll paper again prepecified inclion / eclion crieria o idenif die ha
addreed he reie qeion in he appropriae poplaion and repored on ocome of
inere (reie proocol are inclded in Appendi C.
• Criicall appraied relean die ing he appropriae checkli a pecified in The GidelineManal
272.
• Eraced ke informaion abo he d mehod and rel ino eidence able (eidenceable are inclded in Appendi H.
• Generaed mmarie of he eidence b ocome (inclded in he relean chaper riep):
o Randomied die: mea analed, here appropriae and repored in GRADE profile (forclinical die) ee belo for deail
o Oberaional die: daa preened a a range of ale in GRADE profile
o Diagnoic die: daa preened a a range of ale in adaped GRADE profile and a
narraie mmar i proided
o Prognoic die: daa preened a a range of ale in mmar able, ih marice ford qali
-
8/15/2019 Bookshelf NBK247829 Psoriasis
30/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
30
4.3.1 I/
See he reie proocol in Appendi C for fll deail. The GDG ere conled abo an
ncerain regarding he inclion/eclion of eleced die. Noe ha hi gideline did no
conider he managemen of poriaic arhrii; herefore, die ha ere primaril deigned o
ineigae poriaic arhrii raher han poriai affecing he kin ere eclded. Thi a defined
a die primaril deigned o rea he join raher han he kin componen of he dieae and in a
rhemaolog raher han dermaolog eing. Hoeer, die ere no eclded on he bai of
he proporion of paricipan ih PA alone.
The GDG agreed ha in mo iaion i old be reaonable o erapolae daa from adl
poplaion o children hen here a no or lile daa. Therefore, he GDG agreed o bae
reamen recommendaion on RCT ih erapolaion o children if no eparae paediaric
eidence a fond. An ecepion o hi principle ill be noed in he LETR able of he relean
reie qeion. Noe ha onl o die62,295
ha pecificall addreed poriai in children
ere idenified and inclded in he gideline.
Regarding he differen phenope of poriai, nle oherie aed, daa ere ogh for allpe of poriai and repored eparael if aailable. Plaqe poriai i he mo common form of
he condiion (90% of paien) and i all he pe referred o b boh healhcare profeional
and paien hen ing he erm poriai. Oher pe of poriai inclde gae poriai,
plar poriai hich inclde generalied plar poriai and localied form (ie: palmoplanar
ploi and acrodermaii conina of Halopea) and nail poriai. Unle iplaed oherie,
he erm poriai refer o plaqe poriai in hi gideline; here recommendaion relae o
pe of poriai oher han chronic plaqe dieae, he bpe of poriai i aed in he
recommendaion. Poriai in all i form can be modified b ie. The phrae 'difficlorea ie'
encompae he face, flere, genialia, calp, palm and ole. Poriai a hee ie i epeciall
high impac and/or ma rel in fncional impairmen, reqire pariclar care hen precribing
opical herap and ma be er reian o reamen.
4.3.2 M
D
Where poible, meaanale ere condced o combine he rel of die for each reie
qeion ing Cochrane Reie Manager (ReMan5) ofare. Fiedeffec (ManelHaenel)
echniqe ere ed o calclae rik raio (relaie rik) for he binar ocome: clear/nearl clear
or marked improemen, PASI90, PASI75, relape, ihdraal de o oici, ihdraal de o lack
of efficac, kin aroph, brn, caarac, eere adere een, concordance ih reamen and
erice e. The conino ocome: change in PASI, change in DLQI, draion of remiion,nmber of UV reamen, ime (or nmber of reamen) o remiion, change in Hopial Anie
and Depreion Scale (HADS)/Beck Depreion Inenor (BDI)/Speilberger Sae Trai Anie
Inenor (STAI), change in Poriai Life Sre Inenor (PLSI), change in Poriai Diabili Inde
(PDI), change in HADS, change in Poriai Life Sre Inenor (PLSI) ere analed ing an inere
ariance mehod for pooling eighed mean difference and here he die had differen cale,
andardied mean difference ere ed. Change core ere repored here aailable for
conino ocome in preference o final ale. Hoeer, if onl final ale ere aailable, hee
ere repored and meaanaled ih change core. Where repored, imeoeen daa ere
preened a a haard raio.
Saiical heerogenei a aeed b conidering he chiqared e for ignificance a p50% o indicae ignifican heerogenei. Where ignificanheerogenei a preen, e carried o eniii anali baed on he rik of bia of he die
if here ere difference in d limiaion, ih pariclar aenion paid o allocaion
-
8/15/2019 Bookshelf NBK247829 Psoriasis
31/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
31
concealmen, blinding and lo o follop (miing daa). In cae hen ignifican heerogenei
a no eplained b he aboemenioned eniii anale, e carried o predefined bgrop
anale a pecified in he reie proocol.
Aemen of poenial difference in effec beeen bgrop ere baed on he chiqared
e for heerogenei aiic beeen bgrop. If no eniii anali a fond o
compleel reole aiical heerogenei hen a random effec (DerSimonian and Laird) model
a emploed o proide a more coneraie eimae of he effec.
The mean and andard deiaion of conino ocome for each inerenion grop ere
reqired for meaanali. Hoeer, in cae here andard deiaion ere no repored, he
andard error for he mean difference beeen grop a calclaed if he pale or 95%
confidence ineral ere repored and meaanali a nderaken ih he mean difference and
andard error ing he generic inere ariance mehod in Cochrane Reie Manager (ReMan5)
ofare. Where p ale ere repored a le han, a coneraie approach a nderaken. For
eample, if p ale a repored a p ≤0.001, he calclaion for andard deiaion old be
baed on a p ale of 0.001. If hee aiical meare ere no aailable hen he aailable daa
ere repored in a narraie le b no inclded in he meaanali.
For binar ocome, abole een rae ere alo calclaed ing he GRADEpro ofare ing
een rae in he conrol arm of he pooled rel.
Neork meaanali a condced for he reie qeion on he opical herapie for chronic
plaqe poriai a he rnk and limb and high impac/difficlorea ie. Thi alloed indirec
comparion of all he drg inclded in he reie hen no direc comparion a aailable.
A hierarchical Baeian neork meaanali (NMA) a performed ing he ofare
WinBUGS19. We ed a mliarm random effec model emplae from he Unieri of Briol
ebie (hp://.bri.ac.k/cobm/reearch/mpe/mc.hml). Thi model accon for he
correlaion beeen arm in rial ih an nmber of rial arm. The model ed a a randomeffec logiic regreion model, ih parameer eimaed b Marko chain Mone Carlo
Simlaion.
Neork of eidence ere deeloped and analed baed on he folloing binar ocome:
• Clear/nearl clear or marked improemen (a lea 75% improemen) on Ineigaoraemen of oerall global improemen (IAGI) or clear/nearl clear/minimal (no mild) on
Phician Global Aemen (PGA)
• Clear/nearl clear or marked improemen (a lea 75% improemen) on Paien aemenof oerall global improemen (PAGI) or clear/nearl clear/minimal (no mild) on Paien Global
Aemen
The odd raio ere calclaed and conered ino relaie rik for comparion o he direc
comparion. The ranking of inerenion a alo calclaed baed on heir relaie rik compared
o he conrol grop. For deail on he mehod of hee anale, ee Appendi K and Appendi L.
D
Odd raio, relaie rik or haard raio, ih heir 95% confidence ineral, from mliariae
anale ere eraced from he paper. Daa ere no combined in a meaanali for
oberaional die. Seniii anale ere carried o on he bai of d qali and rel
ere repored a range.
-
8/15/2019 Bookshelf NBK247829 Psoriasis
32/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
32
D
For diagnoic e accrac die, he folloing ocome ere repored: eniii, pecifici,
poiie predicie ale, negaie predicie ale, likelihood raio and pre and poe
probabiliie. In cae here he ocome ere no repored, 2 b 2 able ere conrced from
ra daa o allo calclaion of hee accrac meare. Where poible he rel for eniii
and pecifici ere preened ing Cochrane Reie Manager (ReMan5) ofare.
D
For ineigaing e alidi and reliabili of cale recording he eeri and impac of poriai,
he folloing ocome ere repored: Conergen alidi, dicriminae alidi, inernal
conienc, inerraer reliabili, inraraer reliabili, pracicabili and eniii o change.
Appropriae aiic ere repored for each of hee ocome ih heir 95% confidence ineral
or andard deiaion for mean ale here poible: Pearon prodcmomen correlaion
coefficien, Spearman rank correlaion coefficien, kappa aiic, inracla correlaion, inernal
conienc coefficien (Crohnbach alpha) and ime o adminier he e. Daa ere mmaried
acro ocome and comparion in a ablar forma and an heerogenei a aeed.
4.3.3 T
For mo inerenion eidence reie in hi gideline, randomied conrolled rial (RCT) ere
inclded. Where he GDG belieed RCT daa old no be appropriae hi i deailed in he
proocol in Appendi C. RCT ere inclded a he are conidered he mo rob pe of d
deign ha cold prodce an nbiaed eimae of he inerenion effec.
For diagnoic eidence reie, diagnoic cohor and cae conrol die ere inclded and for
prognoic reie cohor die ere inclded.
4.3.4 T
Eimae of effec from indiidal die ere baed on a modified aailable cae anali (ACA)
here poible or on an inenion o rea (ITT) anali if hi a no poible.
ACA anali i here onl daa ha a aailable for paricipan a he follop poin i analed,
iho making an impaion for miing daa. In he modificaion for binar ocome,
paricipan knon o hae dropped o de o lack of efficac ere inclded in he denominaor for
efficac ocome and hoe knon o hae dropped o de o adere een ere inclded in he
nmeraor and denominaor hen analing adere een. Thi mehod a ed raher han
inenionorea anali o aoid making ampion abo he paricipan for hom ocome
daa ere no aailable, and raher aming ha hoe ho drop o hae he ame een rae ahoe ho conine. Thi alo aoid incorrecl eighing die in meaanali and oer
eimaing he preciion of he effec b ing a denominaor ha doe no reflec he re ample
ie ih ocome daa aailable. If here a a high dropo rae for a d hen a eniii
anali a performed o deermine heher he effec a changed b ing an inenionorea
anali. If hi a he cae boh anale old be preened.
ITT anali i here all paricipan ha ere randomied are conidered in he final anali baed
on he inerenion and conrol grop o hich he ere originall aigned. I a amed ha
paricipan in he rial lo o follop did no eperience he ocome of inere (caegorical
ocome) and he old no coniderabl change he aerage core of heir aigned grop (for
conino ocome). I i imporan o noe ha ITT anale end o bia he rel oard nodifference. ITT anali i a coneraie approach o anale he daa, and herefore he effec ma
be maller han in reali.
-
8/15/2019 Bookshelf NBK247829 Psoriasis
33/758
Poriai
Mehod
Poriai fll gideline (Ocober 2012)
33
4.3.5 U
Thi gideline inclde RCT ih differen ni of anali. Some die randomied indiidal
paricipan o he inerenion (parallel or beeenpaien die) hile oher randomied bod
hale o he inerenion (ihinpaien die, analogo o crooer rial).
I a recognied ha daa from ihinpaien rial hold be adjed for he correlaioncoefficien relaing o he comparion of paired daa. Therefore, if fficien daa ere aailable, hi
a calclaed and he andard error a adjed accordingl.
Addiionall, ihin and beeenpaien daa ere pooled, acceping ha hi ma rel in
ndereighing of he ihinpaien die; hoeer, i i noed ha hi i a coneraie
eimae. Seniii anale ere nderaken o ineigae heher he effec ie aried
conienl for ihin and beeenpaien die and here a no eidence ha he ie of
effec aried in a emaic a.
4.3.6 A
The eidence for ocome from he inclded RCT and oberaional inerenion die ere
ealaed and preened ing an adapaion of he Grading of Recommendaion Aemen,
Deelopmen and Ealaion (GRADE) oolbo deeloped b he inernaional GRADE orking grop
(hp://.gradeorkinggrop.org/). The ofare (GRADEpro) deeloped b he GRADE orking
grop a ed o ae he qali of each ocome, aking ino accon indiidal d qali
and he meaanali rel. The mmar of finding a preened a one able in he gideline
(called clinical eidence profile). Thi inclde he deail of he qali aemen pooled ocome
daa, and h