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Author: Vanessa Ngan, Staff Writer; Chief Editor: Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, March 2014.
This document incorporates and summarises recently published Australian consensus treatment goals  and guidelines published by the British Association of Dermatologists [2,3], American Academy of Dermatology [4-7] and NICE . It is relevant to the treatment of psoriasis in New Zealand.
Psoriasis is a chronic inflammatory skin disease that is characterised by disfiguring, scaling and erythematous plaques that may be itchy and/or painful. Although once thought of as a benign dermatological condition with few serious complications, moderate-to-severe psoriasis is now considered a multisystem disease that is associated with, or increases, the risk of other comorbidities. Psoriasis can be both emotionally and physically debilitating and impact on quality of life significantly.
The diagnosis and assessment of psoriasis and its extent and severity is based on:
|Psoriasis features and symptoms||
Severity is determined using one or more of the following assessment tools.
|Presence of psoriatic arthritis||
|Presence of co-morbidities||
|Assess impact of psoriasis on physical, psychological, and social wellbeing. Questions to ask include:
|Quality of Life (QOL) measurements are important to properly assess the full effect of an illness such as psoriasis on patients. Two dermatology specific tools to assess QOL impact of psoriasis are:
To improve patient care, both the European and Australian consensus programme have been established to develop specific treatment goals for psoriasis. In doing this, the need for defining psoriasis severity was evident. A summary of the Australian consensus for a definition of plaque psoriasis severity is shown below.
|Definition of plaque psoriasis severity: An Australian consensus|
|Mild plaque psoriasis
|Moderate to severe plaque psoriasis
Referral to a specialist is recommended in the following circumstances:
There is no cure for psoriasis. Successful management is very much dependent on the patient fully understanding the chronic nature of psoriasis and the therapeutic options that are available to them. Points to consider prior to initiating therapy include:
Treatment must be individualised and depends on the characteristics of the psoriasis – its body location, thickness of lesions and degree of erythema and scaling. In addition, the patient’s preference or commitment to therapy must also be considered.
To enhance the availability and appropriate use of therapies and increase patient satisfaction, psoriasis treatment goals have been developed by both European and Australian consensus committees. The Australian treatment goals, which are in agreement with the European treatment goals, are summarised in the following table.
|Psoriasis treatment goals for mild plaque psoriasis|
|PASI ≤10 and DLQI ≤10
|Psoriasis treatment goals for moderate to severe plaque psoriasis|
|PASI >10 or PASI ≤10 and DLQI >10
|Response (measured by percentage change in PASI score)*|
∆ PASI ≥75% and DLQI ≤5
∆ PASI ≥50% and <75%
∆ PASI <50
|*% change in PASI score compares PASI score at treatment initiation to PASI score at treatment review. Appropriate time to review varies with each treatment and the range is 6–24 weeks.
** In addition to changing treatment, modify may include adding topicals or other systemic treatments, increasing dose/frequency, or hospital admission. Patient’s wishes should be taken into account in treatment decisions.
The guidelines above provide a framework for initiating and monitoring psoriasis treatment, however there needs to be some flexibility in how they are used in clinical practice. Even though the guideline may indicate modifying or changing your patient’s treatment according to their assessments, there are situations where a treatment change is not actually necessary. Some points to consider are:
Although a high DLQI >10 and a low PASI ≤10 can be considered
The American Academy of Dermatology's position statement on the treatment of patients with moderate to severe psoriasis is as follows:
Therapeutic options in the treatment of chronic plaque psoriasis should be tailored to meet individual patients’ needs. Psoriasis patients with moderate-to-severe psoriasis and thus, candidates for systemic therapy, should be placed on the appropriate therapy from the beginning, i.e. phototherapy, or systemic therapy including biologic therapy. The old paradigm of “stepwise-therapy”, i.e. first phototherapy, then oral systemic therapies and finally biologic therapies in ascending order is not required. The decision for treatment should be based on efficacy, potential adverse effects, prior treatments, patient preference, duration and severity of disease, medical risk factors, co-morbidities, and potential impact on quality of life.
Approximately 80% of psoriasis patients have mild to moderate disease that can be treated with topical agents. Successful treatment is highly dependent on patient acceptance of their topical regimen. It is important to match patient expectations with practical considerations. General principles for using topical therapies include:
Topical treatments include emollients, vitamin D analogues, corticosteroids, salicylic acid, retinoids, coal tar and dithranol. The following table summarises the main topical treatment options.
|Vitamin D analogue (calcipotriol)||
|Calcineurin inhibitor (tacrolimus, pimecrolimus)||
In the last decade biologic response modifiers in the treatment of psoriasis have been showing promising results, treatment is well tolerated and often very effective in moderate to severe disease. While they are often more efficacious than traditional systemic therapies, the long term risks are still largely unknown. In addition, biologic systemic therapy is expensive, hence their use in clinical practice remains limited.
In most countries where biologic response modifiers are being used to treat severe chronic plaque psoriasis or psoriatic arthritis, fully funded access to these agents is controlled by exclusion and inclusion criteria set by government medical agencies. PHARMAC, the governing agency in New Zealand, require patients to meet the following criteria to receive fully funded systemic therapy with adalimumab, etanercept, and infliximab.
|PHARMAC Initial application to use adalimumab, etanercept, and infliximab.
Patient must meet all of the following criteria…..
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