On the development of the European S3 guidelines on the systemic treatment of psoriasis vulgaris: structure and challenges.

BACKGROUND: The development of evidence based guidelines is a demanding and time consuming process. Therefore it is important to share the knowledge and discuss the structure of these guidelines in detail. OBJECTIVES: To present a method report on the development process of the European evidence based guidelines on the systemic treatment of psoriasis vulgaris with the aim to offer guidance to other guidelines groups with lesser experience and to critically appraise the methodology of the guidelines development process. METHODS: The guidelines are based on the previously evaluated literature from three European national evidence based guidelines and an additional systematic search and evaluation of new literature. Further steps included a structured consensus conference and a DELPHI procedure to develop the recommendations, as well as several internal and external reviews. All steps were coordinated by the Division of evidence based medicine in cooperation with a group of methodologists. RESULTS: A total of 114 studies were included, serving as base for the efficacy chapters of the intervention. The recommendations, based on the efficacy and the level of evidence of the included studies were discussed and finally consented by the guidelines group. After subsequent reviews the guidelines were presented to the European Dermatology Forum, European Academy of Dermatology and Venereology and Union Européenne des Médicins Spécialistes for approval and published in October 2009. CONCLUSION: The development of European evidence based guidelines requires a coordinated structure which can be achieved by the integration of an experienced group of methodologists. Nevertheless further improvements are imaginable and might be considered for an update or other European evidence based guidelines.

A critical appraisal of evidence-based guidelines for the treatment of psoriasis vulgaris: 'AGREE-ing' on a common base for European evidence-based psoriasis treatment guidelines.

BACKGROUND: To further improve the standard of care provided to psoriasis patients in Europe, the European Dermatology Forum and the European Academy of Dermatology and Venereology have initiated a project to develop common European psoriasis guidelines. OBJECTIVE: This paper aims to assess the methodological quality and suitability of evidence-based psoriasis guidelines as a base of common European treatment guidelines. METHODS: A systematic literature search of the National Guidelines Clearinghouse, MEDLINE, EMBASE and GIN database for evidence-based psoriasis treatment guidelines published between 2001 and 2007 was performed and the AGREE instrument was used to assess the methodological quality. RESULTS: Out of 166 hits, we identified three evidence-based guidelines. A Dutch guideline that includes systemic treatments and photo(chemo)therapy, a British guideline that includes biologics only, and a German guideline that includes systemic therapy, photo(chemo)therapy and topical therapy. For the majority of the 23 AGREE items assessed, all three guidelines rated high (3-4/4). The highest score was obtained by the British guidelines with 75 points out of 92, followed by the German guidelines with 74 points and the Dutch guidelines with 73 points. All guidelines showed weaknesses in the field of 'applicability'. CONCLUSION: The three guidelines that could be included rated high enough to be considered 'strongly recommended' and were included to serve as a basis for the new common European guidelines. During the development of the European guidelines, special attention should be paid to meet the requirements of good 'applicability'.

European S3-guidelines on the systemic treatment of psoriasis vulgaris.

Of the 131 studies on monotherapy or combination therapy assessed, 56 studies on the different forms of phototherapy fulfilled the criteria for inclusion in the guidelines. Approximately three-quarters of all patients treated with phototherapy attained at least a PASI 75 response after 4 to 6 weeks, and clearance was frequently achieved (levels of evidence 2 and 3). Phototherapy represents a safe and very effective treatment option for moderate to severe forms of psoriasis vulgaris. The onset of clinical effects occurs within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term use, the consequences of high, cumulative UV doses (such as premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicability of the therapy is limited by spatial, financial, human, and time constraints on the part of the physician, as well as by the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs for, and time required of, the patient must be considered.

Low prescription rate for systemic treatments in the management of severe psoriasis vulgaris and psoriatic arthritis in dermatological practices in Berlin and Brandenburg, Germany: results from a patient registry.

BACKGROUND: Many treatment options are available for the management of psoriasis vulgaris. However, detailed data on prescription behaviour in Germany, especially with regard to the use of new treatment options (e.g. biologics) in private practices, are lacking. OBJECTIVE: To assess the treatment choices being made in the management of psoriasis vulgaris and psoriatic arthritis in private dermatological practices. METHODS: We established a patient registry that documented the treatment decisions taken during 4797 patient visits between January 2006 and September 2006 with regard to disease activity and concomitant psoriatic arthritis. RESULTS: Corticosteroids were the most frequently prescribed topical treatment, and methotrexate and fumaric acid esters were the most frequently prescribed systemic treatments. Biologics were prescribed in only 2% of patient visits. Systemic treatments were prescribed in only 31% of visits made by patients suffering from moderate to severe psoriasis (which was diagnosed in 48% of all patient visits) and in only 58% of visits made by patients suffering from psoriatic arthritis (which was diagnosed in 12% of all patient visits). CONCLUSIONS: Anti-psoriatic treatment was too often limited to topical agents. The rather small percentage of patients with moderate to severe psoriasis or psoriatic arthritis who received systemic therapy indicates that the use of systemic treatments in our sample was too restrictive. Novel therapeutic options such as biologics were rarely used in private practices. New strategies to improve the quality of care provided to patients suffering from severe psoriasis are needed.

Do guidelines change the way we treat? Studying prescription behaviour among private practitioners before and after the publication of the German Psoriasis Guidelines.

Evidence-based psoriasis treatment guidelines may help physicians overcome uncertainties in initiating and monitoring systemic treatment and have thus been suggested as a tool for improving the care provided to psoriasis patients. A prospective cohort study of dermatologists' prescription behaviour was performed with two consecutive documentation periods (before and after the publication of the guidelines). 49 dermatologists were asked to provide continuous documentation of their treatment choices for patients with psoriasis by filling in a standardised documentation form. In addition, a questionnaire consisting of eight items was used to assess familiarity with, attitudes towards, and the impact of the psoriasis guidelines on the participating dermatologists. 49 dermatologists documented their treatment choices during 4,491 patient visits before and 4,120 visits after the publication of the German national psoriasis treatment guidelines. The average proportion of prescribed systemic treatments for patients with moderate to severe psoriasis increased from 31 to 35% after the guidelines were published. 80% of the participants stated that the guidelines had led to changes in their treatment decisions, whereas only 20% stated that the guidelines had had no impact in this regard. All but one participant considered the guidelines "useful" or "very useful". The results of the study show that guidelines can be an important tool for improving the quality of care provided to patients with psoriasis.