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## Complete Summary

#### GUIDELINE TITLE

Psoriasis.

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Psoriasis. In: EBM Guidelines.
Evidence-Based Medicine \[Internet\]. Helsinki, Finland: Wiley
Interscience. John Wiley & Sons; 2005 May 25 \[Various\].

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references drug(s) for which important revised regulatory and/or warning
information has been released.

-   [October 17, 2008, Raptiva
    (efalizumab)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Raptiva):
    The U.S. Food and Drug Administration (FDA) notified healthcare
    professionals of extensive labeling changes, including a Boxed
    Warning, to highlight the risks of life-threatening infections,
    including bacterial sepsis, viral meningitis, invasive fungal
    disease, progressive multifocal leukoencephalopathy and other
    opportunistic infections with the use of Raptiva. In addition, the
    prescribing information will be updated to describe a potential risk
    for the permanent suppression of the immune system with repeat
    administration of Raptiva in children. Raptiva is not approved for
    children under 18 years of age.

-   [May 1, 2008, Enbrel
    (etanercept)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Enbrel):
    Amgen and Wyeth Pharmaceuticals informed healthcare professionals of
    changes to the BOXED WARNING section of the prescribing information
    for Enbrel regarding the risk of serious infections, including
    bacterial sepsis and tuberculosis, leading to hospitalization or
    death. The ADVERSE REACTIONS section of the label was updated to
    include information regarding global clinical studies and the rate
    of occurrence of tuberculosis in patients treated with Enbrel.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Psoriasis

#### GUIDELINE CATEGORY

Diagnosis\
Treatment

#### CLINICAL SPECIALTY

Dermatology\
Family Practice\
Internal Medicine

#### INTENDED USERS

Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

Evidence-Based Medicine Guidelines collect, summarize, and update the
core clinical knowledge essential in general practice. The guidelines
also describe the scientific evidence underlying the given
recommendations.

#### TARGET POPULATION

Patients who have psoriasis or cutaneous lesions suspicious for
psoriasis

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Assessment of clinical features and patterns of cutaneous lesions

2.  Assessment for family history of psoriasis

3.  Biopsy, if needed

**Treatment**

1.  No treatment, if minor localized psoriasis on the elbows or knees

2.  Topical treatment including creams or ointments:

    -   Emollients

    -   Topical corticosteroids

    -   Dithranol (Anthralin)

    -   Coal tar

    -   Vitamin D derivatives (Calcipotriol \[calcipotriene\],
        calcitriol)

    -   Combination of calcipotriol with a potent topical corticosteroid

    -   Calcitriol

    -   Tazarotene

3.  Phototherapy including:

    -   Ultraviolet A with a psoralen (PUVA)

    -   Ultraviolet B (UVB) radiation

    -   Combination of phototherapy with retinoids

    -   Climatotherapy (heliotherapy)

4.  Systemic treatment including:

    -   Acitretin, methotrexate, hydroxycarbamide, cyclosporine, and
        sulfasalazine

    -   Biologicals, such as alefacept, efalizumab, etanercept, and
        infliximab

5.  Referral to specialist

**Note**: Antistreptococcal therapy is considered but not recommended.

#### MAJOR OUTCOMES CONSIDERED

-   Psoriasis clearance rate

-   Remission rate

-   Adverse effects of (tolerance to) treatment

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence reviewed was collected from the Cochrane database of
systematic reviews and the Database of Abstracts of Reviews of
Effectiveness (DARE). In addition, the Cochrane Library and medical
journals were searched specifically for original publications.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

A.  Strong research-based evidence. Multiple relevant, high-quality
    scientific studies with homogeneous results.

B.  Moderate research-based evidence. At least one relevant,
    high-quality study or multiple adequate studies.

C.  Limited research-based evidence. At least one adequate scientific
    study.

D.  No research-based evidence. Expert panel evaluation of other
    information.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary. The
recommendations that follow are based on the previous version of the
guideline.

The levels of evidence \[A-D\] supporting the recommendations are
defined at the end of the \"Major Recommendations\" field.

**Definition and Prevalence**

-   Psoriasis is a chronic disease of the skin caused by genetic and
    environmental factors. It is characterized by well-defined plaques
    bearing adherent, silvery scales.

-   The prevalence of psoriasis in Scandinavia and Western Europe is
    approximately 2%. It is rare below 5 years of age. (see picture 1\*)
    There are two peaks of onset: between 16 and 22 years of age in Type
    I psoriasis and between 57 and 60 years of age in Type II psoriasis.
    The genetic background of these two types differ (Elder et al.,
    1994).

-   Genetic predisposition to psoriasis follows a multifactorial
    pattern. Approximately ten susceptibility genes (locus) have been
    identified. The most significant locus (PSORS1) lies within
    chromosome 6p21.3 (Asumalahti et al., 2003). Only about 10% of the
    susceptibility gene carriers will develop the disease (low
    penetrance) (Swanbeck et al., 1997; Elder et al., 1994).

-   Psoriasis is characterized by an abnormal regulation of the
    interaction between T cells and keratinocytes. T cell cytokine
    secretion profile resembles that of Th-1 (Lebwohl, 2003).

-   External factors (infections, streptococcal in particular, skin
    injuries, certain drugs) often trigger the onset of psoriasis
    (Lebwohl, 2003). Stress, smoking, and excessive alcohol consumption
    may also be connected with the onset of psoriasis.

**Clinical Features**

-   Characteristic cutaneous lesions facilitate diagnosis.

    -   The plaques are sharply demarcated, slightly elevated, and
        covered with silvery scales (see pictures 1, 3, and 2\*).

    -   Gentle scraping of the scales reveals minute capillary bleeding
        points (Auspitz sign) (see picture 4\*).

    -   The elbows (see picture 5\*), knees (see picture 6\*), legs,
        lower back, scalp (see pictures 7 and 8\*), and glans penis (see
        picture 9\*) are the sites of predilection.

-   Involvement of the nails is common.

    -   Pitting

    -   Separation of the distal nail plate from the nail bed
        (onycholysis), yellowish flecks beneath the nail plate (\"oily
        macules\"), and subungual hyperkeratosis (see pictures 11, 12,
        and 10\*).

    -   Acrodermatitis continua of Hallopeau is a painful, localized
        pustular form of psoriasis which often leads to nail deformity
        (see pictures 14 and 13\*).

**Common Manifestations of Psoriasis**

-   The most common type is plaque psoriasis, which is a stationary form
    of the disease with the lesions often covered with thick silvery
    scales.

-   Guttate psoriasis is often triggered by tonsillitis. It is widely
    distributed throughout the body.

-   Flexural psoriasis is localized within the main skin folds
    (genitocrural area \[see picture 15\*\], navel, axillae, submammary
    region).

-   Erythrodermic psoriasis (see picture 16\*) is a generalized form of
    the disease and is most refractory to treatment. It may also appear
    in a pustular form (pustular psoriasis).

-   Psoriasis may also affect joints in 5 to 10% of cases.

**Differential Diagnosis**

-   Diagnosis is based on the clinical picture (Lebwohl, 2003).

-   A biopsy may exclude some other skin diseases resembling psoriasis,
    but it rarely is pathognomic (Lebwohl, 2003).

-   A family history of psoriasis may help in diagnosis: up to 50% of
    patients report an affected relative (Swanbeck et al., 1997).

**Scalp**

-   In **seborrhoeic dermatitis** (see the Finnish Medical Society
    Duodecim guideline \"Seborrhoeic dermatitis\" (see picture 17\*) the
    flakes are thinner, \"greasier,\" and the condition responds better
    to treatment. It is often difficult to differentiate seborrhoeic
    dermatitis from psoriasis unless other skin areas offer additional
    information.

-   **Fungal infection** of the scalp (see the Finnish Medical Society
    Duodecim guideline \"Dermatomycoses\") is uncommon in the Western
    populations. It mostly affects children. This diagnosis can be
    excluded by microscopy and negative culture for fungi.

-   **Neurodermatitis** of the neck (lichen simplex nuchae) is
    characterised by an isolated, itchy plaque covered with thin scales.

**Flexures**

-   **Seborrhoeic dermatitis** may resemble flexural psoriasis. Examine
    other skin areas. It is not necessary to differentiate between these
    two conditions, as the treatment is the same.

-   **Fungal infection** (tinea) (see the Finnish Medical Society
    Duodecim guideline \"Dermatomycoses\") may resemble psoriasis;
    however, it usually heals in the centre and expands peripherally.
    Potassium hydroxide (KOH) and fungal culture are diagnostic.

-   **Candidiasis** is not often seen in the young and middle-aged
    patients. It presents as a moist area of erythema and maceration
    with outlying \"satellite eruptions.\"

-   **Erythrasma** is a macular brown area with few symptoms, most often
    found in the armpits or groin. It is caused by overgrowth of
    diphtheroids of the normal skin flora. These areas fluoresce coral
    pink under long-wave ultraviolet radiation (Wood\'s light).

**Hands, Feet**

-   **Hyperkeratotic eczema** of the palms and **palmoplantar
    pustulosis** may be difficult to differentiate from psoriasis (see
    picture 18\*). Examine the entire skin.

-   **Fungal infection** (see the Finnish Medical Society Duodecim
    guideline \"Dermatomycoses\") can easily be diagnosed with
    microscopic examination and culture.

**Treatment**

-   It is not necessary to treat psoriasis if it has no effect on the
    patient\'s quality of life (minor psoriasis on the elbows or knees).

-   The choice of treatment depends on the psoriasis subtype and the
    extent, severity, and site of the lesions and, importantly, on the
    patient\'s preferences. In addition to the age of the patient, the
    availability, feasibility, and cost of the treatment as well as
    response to earlier treatment also have an influence on the choice.

-   Any comorbidity (e.g., hepatic disease, hypertension, alcohol abuse,
    human immunodeficiency virus \[HIV\]) or a possible pregnancy of the
    patient must also be taken into account.

**Topical Treatment**

-   The main form of treatment available for a general practitioner is
    the use of various ointments and creams.

-   Topical treatment may also enhance the effect of other treatment
    forms.

-   The active treatment of mild to moderate plaque psoriasis may
    consist of vitamin D derivatives (calcipotriol and calcitriol).
    These are used regularly twice a day. They are suitable for
    long-term use. Topical corticosteroids are also suitable, but their
    use should be intermittent.

-   **Emollients** may be used as a general treatment in non-acute
    phases of the disease. They can also be used to soften and remove
    the scale from the scalp (plenty of emollient rubbed into the scalp
    in the evening and washed out in the morning). The scalp must not be
    scratched or rubbed to remove the scale since this may worsen the
    symptoms (Köbner phenomenon). Salicylic vaseline (5%) or an
    emollient base with salicylic acid enhances the exfoliating effect.

-   **Topical corticosteroid** (Mason, Mason, & Cork, 2002) \[**A**\]
    ointments are usually more effective than creams. On the face and
    flexures only mild to moderately potent topical corticosteroids
    should be used. On the other body areas treatment results will only
    be achieved with potent to very potent ointments. Topical
    corticosteroids can well be used on the scalp, too. The duration of
    a course of a corticosteroid ointment may vary from one week up to
    four weeks, depending on the age of the patient, the area to be
    treated, and the potency of the preparation. The treatment should
    then be stopped. Then an emollient can be used or another suitable
    treatment regime. Corticosteroids are not suitable for the treatment
    of large skin areas. The treatment of psoriasis in children is
    usually prescribed only after consulting a dermatologist. Systemic
    corticosteroids must not be used for the treatment of psoriasis, as
    disease progression to an extensive form of pustular psoriasis is
    possible. An experienced dermatologist may deviate from this rule
    when treating a difficult-to-manage or critically worsened psoriasis
    (e.g., as a part of combination treatment).

-   Preparations of **coal tar** are suitable for the treatment of
    extensive guttate psoriasis or as follow-up treatment of other
    treatment forms. At present, coal tar preparations are not much used
    due to their smell and mess (Lebwohl, 2003).

-   **Dithranol** (anthralin) is used as a \"short contact\" regimen.
    (Lebwohl & Ali, 2001). 1 to 3% dithranol formula is applied and left
    on for 20 to 30 minutes. The preparation is washed off after the
    application time. The preparation may permanently stain the wash
    basins. Dithranol is also suitable for the treatment of scalp
    psoriasis.

-   **Calcipotriol** (calcipotriene) is a vitamin D analogue. It is
    available as an ointment or cream as well as scalp solution. Its
    efficacy is similar to that of a potent topical corticosteroid. The
    maximum weekly dose is 100 g of 50 micrograms/g ointment, cream, or
    solution. It must be used regularly twice a day in order to get
    effect.

-   **The combination of calcipotriol with a potent topical
    corticosteroid** is more effective than either component alone
    (Mason, 2002; Douglas et al., 2002) \[**A**\]. The combination
    formula is suitable as an initial treatment of plaque psoriasis in
    adults. Once daily dosing is sufficient (Guenther et al., 2002),
    which may improve compliance. The treatment may last for up to four
    weeks. Follow-up treatment may be carried out with calcipotriol
    alone, or with calcipotriol on weekdays and combination therapy on
    weekends. The patient must be observed for corticosteroid-induced
    signs of skin atrophy (thinning of the skin, papery skin, dilated
    capillaries, bruising).

-   **Calcitriol** (Ashcroft et al., \"Systematic review,\" 2000;
    DARE-20008265, 2001) \[**A**\] is an active form of vitamin D, and
    it is available as an ointment. Its efficacy is similar to that of a
    potent topical corticosteroid (Langner, Stapor, & Ambroziak, 2001).
    The treated area must be not more than 35% of total body surface
    area. The maximum dose is 30 g of the ointment (3 micrograms/g)
    daily or 210 g weekly. It can also be applied lightly to sensitive
    skin areas, such as the face and flexures (Ortonne et al., 2003).
    The ointment should be applied twice daily. It has also been used
    together with a topical corticosteroid (Kowalzick, 2001).

-   **Tazarotene** is a topically applied retinoid used as a gel once
    daily (Weinstein et al., 1997) \[**B**\]. Its efficacy is similar to
    that of a potent topical corticosteroid. Irritation is seen in some
    patients (Lebwohl et al., 1998). The addition of a potent topical
    corticosteroid to tazarotene therapy increases the treatment
    success.

**Phototherapy**

-   Phototherapy may be used for extensive psoriasis (\>10% of the body
    surface) (Griffiths et al., 2000; Spuls et al., 1997;
    DARE-980690, 2000) \[**A**\]. Phototherapy should only be prescribed
    with firm criteria. The prescribing physician must be well versed in
    the prescribed form of phototherapy and the doses necessary for the
    patient\'s particular skin type.

-   Indications, suitable doses, and frequency of exposure to
    phototherapies and concomitant treatment require the experience of a
    dermatologist (Hönigsmann, 2001). Ultraviolet A radiation with a
    psoralen (PUVA) and retinoids may only be prescribed by
    dermatologists.

-   Various combination regimens (e.g., retinoids) are recommended to
    reduce the cumulative ultraviolet (UV) dose and with the intention
    to reduce the long-term adverse effects of phototherapy (Lebwohl et
    al., 2001).

-   Climatotherapy (heliotherapy). Skin must tolerate exposure to the
    sun (i.e., the skin must be able to tan and it may not burn easily).
    Sunbathing is started with small UV doses. The time to sunbathe is
    dependent on the skin phototype and degree of tanning. Furthermore,
    the geographical location, time of day, season, weather, altitude,
    and other factors like pollution have a major influence on the time
    needed for sunbathing. Therefore, no single predetermined time
    schedule can be given. As regards plaque psoriasis, a three-week
    course is usually necessary for a good result (Snellman et al.,
    \"Effect of heliotherapy,\" 1993; Snellman et al., \"Supervised
    four-week heliotherapy,\" 1993). Contraindications include
    alcoholism and severe mental health problems. Photosensitising
    medications (e.g., amiodarone, piroxicam, and doxycycline) are also
    a contraindication, as is poor general health. Heliotherapy is an
    effective but relatively expensive treatment modality due to the
    lost working days (Snellman et al., 1998).

-   Ultraviolet B (UVB) radiation is particularly beneficial in guttate
    psoriasis. UVB treatments are divided into the conventional
    broad-band (TL12) UVB therapy (wavelength 385 to 400 nm) and the
    narrow-band (TL01) UVB therapy (wavelength 309 to 313 nm). The
    latter (TL01) is now regarded in most clinics as the treatment of
    choice in the field of phototherapy.

-   The efficacy of narrow-band UVB therapy is at least comparable to
    that of PUVA. The long-term adverse effects of narrow-band UVB are
    not yet known.

-   The efficacy of UVB therapy may be enhanced with the addition of a
    systemic retinoid (ReUVB) and various topical agents compatible with
    phototherapy which may reduce the cumulative UV dose received by the
    patient (Lebwohl et al., 2001).

-   PUVA therapy is an effective but also highly demanding form of
    phototherapy (Voss et al., 2001). The photosensitising effects of
    different psoralens vary ten-fold. During RePUVA therapy the patient
    receives a concomitant systemic retinoid (acitretin). The PUVA
    therapies have fallen out of favour due to increased risk of skin
    cancer associated with tablet-PUVA therapy. Despite the associated
    risks, PUVA may still be the best choice for some patients in
    problematic cases.

**Systemic Treatment**

-   Acitretin, methotrexate (Griffiths et al., 2000) \[**C**\],
    hydroxycarbamide (Griffiths et al., 2000) \[**C**\], cyclosporin
    (Griffiths et al., 2000) \[**A**\], and sulfasalazine (Griffiths et
    al., 2000) \[**B**\] may be prescribed by a dermatologist to
    patients with severe psoriasis. Their use requires special
    experience and regular follow-up. Methotrexate and cyclosporin are
    equally effective for moderate to severe plaque type psoriasis
    (Heydendael et al., 2003). An experienced dermatologist who has seen
    plenty of psoriasis patients may also use combinations of systemic
    psoriasis medications to treat difficult cases or to get a difficult
    situation under control.

-   Biologicals, such as alefacept, efalizumab, etanercept, and
    infliximab, may have a role in the treatment of moderate to severe
    psoriasis refractory to other treatments or when other treatments
    are contraindicated or unsuitable (Granstein, 2001). Alefacept and
    efalizumab inhibit T-cell activation. Tumor necrosis factor
    (TNF)-alpha antagonists infliximab and etanercept are also effective
    in psoriatic arthritis (Krueger and Callis, 2004). A special risk
    associated with TNF-alpha antagonists is an activation of latent
    infections (e.g. tuberculosis).

**Referral to Specialist**

-   Children suffering from psoriasis and adults suffering from
    psoriasis that does not respond to usual treatment modalities should
    be referred to a dermatologist.

-   An experienced dermatologist can be more helpful in the diagnosis of
    problematic psoriasis than sending off a skin biopsy.

-   If excessive corticosteroid use is suspected, the patient should be
    referred to a dermatologist.

**Related Evidence**

-   There is no evidence supporting antistreptococcal interventions in
    psoriasis (Owen et al., 2000) \[**C**\].

-   Combination regimens of topical calcipotriene with acitretin,
    cyclosporin, and psoralen-UV-A appear not to improve treatment
    effects in chronic plaque psoriasis but they may reduce the
    long-term risk of toxic effects (Ashcroft et al., \"Combination
    regimens,\" 2000; DARE-20010166, 2002) \[**B**\].

\*Note: All pictures identified in this summary can be found in the
original guideline document.

**Definitions**:

**Levels of Evidence**

A.  Strong research-based evidence. Multiple relevant, high-quality
    scientific studies with homogeneous results.

B.  Moderate research-based evidence. At least one relevant,
    high-quality study or multiple adequate studies.

C.  Limited research-based evidence. At least one adequate scientific
    study.

D.  No research-based evidence. Expert panel evaluation of other
    information.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=8260)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Concise summaries of scientific evidence attached to the individual
guidelines are the unique feature of the Evidence-Based Medicine
Guidelines. The evidence summaries allow the clinician to judge how
well-founded the treatment recommendations are. The type of supporting
evidence is identified and graded for select recommendations (see the
\"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Accurate diagnosis and effective treatment of psoriasis

#### POTENTIAL HARMS

**Side Effects of Medication**

-   *Calcipotriol*. In a systematic review, calcipotriol was found to
    cause significantly more skin irritation than topical
    corticosteroids.

-   *Sulfasalazine*. In one randomized controlled trial (RCT), the
    efficacy of sulfasalazine was offset to a degree by patient
    intolerance and side effects, particularly nausea, vomiting, and
    rashes.

-   *Tablet-psoralen-ultraviolet-light (PUVA) therapy* was associated
    with increased risk of skin cancer.

-   Irritation is seen in some patients using *tazarotene*.

-   *Topical corticosteroids* can induce skin atrophy (thinning of the
    skin, papery skin, dilated capillaries, bruising).

-   *Coal tar* preparations are not much used because of their smell and
    mess.

-   A special risk associated with *infliximab* and *etanercept* is
    activation of latent infections (e.g., tuberculosis)

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   *Systemic corticosteroids* should not by used for treatment of
    psoriasis in children, as the disease progression to an extensive
    form of pustular psoriasis is possible.

-   Contraindications to *heliotherapy include* alcoholism, severe
    mental health problems, photosensitizing medication (e.g.,
    amiodarone, piroxicam, and doxycycline), and poor general health.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Psoriasis. In: EBM Guidelines.
Evidence-Based Medicine \[Internet\]. Helsinki, Finland: Wiley
Interscience. John Wiley & Sons; 2005 May 25 \[Various\].

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2002 May 7 (revised 2005 May 25)

#### GUIDELINE DEVELOPER(S)

Finnish Medical Society Duodecim - Professional Association

#### SOURCE(S) OF FUNDING

Finnish Medical Society Duodecim

#### GUIDELINE COMMITTEE

Editorial Team of EBM Guidelines

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Erna Snellman

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

#### GUIDELINE AVAILABILITY

This guideline is included in \"EBM Guidelines. Evidence-Based
Medicine\" available from Duodecim Medical Publications, Ltd, PO Box
713, 00101 Helsinki, Finland; e-mail: <info@ebm-guidelines.com>; Web
site: [www.ebm-guidelines.com](http://www.ebm-guidelines.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on December 17, 2002. The information
was verified by the guideline developer as of February 7, 2003. This NGC
guideline was updated by ECRI on October 4, 2004. This summary was
updated by ECRI on July 21, 2005 following the Food and Drug
Administration (FDA) advisory on Raptiva (efalizumab). This summary was
most recently updated on November 14, 2005. This summary was updated by
ECRI on February 7, 2006 following the Food and Drug Administration
(FDA) advisory on Hydrea and Droxia (hydroxyurea capsules). This summary
was updated by ECRI Institute on May 15, 2008 following the U.S. Food
and Drug Administration advisory on Enbrel (etanercept). This summary
was updated by ECRI Institute on October 30, 2008 following the U.S.
Food and Drug Administration advisory on Raptiva (efalizumab).

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/10/2008