Highlights of the updated Dutch evidence- and consensus-based guideline on psoriasis 2017

Linked Comment: https://doi.org/10.1111/bjd.17390.

The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria

This evidence- and consensus-based guideline was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The conference was held on 1 December 2016. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-founded network of excellence, the Global Allergy and Asthma European Network (GA²LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) with the participation of 48 delegates of 42 national and international societies. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria are disabling, impair quality of life and affect performance at work and school. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 1: Diagnosis

Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction of the incidence of postherpetic neuralgia and other complications. The guideline development followed a structured and predefined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this first part of the guideline, diagnostic means have been evaluated. The expert panel formally consented recommendations for the management of patients with (suspected) HZ, referring to the assessment of HZ patients, considering various specific clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.

European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 2: Treatment

Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction in the incidence of postherpetic neuralgia (PHN) and other complications. The guideline development followed a structured and pre-defined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence-Based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this second part of the guideline, therapeutic interventions have been evaluated. The expert panel formally consented recommendations for the treatment of patients with HZ (antiviral medication, pain management, local therapy), considering various clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.

The quality of European dermatological guidelines: critical appraisal of the quality of EDF guidelines using the AGREE II instrument

Clinical practice guidelines are systematically developed tools to assist clinicians and health policy makers in decision making for clearly defined clinical situations. In the light of the demand for evidence-based medicine and quality in health care and the increasing methodological requirements concerning guidelines development, it is important to evaluate existing practice guidelines to systematically identify strengths and weaknesses. Currently, the most accepted tool for the methodological evaluation of guidelines is the Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument. Intention of this assessment is to identify and critically appraise clinical practice guidelines commissioned by the European Dermatology Forum (EDF). A quality assessment of a predefined set of guidelines, including all available clinical practice guidelines published on the EDF guidelines internet site, was performed using the AGREE II instrument. To assure an objective assessment, four independent assessments were performed by evaluators situated in different European countries. Twenty-five EDF guidelines covering different dermatological topics were identified and evaluated. The assessment included seven guidelines developed on the highest methodological standard (systematic literature search and structured consensus conference, S3). Eighteen guidelines were identified that were based on either a structured consensus process (S2k), a systematic literature assessment (S2e) or on informal consensus only (S1). The methodological and reporting quality among the evaluated guidelines was heterogeneous. S3 guidelines generally received the highest scores. The domains 'clarity of presentation' and 'scope and purpose' achieved the highest mean ratings within the different domains of assessment, whereas the domains of 'applicability', 'stakeholder involvement' and 'editorial independence' scored poorly. Considering the large variations in the achieved scores, there is need for methodological harmonization within the EDF guidelines to achieve comparable methodological standards.

Risk of complications due to anticoagulation during dermatosurgical procedures: a systematic review and meta-analysis

Background Management of anticoagulation and anti-platelet drugs during cutaneous surgery is still a challenge for many dermatologists and standards of care with respect to stopping, continuing or bridging vary widely. Methods We performed a systematic review (Medline, Cochrane Library, until August 27th, 2013) of studies assessing the risk of complications due to anticoagulation during cutaneous surgery. Primary outcomes were mild-moderate and severe postsurgical bleeding. The secondary outcomes were excessive and uncontrollable intraoperative bleeding and other postsurgical complications as wound dehiscence, erythema, wound infection. Results 1.287 publications were identified and 10 studies were included into the review. The frequencies of bleeding in the control groups in general were low (about 1%). In patients on aspirin, increased risks were seen neither with respect to mild-moderate postoperative bleeding (RR 1.1, CI 0.5-2.3), nor with respect to severe bleeding (RR 0.9, CI 0.2-4.6). The studies with patients on warfarin showed a risk for mild-moderate bleeding that was three times as high as in controls (RR 3.2, CI 1.4-7.1) and for severe bleeding that was 15 times higher (RR 14.8, CI 2.7-80.4). In general the study sizes were small and the methodological quality low. Conclusion The risk of bleeding due to a medication with aspirin seems to be negligible. With warfarin, the risk is increased; an exact estimate of the risk increase is difficult to give, because of the lack of sufficient high quality studies. A two-fold increase appears likely, the 15-fold increase is most likely due to statistical reasons arising from the rareness of the event in the small number of included patients. Stopping, bridging or continuing a medication should always be an individual decision. In accordance with guidelines from internal medicine for most patients it will be recommendable to continue with the medication.

Efficacy of systemic therapies for moderate-to-severe psoriasis: a systematic review and meta-analysis of long-term treatment

BACKGROUND

Despite the chronicity of psoriasis, most systematic reviews focus on short-term treatment.

METHODS

The systematic search strategy and results from the German Psoriasis Guidelines were adapted. To update the data a literature search in Medline, Embase and the Cochrane Library was conducted. The proportion of participants achieving ≥75% decrease in Psoriasis Area and Severity Index (PASI) as well as Dermatology Life Quality Index (DLQI) reduction at different time points were assessed. Trials were summarized with respect to time periods and study designs. Suitable trials were included in a meta-analysis. Particular attention was paid to statistical approaches of handling dropouts.

RESULTS

A total of 33 articles including 27 trials totaling 6575 patients with active treatment were included in the systematic review. Seven randomized controlled trials were eligible for the meta-analysis. Over a 24 week treatment period infliximab [risk difference (RD) 78%, 95% confidence interval (CI) 72-83%] and ustekinumab 90 mg every 12 weeks (RD 77%, 95% CI 71-83%) were the most efficacious treatments. Adalimumab (RD: 60%, 95% CI 45-74%) showed results within the range of different etanercept dosages (etanercept 50 mg once weekly: RD 62%, 95% CI, 52-72%), (etanercept 25 mg twice weekly: RD 45%, 95% CI 34-56%), (etanercept 50 mg twice weekly: RD 56%, 95% CI 49-62%) and (etanercept 50 mg twice weekly until week 12, then 25 mg twice weekly: RD 50%, 95% CI 42-57%). After 24 weeks a decrease in efficacy for inflximab, adalimumab and etanercept was observed.

CONCLUSIONS

More sufficient data is required to draw reliable conclusions in extended long-term treatment and head-to-head comparisons are necessary.

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.

German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version)

Psoriasis vulgaris is a common and chronic inflammatory skin disease which has the potential to significantly reduce the quality of life in severely affected patients. The incidence of psoriasis in Western industrialized countries ranges from 1.5 to 2%. Despite the large variety of treatment options available, patient surveys have revealed insufficient satisfaction with the efficacy of available treatments and a high rate of medication non-compliance. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologische Gesellschaft and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis. The guidelines focus on induction therapy in cases of mild, moderate, and severe plaque-type psoriasis in adults. The short version of the guidelines reported here consist of a series of therapeutic recommendations that are based on a systematic literature search and subsequent discussion with experts in the field; they have been approved by a team of dermatology experts. In addition to the therapeutic recommendations provided in this short version, the full version of the guidelines includes information on contraindications, adverse events, drug interactions, practicality, and costs as well as detailed information on how best to apply the treatments described (for full version, please see Nast et al., JDDG, Suppl 2:S1-S126, 2006; or http://www.psoriasis-leitlinie.de ).