NICE has published Referral Advice - a guide to appropriate referral from general to specialist services, which deals with 11 common complaints. Last month we covered persistent otitis media with effusion (glue ear) in children. In this issue we reproduce the advice on psoriasis.

The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred.


Psoriasis affects 1-2% of people in the UK. It is a chronic, relapsing condition which can present at any age. The rash has various distinct patterns. Patients with the most common form (plaque psoriasis) typically have red, scaly plaques, most commonly on the extensor aspects (knees, elbows), over the sacrum or scalp, in the flexures, and on the soles and palms. Plaques can become inflamed and/or aggravated (unstable psoriasis) on starting topical treatments, after prolonged use of topical corticosteroids or after suddenly stopping systemic steroids.

Very rarely, psoriasis presents as generalised erythema with less scaling (erythrodermic psoriasis) or with numerous pustules (generalised pustular psoriasis). There is also a localised form of pustular psoriasis affecting the palms and soles. In some patients psoriasis presents as showers of small, scaly, red lesions (guttate psoriasis) following a streptococcal infection. In older people particularly, the lesions may be eczematous. Psoriasis can cause nail deformity. In some patients it is associated with arthritis.

In some patients symptoms are sufficient to cause disability and can have a major social and psychological impact. With proper management, the outlook for most patients can be greatly improved.

Primary care

Treatment may typically include emollients, vitamin D analogues, topical dithranol, differing strengths of topical corticosteroids, coal tar and topical retinoids (see the British National Formulary, Section 13.5). Treatment should be reviewed at around 1-2 months. It is important to assess whether the products have been correctly applied.

Specialist services

These are in a position to:

  • confirm or establish the diagnosis
  • provide inpatient and day-care treatment facilities
  • provide, in conjunction with other healthcare professionals, advice on the condition and its treatment, together with social and psychological support
  • assess and supervise the use of phototherapy and PUVA, as well as oral retinoids, cytotoxic therapy and immunosuppressive therapy
  • treat psoriasis that is unresponsive to therapies tried in primary care, or to resolve problems where the patient cannot tolerate such treatment
  • offer acute treatment in patients with severe conditions such as erythrodermic psoriasis or generalised pustular psoriasis
  • provide and support specialist nursing services working in primary and secondary care
  • provide assessment and advice for patients with painful psoriatic arthropathy.
Referral Advice
Most patients with psoriasis can be managed in primary care. Referral to specialist services, which may be prompted by features such as sleep disturbance, social exclusion, reduced quality of life or reduced self-esteem, is advised if:
the patient has generalised pustular or erythrodermic psoriasis
the patient's psoriasis is acutely unstable
the patient has widespread guttate psoriasis (so that he/she can benefit from early phototherapy)
the condition is causing severe social or psychological problems
the rash is sufficiently extensive to make self-management impractical

the rash is in a sensitive area (such as face, hands, feet, genitalia) and the symptoms particularly troublesome

the rash is leading to time off work or school which is interfering with employment or education
the patient requires assesement for the management of associated arthropathy
the rash fails to respond to management in general practice. Failure is probably best based on the subjective assesement of the patient. Sometimes failure occurs when patients are unable to apply the treatment themselves
The starring system developed by NICE to identify referral priorities
Arrangements should be made so that the patient:
is seen immediately1
is seen urgently2
is seen soon2
has a routine appointment2
is seen within an appropriate time depending on his or her clinical circumstances (discretionary)

1 within a day
2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.

Reproduced with kind permission from: Referral Advice - A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.

The complete document can be downloaded from the NICE website

Guidelines in Practice, August 2002, Volume 5(8)
© 2002 MGP Ltd
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