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German S3-guidelines on the treatment of psoriasis vulgaris (short version)

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Abstract

Psoriasis vulgaris is a common and often chronic inflammatory skin disease. The incidence of psoriasis in Western industrialized countries ranges from 1.5 to 2%. Patients afflicted with severe psoriasis vulgaris may experience a significant reduction in quality of life. 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 (Richards et al. in J Am Acad Dermatol 41(4):581–583, 1999). To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologische Gesellschaft (DDG) and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis first published in 2006 and now updated in 2011. The Guidelines focus on induction therapy in cases of mild, moderate, and severe plaque-type psoriasis in adults. This short version of the guidelines presents the resulting series of therapeutic recommendations, which were based on a systematic literature search and discussed and 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. in JDDG Suppl 2:S1–S104, 2011 or http://www.psoriasis-leitlinie.de).

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Acknowledgments

The update of the guidelines was generated upon request by the Deutsche Dermatologische Gesellschaft (DDG) and the Berufsverband Deutscher Dermatologen (BVDD). The project was supported by the ‘Förderverein der Deutschen Dermatologischen Gesellschaft’, the funding body of the DDG.

Conflict of interest

The documentation and disclosure of potential conflicts of interest was based on the standardized form “Declaration of Conflicts of Interest” provided by the AWMF. The completed forms are available online at http://www.psoriasis-leitline.de. Given the diversity of the members of the guidelines group, it is assumed that any potential conflicts of interest balance each other out.

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Authors and Affiliations

  1. Division of Evidence Based Medicine (dEBM), Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany

    A. Nast, A. Sammain, R. Erdmann, S. Rosumeck & B. Rzany

  2. Zentrum der Dermatologie und Venerologie, Klinikum der Johann Wolfgang Goethe Universität, Frankfurt am Main, Germany

    W. H. Boehncke & T. Weberschock

  3. Klinik für Dermatologie, Venerologie, Allergologie, Universitätsklinikum Schleswig–Holstein, Campus Kiel, Kiel, Germany

    U. Mrowietz

  4. Haut-u. Allergieklinik, Klinikum Hanau, Hanau, Germany

    H. M. Ockenfels

  5. Psoriasisstudienzentrum Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin, Berlin, Germany

    S. Philipp

  6. Dermatologikum Hamburg, Hamburg, Germany

    K. Reich

  7. Osnabrück, Germany

    T. Rosenbach

  8. Oldenburg, Germany

    M. Schlaeger

  9. Mahlow, Germany

    M. Sebastian

  10. Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin, Berlin, Germany

    W. Sterry

  11. Buchholz, Germany

    V. Streit

  12. Klinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany

    M. Augustin

  13. Deutscher Psoriasis Bund e.V, Hamburg, Germany

    J. Klaus & J. Koza

  14. Ravenstein, Germany

    S. Müller

  15. Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Berlin, Germany

    H. D. Orzechowski

  16. Berolina Klinik, Löhne, Germany

    G. Schmid-Ott

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Appendix 1: Measures for excluding tuberculosis (scheme) modified after Diel et al. [51]

Appendix 1: Measures for excluding tuberculosis (scheme) modified after Diel et al. [51]

(1) Patient history

Immunosuppression

Other risk factors for TB

Prior LTBI/TB

(Occupational) TB contact

Origin

BCG vaccine status

TST/IGRA status

Chest X-rays for comparison

(2) Clinical examination

(3) Chest X-ray in two planes, CT of thorax if needed

If there are radiological signs of prior but inadequately or untreated TB without signs of activity, regardless of results of IGRA test:

chemopreventive therapy with isoniazid (INH) for nine months

(4) IGRA test

IGRA negative:

generally no chemoprevention

IGRA positive:

after ruling out the need for therapy: chemopreventive therapy with isoniazid (INH) for nine months

Complementary TST

If previous exposure to someone with infectious pulmonary TB is plausible despite negative IGRA tests and if BCG vaccine is unlikely given the patient’s native country.

Or for equivocal results on repeated IGRA test.

Positive TST determines further procedures

Bacteriology if needed

  1. LTBI latent tuberculosis infection, TB tuberculosis, TST tuberculin skin test, IGRA Interferon-Gamma Release Assay

The Interferon-Gamma Release Assay (IGRA) is based on detection of INF-γ, which is secreted by T lymphocytes that are sensitized during a current or previous infection with mycobacterium tuberculosis (MTB).

The two commercially available IGRA tests that are sold in Germany use direct measurement of IFN-γ concentration in whole blood (QuantiFERON-TB® Gold In-Tube, Cellestis, Australia; QFT) or measurement of the number of IFN-γ secreting T lymphocytes from isolated peripheral mononucleated cells (PBMC; T-SPOT.TB®, Oxford Immunotec, Great Britain) [51].

Usually at least one of the tests is offered by routine diagnostic laboratories, or the samples are sent by the lab to one that does offer them. The QuantiFERON-TB® Gold In-Tube (QFT) test requires three special tubes coated with antigen which may be obtained from the respective laboratory.

For the T Spot.TB test, 8 ml of fresh, heparinized whole blood are needed from adult patient and at least 2–4 ml from children. Vacutainer Cell Preparation tubes or Standard Lithium Heparin tubes may be used. The sample must then be thoroughly shaken. For both tests, the samples may be transported at room temperature (QuantiFERON-TB® within 16 h/T Spot.TB test within 8 h).

For information on outpatient billing, see the resolution of the German Association of Physicians/Health Insurers (Arbeitsgemeinschaft Ärzte/Ersatzkassen), 255th session (written resolution) from 24 September 2010 on the addition of fee number 32670 in section 32.3.7 of chapter 32 of the German Physician Fee Schedule (E-GO) (Resolution No. 930) effective as of 1 January 2011, Dtsch Arztebl 2010; 107(42): A-2069/B-1801/C-1773. For inpatient billing, see OPS Code 1930.0.

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Nast, A., Boehncke, W.H., Mrowietz, U. et al. German S3-guidelines on the treatment of psoriasis vulgaris (short version). Arch Dermatol Res 304, 87–113 (2012). https://doi.org/10.1007/s00403-012-1214-8

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