Systematic Review and Critical Appraisal of Psoriasis Clinical Practice Guidelines

A Global Guidelines in Dermatology Mapping Project (GUIDEMAP)

Hsi Yen; Chun-Hsien Huang; I-Hsin Huang; Wei-Kai Hung; Hsing-Jou Su; Hsuan Yen; Cheng-Chen Tai; William Y. Haw; Carsten Flohr; Zenas Z.N. Yiu; Ching-Chi Chi


The British Journal of Dermatology. 2022;187(2):178-187. 

In This Article

Abstract and Introduction


Background: Clinical practice guidelines (CPGs) developed with rigorous methods can help optimize clinical care for patients with psoriasis.

Objectives: To conduct an updated systematic review and comprehensive critical appraisal of global psoriasis CPGs.

Methods: A search of MEDLINE and Embase for psoriasis CPGs published between 1 January 2015 and 31 March 2021 was performed. Other guideline repositories were also searched for relevant CPGs. Descriptive analysis was conducted to summarize included guidelines. Three critical appraisal tools were used to assess the quality of included CPGs: the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, Lenzer et al.'s red flags, and the US Institute of Medicine's (IOM) criteria of trustworthiness.

Results: We included 33 psoriasis CPGs, with 25 openly accessible. Most CPGs were from high sociodemographic index countries in North America and Europe. Five CPGs received 'excellent quality' appraisals across all six AGREE II domains. Stakeholder involvement, rigour of development and applicability were the three domains with the lowest appraisal scores for AGREE II. Twenty-two CPGs raised at least one red flag indicative of potential bias. By the IOM's standards, external review of the guideline draft prior to publication and clear updating procedures were most often not addressed by guidelines, and only three CPGs were assessed as having higher overall trustworthiness.

Conclusions: Most psoriasis guidelines were unable to consistently demonstrate high quality across multiple appraisal tools. The EuroGuiDerm guideline on the systemic treatment of psoriasis vulgaris was the only CPG to receive 'excellent quality' across all six AGREE II domains, to raise no Lenzer's red flags, and to have higher trustworthiness by IOM criteria.


Psoriasis is a chronic multisystemic inflammatory disorder commonly presenting as a papulosquamous cutaneous disease.[1] It affects approximately 64·6 million individuals worldwide, with rising global incidence observed over the last 30 years.[2] Multiple comorbidities have been associated with psoriasis, including psoriatic arthritis, cardiovascular disease, metabolic syndrome, cognitive impairment, psychiatric disorders, inflammatory bowel disease, uveitis, autoimmune diseases and malignancies.[3–12] Psoriasis has further been shown to be associated with increased mortality.[13] Therefore, psoriasis presents a considerable and growing global burden, highlighting the need for effective clinical recommendations.

Clinical practice guidelines (CPGs) are informed by review of scientific evidence and help optimize patient care by translating evidence into standardized care.[14] Well written CPGs based on systematic and rigorous standards of development can help improve health outcomes and empower patients to make informed decisions.[15] A prior scoping review explored the distribution of CPGs for dermatological conditions with the highest disease burden globally as part of the Global Guidelines in Dermatology Mapping Project (GUIDEMAP).[16] GUIDEMAP provided a comprehensive global overview of CPGs dedicated to skin diseases, and established an open-access repository ([17] Psoriasis had the third highest representation of all CPGs, with an increasing trend from 2014 to 2019 and a significant proportion focusing on treatment recommendations.[16] Despite the rapid increase in the number of CPGs, challenges remain. These include redundancy of different teams working on CPGs with similar findings, inconsistencies in methodology across different guidelines, and outdated guidelines.[18] Guidelines that do not utilize systematic methods such as detailed eligibility criteria and comprehensive search of databases can reduce the reliability of recommendations.[19]

One method to determine quality of CPGs is through critical appraisal. A survey of the British Journal of Dermatology readership (with most of the 1043 responders being healthcare providers) found quality of guideline development, evidence underlying recommendations and explicit guideline funding to be important to CPGs.[20] These are all key domains evaluated by a critical appraisal process, yet an updated and comprehensive appraisal for psoriasis CPGs remains lacking. The objective of this study was to conduct a systematic search and critical appraisal of psoriasis CPGs, identifying high-quality CPGs that can best improve the quality of care in clinical practice.