Secondary care assessment In order to provide an accurate secondary diagnosis and understand the most appropriate treatment option, the severity of the disease should be scored. A range of measures are used in eczema and psoriasis – the Eczema Area and Severity Index (EASI) and the Psoriasis Area and Severity Index (PASI) respectively. 25,26 The Dermatology Life Quality Index (DLQI) can also be used to measure the health-related quality of life of adult patients suffering from a skin disease. 27 Patients diagnosed with severe or complex psoriasis or eczema should then expect information to be given within three months of the first episode predicting the likely course of disease over the first year, to receive high quality and proactive treatment and care, and to see a 10% improvement in their dermatology disease-related quality of life score within three months of referral. 11 Access to treatment Once a patient is diagnosed with an inflammatory skin condition, swift access to follow up care, including optimal treatment, is key to reducing the severity of symptoms and the accompanying burden of the condition – both on individuals and the NHS. People with long-term skin conditions require maintenance treatment, in particular emollients, to reduce the likelihood of a flare-up in disease activity. In the case of eczema, NICE recommends a stepped approach to the treatment of the condition, with a treatment stepped up or down depending on the severity of the condition. 28 Treatment of a flare-up will often require temporarily increasing the intensity of treatment. Patients with severe or widespread atopic eczema that has not responded to existing treatments may require further treatment escalation, including NICE approved biologics and advanced therapies. Once initiated, the initial patient response should be assessed, and thereafter regularly during therapy. 29 Many local health systems in England have specific pathways in place relating to the use of these treatments that can be consistently applied by healthcare professionals in their area, to ensure adherence to NICE guidance. Primary Care Management The first point of contact for patients with eczema and psoriasis symptoms is their GPs; approximately 75% of all NHS consultations for skin problems take place in GP surgeries. 13 Here an initial diagnosis based on symptoms takes place. Early diagnosis and appropriate treatment of skin conditions such as eczema and psoriasis is critical to reducing the likelihood of an individual going on to develop associated conditions as well as other complications and comorbidities. 24 Given the significant socio-economic and psychological impact of severe disease on affected individuals, early diagnosis is key to enabling access to support services that can help patients to effectively manage their condition, as is reliable and consistent information and a clear care plan. Whilst inflammatory skin conditions are predominantly managed in primary care, for patients with severe psoriasis or eczema referral to secondary care may be required to provide optimum care and monitoring. For patients that need specialist support, NHS England’s objective is to ensure 90% of patients and referrers have a correct diagnosis within three months of referral. 11 NHS England’s referral optimisation guidance advocates the use of pre-referral specialist advice, such as advice and guidance through the NHS e-Referral service, followed by specialist triage, as the primary referral pathway for access to specialist dermatology services. 5 This is designed to improve the interface between primary, intermediate and secondary care for people with skin conditions, facilitating a clinical dialogue prior to a referral being considered. Where it is advised that a referral is required, the specialist can then direct the advice request to the most appropriate clinician, clinic and/or diagnostic pathway.
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FROM NATIONAL GUIDANCE TO LOCAL ACTION
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