the guidelines for safety monitoring should be followed. Patients – particularly if on newly registered drugs – should have long-term follow-up through enrolment in pharmacovigilance registries. A number of clinical guidelines for the treatment of psoriasis have been developed, including the European psoriasis guidelines and NICE guidelines (150–152). Treating the whole person: beyond the skin manifestations Treating the skin symptoms is not sufficient to control this complex disease, which has unpredictable and varied manifestations and associated diseases. As outlined in Chapter 3, many people with psoriasis experience psoriatic arthritis thus patients with psoriasis should be screened for the presence of early joint symptoms and if diagnosed with psoriatic arthritis should start appropriate treatment to prevent disease progression and joint destruction. As psoriatic arthritis can develop over time, such screening must be repeated at regular intervals. Several tools have been developed to help detect early signs of psoriatic arthritis (153). Understanding triggers Several triggering factors have been identified leading to the first manifestation of psoriasis or flares of a stable chronic disease. Understanding and minimizing these triggers can be an important part of managing psoriasis. In a number of studies from different countries, obesity/weight gain has been identified as a significant trigger for psoriasis (114). Studies have shown that obese psoriasis patients undergoing bariatric surgery with subsequent significant weight loss show improvement of skin lesions (154–156). Obesity is also associated with reduced efficacy of psoriasis treatment (157,158) and is an independent risk factor for cardiovascular disease. Thus, weight loss intervention programmes should be part of psoriasis management. Tobacco smoking is another important risk factor for psoriasis (114). Counselling for smoking cessation should be included in caregiving. Certain infections can also serve as triggers for psoriasis. Streptococcal throat infection is one important aggravating or initiating factor (159). Periodontitis has also been associated with an increased risk for psoriasis (160). Tonsillectomy in adult patients with recurrent tonsillitis can improve the course of psoriasis and reduce the need for therapy (159). Stress represents a strong aggravating factor for psoriasis in both adults and children, regardless of the nature of the stressor (161). Barriers to quality care Patients suffering from psoriasis face many barriers when dealing with health professionals and health systems. Patients with skin diseases often encounter these barriers, which include a low level of knowledge about skin diseases among non-dermatology trained health professionals, high costs of treatment and limited access to health care. Many low- and middle-income countries have no skin specialists and referral is difficult due to geographic distance and availability of travel funds. There are also barriers specific to Female, Scotland: “I was diagnosed with scalp psoriasis at age 13, having to use sticky messy ointments almost every night was bad enough, as a young teenager. ... I was diagnosed with psoriatic arthritis at age 26. ... I was given antiinflammatories, but had continuing flares in my hands, feet, knees, ankles, wrists over many years, swelling and much pain. The attitude then, was ‘it won’t be serious’ – it was and is. ... I now have deformed feet and ankles, and cannot walk far. I have had to have extensive foot surgery.” Source: Psoriasis Scotland Arthritis Link Volunteers. Global report on psoriasis 24 patients with psoriasis, such as the persistent belief about the alleged contagiousness of the condition, which results from a lack of public awareness and misunderstanding. Adherence to psoriasis treatment is a challenge, and a lack of adherence by many psoriasis patients can be a reason for suboptimal management (162,163). Inadequate access to health care According to the WHO World health statistics 2015, access to health care is still limited in many countries (164). The density of physicians per 10 000 population is ≤1 in 21 Member States, and ≤10 in 65 Member States. It should be noted that the data on the density of