How can a hierarchy system be applied to clinical practice guidelines for different dermatological diseases and procedures?

Applying a Hierarchy System to Dermatology Clinical Practice Guidelines

Prioritize guidelines using the AGREE II instrument as your primary quality assessment tool, focusing on the six core domains to systematically rank guidelines from highest to lowest quality for clinical application. 1

Framework for Hierarchical Classification

Tier 1: Highest Quality Guidelines

Use guidelines that meet all of the following criteria:

• Score ≥90% across all six AGREE II domains (scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, and editorial independence) 2
• Raise zero "red flags" for potential bias using Lenzer's criteria 2
• Meet Institute of Medicine (IOM) trustworthiness standards, including external review and clear updating procedures 2
• Published by major dermatology societies in high-impact journals (British Journal of Dermatology, Journal of the American Academy of Dermatology, Journal of the European Academy of Dermatology and Venereology) 1

Example: The EuroGuiDerm guideline on systemic treatment of psoriasis vulgaris is the only guideline meeting all these criteria simultaneously 2

Tier 2: Good Quality Guidelines

Apply guidelines that demonstrate:

• High scores (>90%) in scope/purpose and clarity/presentation domains but have deficiencies in other AGREE II domains 3
• Use of GRADE methodology for evidence evaluation (implemented in British Association of Dermatologists guidelines from 2016 onwards) 4
• Multidisciplinary development teams including relevant specialists beyond dermatology 1
• International collaboration rather than single-country development 1
• Open access availability without paywalls 1

Tier 3: Acceptable Guidelines with Limitations

Use cautiously when higher-tier guidelines are unavailable:

• Guidelines with item scores ≤2/4 in critical areas such as stakeholder involvement, updating procedures, or organizational barriers 3
• Consensus statements rather than formal guidelines 1
• Guidelines lacking funding disclosure statements 1
• Industry-funded guidelines (approximately 7-8% of dermatology CPGs) even if editorial independence is claimed 1

Tier 4: Avoid or Use Only as Last Resort

Do not rely on guidelines that:

• Are behind paywalls (15% of dermatology CPGs), limiting accessibility 1
• Lack conflict of interest management, particularly for systemic treatment recommendations 1
• Have no defined updating schedule (should be updated every 3-5 years per NICE and German standards) 1
• Are published only in non-indexed sources (28.3% of dermatology CPGs) 1

Disease-Specific Prioritization Strategy

High-Burden Conditions (Priority Application)

Focus guideline implementation on conditions with highest disability-adjusted life-years (DALYs):

• Atopic dermatitis (30 CPGs available, proportionate to disease burden) 1
• Psoriasis (29 CPGs available) 1
• Acne (under-represented relative to disease burden despite being the #1 dermatology consultation reason worldwide) 1, 5

Over-Represented Conditions (Use Selectively)

Exercise caution with guideline proliferation:

• Melanoma (41 CPGs, disproportionately high relative to DALY burden, driven by high-income countries) 1
• Keratinocyte carcinomas (23 CPGs, similarly over-represented) 1

Under-Represented Conditions (Seek Alternative Evidence)

Recognize guideline gaps requiring supplementation with primary literature:

• Cellulitis (7 CPGs only) 1
• Scabies (5 CPGs) 1
• Alopecia areata (3 CPGs) 1
• Tinea capitis (1 CPG) 1

Practical Implementation Algorithm

Step 1: Identify Available Guidelines

Search the GUIDEMAP repository at https://sites.manchester.ac.uk/guidemap/ for comprehensive dermatology CPG listings 1

Step 2: Apply Quality Filters

Systematically assess each guideline:

1. Check AGREE II domain scores - prioritize those with ≥90% in rigour of development 2
2. Verify funding sources - flag pharmaceutical industry funding 1
3. Assess conflict of interest management - ensure voting restrictions for conflicted members on treatment recommendations 1
4. Confirm update status - guidelines >5 years old require critical evaluation 1

Step 3: Geographic and Resource Considerations

Adapt guidelines to local context:

• 72.1% of dermatology CPGs originate from high-SDI countries, potentially limiting applicability to resource-limited settings 1
• Seek regional guidelines when available (Europe 51.8%, North America 21.2%, Asia 15.5%) 1
• Consider multidisciplinary CPGs (53.1% of dermatology guidelines) for complex conditions requiring specialist input 1

Step 4: Treatment Scope Matching

Select guidelines appropriate to clinical need:

• Treatment/management only (42.9% of CPGs) 1
• Diagnostic/treatment combined (30.5% of CPGs) 1
• Comprehensive diagnostic/treatment/prevention (20.4% of CPGs) 1

Critical Pitfalls to Avoid

Transparency Issues

Most atopic dermatitis guidelines are "not as clear, unbiased, trustworthy and evidence based (CUTE) as they should be" despite 40 CPGs being available 1

Conflict of Interest Blind Spots

With multiple new systemic treatments approved (dupilumab, baricitinib, upadacitinib, abrocitinib, tralokinumab), rigorous COI management is essential - the guideline chair must have zero conflicts, and conflicted members cannot vote on systemic treatment recommendations 1

Evidence-Disease Burden Mismatch

Weak correlation (R² = 0.1676) exists between CPG production and actual disease burden, meaning guideline availability does not reflect clinical need 1

Access Barriers

15% of CPGs remain behind paywalls, creating inequalities between developed and developing countries 1