Systemic sequential therapy of psoriasis: a new paradigm for improved therapeutic results

Association between cardio-cerebrovascular disease and systemic antipsoriatic therapy in psoriasis patients using population-based data: A nested case-control study

The effect of antipsoriatic therapy on cardio-cerebrovascular disease (CCVD) is not well described. Thus, we performed a population-based nested case-control study to investigate the effect of systemic antipsoriatic therapy on CCVD in psoriasis patients. Using nationwide cohort data from the Korean National Health Insurance Claims database, newly diagnosed psoriasis patients were identified. Among the enrolled participants, postenrollment development of CCVD events (ischemic heart disease, myocardial infarction, cerebral infarction, and cerebral hemorrhage) was investigated. To evaluate the effect of systemic antipsoriatic therapy on CCVD risk, we calculated the proportion of the treatment period with systemic antipsoriatic therapy during the study period (PTP [%]: the sum of all systemic antipsoriatic therapy durations divided by total observation period). Among 251 813 participants, 6262 experienced CCVD events during the study period (CCVD group). Controls included 245 551 patients without CCVD history during the study period (non-CCVD group). The non-CCVD group had greater PTP than the CCVD group (CCVD 2.12 ± 7.92, non-CCVD 2.64 ± 9.64; P < 0.001). In multiple logistic regression analysis, PTP was inversely associated with the CCVD risk after adjusting for age, sex, diabetes, hypertension, and dyslipidemia. A 10% increase in PTP reduced CCVD risk by 0.96 (95% confidence interval 0.93 to 0.99). Reduced CCVD risk was robust for both conventional antipsoriatic therapy and biologics. Our study found that systemic antipsoriatic therapy use was inversely associated with CCVD risk in psoriasis patients. These findings suggested that systemic antipsoriatic therapy could reduce CCVD development in patients with psoriasis.

Evidence for a causal relationship between psoriasis and cutaneous melanoma: a bidirectional two-sample Mendelian randomized study

Background and objective

Existing cross-sectional and retrospective studies were unable to establish a causal relationship between psoriasis and cutaneous melanoma (CM). We sought to evaluate the causal role between psoriasis and CM.

Methods

We performed a bidirectional two-sample Mendelian randomization analysis using summary statistics from genome-wide association studies of psoriasis and CM among individuals of predominantly European ancestry. Mendelian randomization-Egger regression, inverse variance weighting, Mendelian Randomization Pleiotropy RESidual Sum and Outlier, weighted mode, and weighted median were used to examine the causal effect between psoriasis and CM.

Results

Genetically predicted psoriasis was a significant risk factor for CM (odds ratio, 1.69; 95% confidence interval, 1.15-2.48; P = 0.025). In contrast, no association was observed between genetically predicted CM and psoriasis.

Conclusion

Our findings corroborated the existence of genetically predicted psoriasis increases risk of CM. Enhanced early screening of cutaneous melanoma in patients with psoriasis may improve clinical burden. However, we did not find evidence for a causal link from CM to psoriasis, so further studies are required to elucidate the effect of CM activity on psoriasis.

Systemic monotherapy with acitretin for erythrodermic psoriasis: results of a retrospective study of 81 patients

Background

Erythrodermic psoriasis (EP) remains challenging to manage because it is rare and has complex complications. Although acitretin is recommended as an appropriate choice for EP, there is a lack of large-scale evidence.

Objectives

This study aims to assess the efficacy and safety of acitretin as systemic monotherapy in EP patients.

Design

We retrospectively analyzed data from patients with EP who received at least 3 months of acitretin as systemic monotherapy during hospitalization and out-patient follow-up from January 2005 to May 2021 at the Peking Union Medical College Hospital, China.

Methods

The efficacy was clinically evaluated after 1, 2, 4, and 12 weeks of treatment, which was classified as a good response (>75% of lesions cleared), partial response (50%-75% cleared), moderate response (25-50% cleared), or no response (<25% cleared). Safety was assessed on the basis of physical examination results and significant changes in laboratory examination results after 12 weeks of treatment.

Results

Overall, 81 patients (79.0% men; mean age, 47.9 years) were included. The acitretin dose ranged from 20 to 60 mg/day (0.3 to 0.8 mg/kg/day). The rates of good, partial, and moderate responses were 0.0%, 2.5%, and 42.0% at 1 week; 3.7%, 34.6%, and 61.7% at 2 weeks; 29.6%, 58.0%, and 12.4% at 4 weeks; and 85.2%, 13.6%, and 1.2% at 12 weeks after treatment initiation, respectively. EP patients transformed from psoriasis vulgaris showed a higher good/partial response rate compared with that of EP patients that developed from pustular or articular psoriasis (44.6% vs. 14.3%, p = 0.035). Patients with concurrent infection showed a lower rate of good/partial response compared with that of those without concurrent infection (16.7% vs. 44.4%, p = 0.049). Adverse effects were seen in 45 (55.6%) patients in 12 weeks, and dyslipidemia (n = 31; 38.3%), xerosis (n = 24; 29.6%), and elevated liver enzymes (n = 6; 7.4%) were most commonly reported. Twenty-three patients were followed up for over 3 years, and six (26.1%) patients had EP recurrence.

Conclusions

Acitretin as a systemic monotherapy showed satisfactory effectiveness for EP, especially in patients developed from psoriasis vulgaris and without infection.

Repurposing approved therapeutics for new indication: Addressing unmet needs in psoriasis treatment

Psoriasis is a chronic inflammatory autoimmune condition manifested by the hyperproliferation of keratinocytes with buildup of inflammatory red patches and scales on skin surfaces. The available treatment options for the management of psoriasis have various drawbacks, and the clinical need for effective therapeutics for this disease remain unmet; therefore, the approaches of drug repurposing or drug repositioning could potentially be used for treating indications of psoriasis. The undiscovered potential of drug repurposing or repositioning compensates for the limitations and hurdles in drug discovery and drug development processes. Drugs initially approved for other indications, including anticancer, antidiabetic, antihypertensive, and anti-arthritic activities, are being investigated for their potential in psoriasis management as a new therapeutic indication by using repurposing strategies. This article envisages the potential of various therapeutics for the management of psoriasis.

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Psoriasis is an autoimmune inflammatory skin disorder with complex physiology.

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Conventional treatments for psoriasis cause severe adverse effects; therefore an unmet need remains for safer and more effective therapies for psoriasis.

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Various drugs that effectively decrease the inflammation and proliferation of skin cells can be repurposed for the management of psoriasis.

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Repurposed drugs provide various incentives to the pharmaceutical industry.

Long-term Safety of Oral Systemic Therapies for Psoriasis: A Comprehensive Review of the Literature

Oral systemic therapies are important treatment options for patients with moderate-to-severe psoriasis, either as monotherapy or in therapy-recalcitrant cases as combination therapy with phototherapy, other oral systemics or biologics. Long-term treatment is needed to maintain sufficient disease control in psoriasis, but continuous use of systemic treatments is limited by adverse events (AEs) and cumulative toxicity risks. The primary aim of this comprehensive literature review was to examine the long-term safety profiles of oral agents commonly used in the treatment of adults with psoriasis. Searches were conducted in EMBASE and PubMed up to November 2018, and 157 relevant publications were included. Long-term treatment with acitretin could be associated with skeletal toxicity and hepatotoxicity, although evidence for skeletal toxicity is mixed and hepatotoxicity is rare, particularly at low doses. Other safety issues include hyperlipidaemia and potential for teratogenicity up to 2-3 years after discontinuation of treatment. There is a paucity of data on long-term treatment with apremilast. Continued exposure to apremilast does not seem to increase the incidence of common AEs, such as gastrointestinal (GI) AEs, upper respiratory tract infections and headache, while the long-term risks for depression, suicidal thoughts and weight loss are unknown. Long-term ciclosporin treatment is associated with renal toxicity, hypertension, non-melanoma skin cancer, neurological AEs and GI AEs. Long-term methotrexate treatment is associated with hepatotoxicity, GI AEs, haematological toxicity, renal toxicity and alopecia. Finally, long-term treatment with fumaric acid esters (FAE) is associated with GI AEs, flushing, lymphocytopenia, proteinuria and elevated liver enzymes. Median drug survival estimates varied considerably: ~  2.9-9.7 months for apremilast; ~ 5.4 months for ciclosporin; ~ 8.6 months for acitretin; ~ 12.1-21.6 months for methotrexate; and ~  54.8 months for FAE. These long-term safety profiles may help to guide clinicians to select the optimal oral systemic treatment for the long-term treatment of psoriasis in adults.

Pharmacological Management of Pediatric Pustular Psoriasis

Therapeutic management of pustular psoriasis remains a challenge despite the rapid advance in psoriasis research and the development of drugs, especially biologics. Treatment guidelines have been established for pustular psoriasis, but no controlled studies are present for juvenile pustular psoriasis (JPP). Search of the literature reveals that current evidence of JPP treatment is limited to case reports and case series. Among the conventional drugs for JPP, oral retinoid is the most commonly used, yet concerns for growth disturbance exist. Cyclosporine and methotrexate have also been administered as first-line treatment. Etanercept is the first biological agent approved for juvenile plaque psoriasis, followed by adalimumab. However, infliximab is usually recommended for JPP because of the rapidity of onset, despite not being approved for use in pediatric psoriasis patients. More recently, secukinumab, ixekizumab, brodalumab, guselkumab, and risankizumab have been approved for adult pustular psoriasis in selected countries. Controlled studies are needed to prove the efficacy and long-term safety of the therapeutic treatments currently used for JPP.

Safety considerations with combination therapies for psoriasis

Introduction: Psoriasis is a chronic inflammatory skin disease that waxes and wanes, and long-term remission can be difficult to achieve regardless of disease severity. Currently, numerous treatment options are available for psoriasis including steroid and non-steroid topical agents, phototherapy, oral systemic agents, and biologics, with many more therapeutic agents under development.Areas covered: This article will review various combination therapy strategies such as rotational therapy and sequential therapy and describe a variety of safe and effective combination therapies for the treatment of psoriasis. Two or more agents with different mechanisms of action and safety profiles can be used to achieve and/or maintain adequate disease control while minimizing the toxicity of treatments. Combination therapy can also be used when a single agent is not enough for treating recalcitrant disease. Choosing a combination regimen that maximizes safety and efficacy while considering patient usability and compliance can be a challenge.Expert opinion: Given the various treatment options currently available for psoriasis and more agents under development, combination therapy will continue to be a valuable treatment strategy for any patient with psoriasis. It is crucial for clinicians to carefully consider the fine balance between safety and efficacy when combining various therapeutic agents.

The Frequent Use of Oral Retinoids in Combination with other Treatments for Psoriasis: A Retrospective Analysis

Background:

Combination treatment in psoriasis may be common, logical, and appropriate, even if not well tested or well documented by clinical trials. While oral retinoids such as acitretin can be used as monotherapy, efficacy can be further augmented by combination use with other agents. Similarly, because of its safety profile, acitretin can be added in low doses to help patients who have not achieved adequate control with other psoriasis treatments.

Objective:

The purpose of this study was to assess how oral retinoids are used in combination with other drugs to treat psoriasis.

Methods:

We assessed the use of acitretin and other oral retinoids for the treatment of psoriasis using two sources of information: nationally representative survey data from the National Ambulatory Medical Care Survey (NAMCS) and local data obtained by chart review of 518 patients seen in a university dermatology clinic.

Results:

In the NAMCS, oral retinoids were prescribed with other psoriasis medications at 71% of visits. In the chart review, combination use was even more frequent (96% of subjects were on combination treatment) and included combinations of acitretin with topicals, phototherapy, and other systemic treatments. Adverse events were reported in 53% of patients treated with acitretin, although none were severe.

Conclusion:

Use of acitretin in combination with many other psoriasis treatments is a common practice. Mucocutaneous side effects of oral retinoids are common but with appropriate dosing are generally mild.

Integrating Biologic Agents into Management of Moderate-to-Severe Psoriasis: A Consensus of the Canadian Psoriasis Expert Panel

Background:

Approximately 2% of people worldwide have psoriasis, with as many as 1 million people with psoriasis in Canada alone.1,2 The severity of psoriasis ranges from mild to severe. It can lead to substantial morbidity and psychological stress and have a profound negative impact on patient quality of life.3,4 Although available therapies reduce therapies reduce the extent and severity of the disease and improve quality of life,3 reports have indicated a patient preference for more aggressive therapy and a dissatisfaction with the effectiveness of current treatment options.5

Objective:

A Canadian Expert Panel, comprising Canadian dermatologists, convened in Toronto on 27 February 2004 to reach a consensus on unmet needs of patients treated with current therapies and how to include the pending biologic agents in and improve the current treatment algorithm for moderate-to-severe psoriasis. Current treatment recommendations suggest a stepwise strategy starting with topical agents followed by phototherapy and then systemic agents.3,6,7 The Panel evaluated the appropriate positioning of the biologic agents, once approved by Health Canada, for the treatment of moderate-to-severe psoriasis.

Methods:

The Panel reviewed available evidence and quality of these data on current therapies and from randomized, controlled clinical trials.8–14 Subsequently, consensus was achieved by small-group workshops followed by plenary discussion.

Results:

The Panel determined that biologic agents are an important addition to therapies currently available for moderate-to-severe psoriasis and proposed an alternative treatment algorithm to the current step wise paradigm.

Conclusion:

The Panel recommended a new treatment algorithm for moderate-to-severe psoriasis whereby all appropriate treatment options, including biologic agents, are considered together and patients' specific characteristics and needs are taken into account when selecting the most appropriate treatment option.

Erythrodermic psoriasis: pathophysiology and current treatment perspectives

Erythrodermic psoriasis (EP) is a rare and severe variant of psoriasis vulgaris, with an estimated prevalence of 1%-2.25% among psoriatic patients. The condition presents with distinct histopathologic and clinical findings, which include a generalized inflammatory erythema involving at least 75% of the body surface area. The pathogenesis of EP is not well understood; however, several studies suggest that the disease is associated with a predominantly T helper 2 (Th2) phenotype. Given the morbidity and potential mortality associated with the condition, there is a need for a better understanding of its pathophysiology. The management of EP begins with a comprehensive assessment of the patient's presentation and often requires multidisciplinary supportive measures. In 2010, the medical board of the US National Psoriasis Foundation published consensus guidelines advocating the use of cyclosporine or infliximab as first-line therapy in unstable cases, with acitretin and methotrexate reserved for more stable cases. Since the time of that publication, additional information regarding the efficacy of newer agents has emerged. We review the latest data with regard to the treatment of EP, which includes biologic therapies such as ustekinumab and ixekizumab.

Systemic Treatment of Pediatric Psoriasis: A Review

Psoriasis is a chronic, immune-mediated, inflammatory skin disease, affecting 1-3% of the white population. Although the existence of two psoriasis incidence peaks has been suggested (one in adolescence before 20 years of age and another in adulthood), its onset may occur at any age, including childhood and adolescence, in which the incidence is now estimated at 40.8 per 100,000. As for adult psoriasis, pediatric psoriasis has recently been associated with obesity, metabolic syndrome, increased waist circumference percentiles and metabolic laboratory abnormalities, warranting early monitoring and lifestyle modifications. In addition, due to psoriasis' chronic nature and frequently occurring relapses, psoriatic patients tend to have an impaired quality of life, often requiring long-term treatment. Therefore, education of both pediatric patients and their parents is essential to successful and safe disease management. Given the lack of officially approved therapies, the very limited evidence-based data from randomized controlled trials, and the absence of standardized guidelines, to date, pediatric psoriasis treatment is primarily based on published case reports, case series, guidelines for adult psoriasis, expert opinions and experience with these drugs in other pediatric disorders coming from the disciplines of rheumatology, gastroenterology and oncology. This review focuses on the use of systemic treatments in pediatric psoriasis and their specific features, analyzing the few literature evidences available, expanding the treatment repertoire and guiding dermatologists in better managing of recalcitrant pediatric psoriasis.

Systemic Agents for Severe Atopic Dermatitis in Children

Atopic dermatitis (AD), or eczema, is a chronic inflammatory skin condition characterized by relapsing pruritic, scaly, erythematous papules and plaques frequently associated with superinfection. The lifelong prevalence of AD is over 20 % in affluent countries. When a child with severe AD is not responding to optimized topical therapy including phototherapy, and relevant triggers cannot be identified or avoided, systemic therapy should be considered. If studies show early aggressive intervention can prevent one from advancing along the atopic march, and relevant triggers such as food allergies cannot be either identified or avoided, systemic therapy may also play a prophylactic role. Though the majority of evidence exists in adult populations, four systemic non-specific immunosuppressive or immunomodulatory drugs have demonstrated efficacy in AD and are used in most patients requiring this level of intervention regardless of age: cyclosporine, mycophenolate mofetil, methotrexate, and azathioprine. This article reviews the use of these medications as well as several promising targeted therapies currently in development including dupilumab and apremilast. We briefly cover several other systemic interventions that have been studied in children with atopic dermatitis.

Acitretin in psoriasis: an evolving scenario

Acitretin, an active metabolite of etretinate, is the most widely used systemic retinoid in the treatment of psoriasis. There are several unique characteristics of this drug, which set it apart from other options in the therapeutic armamentarium of psoriasis. It is highly efficacious as monotherapy in some specific clinical subtypes of psoriasis. It has dose-sparing effects when used as combination therapy with conventional systemic drugs as well as the biologics. It is a good option for long-term maintenance therapy. Side effects are common but usually mild and can be managed by its proper dosing and monitoring. With appropriate patient selection, gradual dose escalation, and patient counseling, we can deliver good results in psoriasis with this useful drug. This review gives a comprehensive recount of acitretin use in the present era of biologics in psoriasis.

Cyclosporine regimens in plaque psoriasis: an overview with special emphasis on dose, duration, and old and new treatment approaches

Cyclosporine A (CsA) is one of the most effective systemic drugs available for the treatment of psoriasis, as evidenced by the results of several randomized studies and by a prolonged experience in dermatological setting. In clinical practice, CsA is usually used for the induction of psoriasis remission at a daily dose included in the range of 2.5–5 mg/kg and with intermittent short-term regimens, lasting on average 3–6 months. The magnitude and rapidity of response are dose dependent, as well as the risk of development of adverse events. Therefore, the dose should be tailored to patient's needs and general characteristics and adjusted during the treatment course according to both the efficacy and tolerability. Some studies support the feasibility of pulse administration of CsA for a few days per week for both the induction and the maintenance of response in psoriasis patients. This paper will review the data on CsA regimens for plaque-type psoriasis and will focus the attention on dose, treatment duration, novel schedules, and role in combination therapies, including the association with biologicals.

Guidelines for the use of acitretin in psoriasis. Psoriasis Group of the Spanish Academy of Dermatology and Venereology

Phototherapy, classic systemic treatments (methotrexate, acitretin, and ciclosporin), and biologic agents (etanercept, infliximab, adalimumab, and ustekinumab) constitute a broad therapeutic arsenal that increases the likelihood of achieving control of severe and extensive disease in patients with psoriasis. Acitretin continues to be a very valuable tool in both monotherapy, in which it is combined with other systemic treatments (classic or biologic), and in sequential therapy. Thanks to its lack of a direct immunosuppressive effect and its ability to achieve a long-term response, acitretin has an important role in the treatment of psoriasis, although this has not always been acknowledged in relevant treatment guidelines. We present consensus guidelines for the use of acitretin in psoriasis drawn up by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology. These guidelines provide a detailed account of acitretin, including pharmacological properties, indications and contraindications, adverse effects, and factors that should be taken into account to enhance the safe use of this drug. They also propose treatment strategies for use in routine clinical practice. The overall aim of these guidelines is to define the criteria for the use and management of acetretin in psoriasis.

Developing a diagnostic checklist of traditional Chinese medicine symptoms and signs for psoriasis: a Delphi study

BACKGROUND

Psoriasis is a chronic inflammatory skin disease with a genetic basis. Its ill-defined causes make it difficult to diagnose. This study aims to develop a diagnostic checklist for psoriasis classification in the context of traditional Chinese medicine.

METHODS

A Delphi study was conducted with three rounds by a panel of 16 dermatology experts to develop a checklist for traditional Chinese medicine symptoms and signs of psoriasis. Dermatology experts in psoriasis research, nine in Yunnan and seven in Beijing, were selected as the expert panel. The initial list of symptoms and signs in psoriasis was developed by reviewing the literature retrieved from Chinese and English journals. Experts rated each item of the list on a 5-point Likert scale. The list was revised and re-evaluated in the same manner for a total of 3 rounds before it was finalized.

RESULTS

One hundred and thirty items were extracted from the literature review. After three rounds of expert ratings, 96 items were retained with eight domains: color, type and shape of skin lesion, physical expression, tongue and coating, pulse, associated factors, and living environment. Intraclass correlation coefficient and Kappa statistics indicated an inter-rater agreement in the final checklist.

CONCLUSION

A checklist containing 96 items in 8 domains was developed for psoriasis diagnosis using traditional Chinese medicine symptoms and signs.

1,4-dihydroxy-2-naphthoic Acid Induces Apoptosis in Human Keratinocyte: Potential Application for Psoriasis Treatment

Psoriasis, which affects approximately 1–3% of the population worldwide, is a chronic inflammatory skin disorder characterized by epidermal keratinocytes hyperproliferation, abnormal differentiation, and inflammatory infiltration. Decrease in keratinocyte apoptosis is a specific pathogenic phenomenon in psoriasis. Chinese herbs have been used for the treatment of psoriasis in China showing promising effect in clinical trials. A traditional Chinese medicine has relatively fewer side effects with longer remission time and lower recurrence rate. The extract of Rubia cordifolia L. (EA) was previously found by us to induce HaCaT keratinocytes apoptosis. In this study we identified one of the components in Rubia cordifolia L., the anthraquinone precursor 1,4-dihydroxy-2-naphthoic acid (DHNA), induces HaCaT keratinocytes apoptosis through G0/G1 cell cycle arrest. We have also demonstrated that DHNA acts through both caspase-dependent and caspase-independent pathways. Besides, cytotoxicity and IL-1α release assays indicate that DHNA causes less irritation problems than dithranol, which is commonly employed to treat psoriasis in many countries. Since DHNA possesses similar apoptotic effects on keratinocytes as dithranol but causes less irritation, DHNA therefore constitutes a promising alternative agent for treating psoriasis. Our studies also provide an insight on the potential of using EA and DHNA, alternatively, as a safe and effective treatment modality for psoriasis.

Oral vitamin D, still a viable treatment option for psoriasis

Vitamin D as a topical treatment has become one of the mainstays for treatment of psoriasis vulgaris. Oral vitamin D on the other hand has for the most part become a forgotten option. But a review of the literature on oral vitamin D as a treatment for psoriasis reveals that this treatment is efficacious. The main side effect of this therapy is hypercalcemia, which appears to be easily monitored and avoidable with proper dosing and monitoring. The literature also suggests a correlation between low levels of serum vitamin D in this patient population associated with increased severity of disease involvement. In addition, oral vitamin D improves psoriatic arthropathy. Moreover, vitamin D has been proven to have many health benefits such as prevention of cancer, improved cardiovascular health among many others. Psoriatic patients as a population are at increased risk of developing adverse health complications such as cardiovascular disease, and oral vitamin D may prove to be of benefit in this population. Oral vitamin D is inexpensive and easily available. It is still a viable option and should not be forgotten as a possible treatment for psoriasis.

A pharmacoeconomic analysis of severe psoriasis therapy: a review of treatment choices and cost efficiency

INTRODUCTION

Psoriasis is a chronic, inflammatory disease afflicting 2% of the US population; it results in significant morbidity. The annual healthcare costs related to psoriasis are an estimated $11.3 billion and, with an expanding biologic market, an updated costs analysis is needed.

AREAS COVERED

Current treatments, including systemic agents (acitretin, cyclosporine, methotrexate), phototherapies and all available biologics (adalimumab, etanercept, infliximab, alefacept, ustekinumab) appropriate for severe psoriasis are described mechanistically and with regard to their efficacy, quality-of-life improvements and side effects. A cost-efficacy model considering US health-system-based annual costs, clinical and quality-of-life improvements was created. Reported Psoriasis Area and Severity Index improvement of 75% from baseline (PASI-75) scores, Dermatology Life Quality Index (DLQI) improvements and estimated costs of medications are described. Annual costs ranged from $1330 for methotrexate to $48,731 for high-dose etanercept. The lowest cost per achieving DLQI minimally important difference was from phototherapy; the highest was from alefacept. The lowest costs per patient achieving PASI-75 was from methotrexate and the highest was from alefacept.

EXPERT OPINION

Phototherapies and methotrexate offer high efficacy for their costs. Therapeutic approaches must be individualized for each patient given all considerations described.

Cost effectiveness of the two-compound formulation calcipotriol and betamethasone dipropionate gel in the treatment of scalp psoriasis in Scotland

OBJECTIVES

To compare the cost effectiveness of the two-compound formulation (TCF) calcipotriol plus betamethasone dipropionate gel used first-, second- or third-line to standard topical treatments for moderately severe scalp psoriasis from a Scottish NHS perspective.

RESEARCH DESIGN AND METHODS

Treatment pathways for scalp psoriasis patients in primary care were defined by Scottish prescribing statistics, an interview programme and published sources. The extensive 1-year Markov model included 12 different topical treatment pathways, each simulating three lines of therapy. Seven pathways contained the TCF gel in first-, second- or third-line. The remaining five pathways were included as comparators, reflecting the heterogeneity across clinical practice. The cost effectiveness of TCF gel was compared to the average of five non-TCF gel pathways. The clinical effectiveness measure was the ability of topical treatments to control disease at 4 weeks. Response rates were derived from indirect comparisons of ten randomised controlled trials. Utilities were elicited from SF-36 (v2) scores in one TCF gel trial. The main outcome was the incremental cost per quality-adjusted life-year (QALY). Extensive sensitivity analyses were performed to assess the robustness of the results.

RESULTS

TCF gel used first-, second- or third-line was projected to increase QALYs (around 0.0025) with cost savings per patient (£20-30) over 1 year. The study analysis acknowledged a number of limitations including lack of quality comparator data, the need to make assumptions in the absence of evidence and lack of model validation. However the results showed that TCF gel was the dominant treatment strategy across a broad range of credible scenarios.

CONCLUSIONS

Scalp psoriasis is difficult to treat. Many different topical preparations can be used but several factors such as greasiness, irritation, time needed to apply, and lack of efficacy often result in reduced adherence to treatment regimens. Where cosmetic properties are important for patient acceptability and compliance is a major issue contributing to treatment failure, the once-daily TCF gel offers patients with scalp psoriasis an attractive, cost-saving treatment option.

A review of acitretin for the treatment of psoriasis

BACKGROUND

Acitretin is an oral retinoid that is approved for the treatment of psoriasis. It is unique compared to other systemic therapies for psoriasis such as methotrexate and cyclosporine in that it is not immunosuppressive. It is, therefore, safe for use in psoriasis patients with a history of chronic infection such as HIV, hepatitis B, hepatitis C or malignancy who have a contraindication to systemic immunosuppressive therapy and require systemic therapy because topical therapy is inadequate and they are unable to commit to phototherapy. Acitretin is one of the treatments of choice for pustular psoriasis. Even though acitretin is less effective as a monotherapy for chronic plaque psoriasis, combination therapy with other agents, especially UVB or psoralen plus UVA phototherapy, can enhance efficacy.

OBJECTIVE

To provide an updated review of the safety and efficacy of acitretin in the treatment for psoriasis.

METHODS

Literature review of journal articles from 2008 to 2009 since the last review of acitretin evaluated medical literature from 2005 to 2008.

RESULTS/CONCLUSION

Acitretin is an effective systemic therapy for psoriasis and is generally well tolerated at low doses for long-term use. If monotherapy with acitretin is inadequate, it can be used in combination with other treatments, particularly UVB phototherapy, to increase efficacy.

Cyclosporine and psoriasis: 2008 National Psoriasis Foundation Consensus Conference

BACKGROUND

Cyclosporine is a valuable option for the treatment of psoriasis. This report summarizes studies regarding the use of cyclosporine since the last guidelines were published in 1998.

OBJECTIVE

A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options. Our aim was to achieve a consensus on new updated guidelines for the use of cyclosporine in the treatment of psoriasis.

METHODS

Reports in the literature were reviewed regarding cyclosporine therapy.

LIMITATIONS

There are few evidence-based studies on the treatment of psoriasis with cyclosporine.

RESULTS

A consensus was achieved on the use of cyclosporine in psoriasis including specific recommendations on dosing, monitoring, and use of cyclosporine in special situations. The consensus received approval from members of the National Psoriasis Foundation Medical Board.

CONCLUSIONS

Cyclosporine is a safe and effective drug for the treatment of psoriasis. It has a particularly useful role in managing psoriatic crises, treating psoriasis unresponsive to other modalities, bridging to other therapies, and treating psoriasis within a rotational scheme of other medications. Appropriate patient selection and monitoring will significantly decrease the risks of side effects.

A prospective, randomized clinical trial comparing topical aloe vera with 0.1% triamcinolone acetonide in mild to moderate plaque psoriasis

BACKGROUND

Topical aloe vera (AV) has been used to treat various skin conditions, including psoriasis, with good results.

OBJECTIVES

This study aims to compare the efficacy of AV and 0.1% triamcinolone acetonide (TA) in mild to moderate plaque psoriasis.

METHODS

A randomized, comparative, double-blind, 8-week study was designed. Eighty patients randomly received AV or 0.1% TA cream and their clinical response were evaluated using the Psoriasis Area Severity Index (PASI) and the Dermatology Life Quality Index (DLQI).

RESULTS

After 8 weeks of treatment, the mean PASI score decreased from 11.6 to 3.9 (-7.7) in the AV group and from 10.9 to 4.3 (-6.6) in the TA group. Between-group difference was 1.1 (95% confidence interval -2.13, -0.16, P = 0.0237). The mean DLQI score decreased from 8.6 to 2.5 (-6.1) in the AV group and from 8.1 to 2.3 (-5.8) in the TA group. Between-group difference was 0.3 (95% confidence interval -1.18, -0.64, P = 0.5497). There was no follow-up period after the 8-week treatment.

CONCLUSIONS

AV cream may be more effective than 0.1% TA cream in reducing the clinical symptoms of psoriasis; however, both treatments have similar efficacy in improving the quality of life of patients with mild to moderate psoriasis.

The use of ciclosporin in psoriasis

Ciclosporin is a cyclic undecapeptide discovered in the 1970s to possess a potent inhibitory action on T lymphocytes. The subsequent discovery, in 1979, that it was remarkably effective in treatment of psoriasis transformed thinking about the nature of the disease, which subsequently became generally recognized as autoimmune in nature. Ciclosporin remains one of the most effective and rapidly acting treatments currently available for psoriasis. Virtually all the diverse manifestations of this disease can respond. The main side effects are nephrotoxicity and hypertension. There is considerable variation between individuals in susceptibility to these so careful monitoring is required. Ciclosporin should be used in single or intermittent short courses for all except the most severe cases as this is safer than continuous treatment. The rate of improvement depends very much on the dose, which ranges from 2 to 5.0 mg/kg/day. Ciclosporin can be combined with any topical treatment and a useful dose-sparing effect can be achieved in this way if patients are compliant. In severe cases ciclosporin is often used in combination with other systemic antipsoriatic drugs in order to spare the dose of each agent and reduce toxicity. Concurrent or intercurrent use of ultraviolet therapy is discouraged due to the increased risk of non-melanoma skin cancer. This article reviews the mode of action, pharmacokinetics, indications, contraindications, side effects, dosage regimens, pretreatment screening and monitoring, drug interactions, and use of treatment combinations with ciclosporin in the management of psoriasis.

Case studies in severe psoriasis: A clinical strategy

Individuals with moderate-to-severe psoriasis perceive that the disease exerts profound emotional, social and physical effects on their lives, and a significant percentage report that they do not consider their treatment sufficiently aggressive. A survey of individuals with a variety of chronic diseases reveals that those with psoriasis have the lowest estimation of their health-related quality of life, lower than that of patients with arthritis, congestive heart failure, chronic lung disease or depression. Although psoriasis can be treated effectively, many treatments are associated with long-term risks. Toxicity-sparing treatment strategies that include combination, rotational and sequential regimens can help to control moderate-to-severe psoriasis while reducing risk. Algorithms for the treatment of moderate-to-severe psoriasis detail possible options for specific types of psoriasis and for patients with specific needs. The purpose of the algorithms is to make optimum use of phototherapy, traditional cytotoxic and immunosuppressive agents, retinoids, and newer biologic agents.

Management of childhood psoriasis

Treating children with psoriasis represents one of the most rewarding yet constantly challenging endeavors in dermatology. These patients require time, energy, enthusiasm, empathy, and current, comprehensive knowledge of the unique clinical presentations in children and available therapies, including clinical action spectrum, mechanism of action, potential toxicity, and monitoring. Longitudinal trials examining the epidemiology and natural history of psoriasis, as well as the safety and efficacy of current and emerging treatments, are desperately needed in the pediatric population. Partner with the patient, family, and other multidisciplinary providers to form an educational and therapeutic alliance. Early in the course of disease, schedule frequent visits for reinforcement of the therapeutic plan, education, clinical and treatment monitoring, and support. As the disease and the patient's physical, psychosocial and emotional level of functioning evolve, so too will the requirement for follow-up and monitoring. Patient advocacy and education groups, such as the National Psoriasis Foundation (www.psoriasis.org; 800-723-9166) are excellent resources and can serve as an extension of your comprehensive care.

An updated review of acitretin--a systemic retinoid for the treatment of psoriasis

BACKGROUND

Acitretin is a systemic retinoid used for psoriasis. It normalizes cellular differentiation and maturation and is also used as a chemopreventive agent against cutaneous malignancies. However, it is not used frequently because of its side-effect profile.

OBJECTIVE

Safety and efficacy of acitretin was evaluated as monotherapy, as well as in combination with other systemic agents.

METHODS

Medical literature from 2005 to 2008 was reviewed. The most scientifically rigorous clinical trials were selected for Psoriasis Area and Severity Index. Articles were limited to case reports or clinical trials, human subjects and English language journals.

RESULTS/CONCLUSION

Acitretin is effective as monotherapy for pustular and erythrodermic psoriasis and for plaque psoriasis (with other systemic agents). Side effects of acitretin use occur more commonly with high doses. Hence, acitretin is safe and effective for psoriasis.

Comparative effects of biological therapies on the severity of skin symptoms and health-related quality of life in patients with plaque-type psoriasis: a meta-analysis

BACKGROUND

The comparative effects of biological response modifiers (BRMs) on the severity of psoriasis and its effects on health-related quality of life (HRQoL) have not been evaluated.

OBJECTIVE

To conduct a meta-analysis to assess the effects of available biological agents on the severity of psoriasis, as well as to provide data on the effects of these agents on HRQoL.

METHODS

Medline and other databases were searched for randomized controlled trials (>or= 10 weeks' duration in adults) comparing biological therapies for moderate-to-severe psoriasis with placebo. A Mantel-Haenszel fixed-effects model was employed to estimate the pooled relative risks (RR) of patients achieving >or= 75% reduction of baseline Psoriasis Area and Severity Index (PASI 75) after >or= 10 weeks of treatment. Similar analyses were also conducted on PASI 50 and PASI 90. Using a random-effects model, we estimated the likelihood of achieving PASI 50, PASI 75, and PASI 90 at 10-12 weeks and 24 weeks. Data on the effects of different BRMs (vs. placebo) on HRQoL were also presented. Numbers (%) of patients discontinuing treatment were presented as a general index of drug tolerability.

RESULTS

Patients receiving infliximab 5 mg/kg intravenously at weeks 0, 2, and 6, then every 8 weeks, had the highest RR of achieving PASI 75, with a pooled RR value of 25.48 (95% confidence interval [CI], 14.04-46.23); followed by etanercept 50 mg administered subcutaneously (SC) twice weekly with RR = 11.92 (95% CI, 8.17-17.39); etanercept 25 mg SC twice weekly with RR = 10.68 (95% CI, 6.15-18.57); efalizumab 1-2 mg/kg SC per week with RR = 7.47 (95% CI, 5.20-10.73); and alefacept administered weekly (various doses) with RR = 3.37 (95% CI, 2.18-5.23). (All RR values were estimated vs. placebo.) Similar findings were observed with regard to proportions of patients achieving PASI 50 and PASI 90. The random-effects analysis suggested that infliximab significantly increased the likelihood of achieving PASI 50, PASI 75, and PASI 90 compared with placebo at 10-12 weeks; however, there were no significant differences between biological treatments at 24 weeks. Each BRM improved HRQoL compared with placebo according to findings from the Dermatology Life Quality Index. Proportions of patients discontinuing treatment were similar in active-treatment and placebo groups.

CONCLUSIONS

Infliximab significantly reduced disease severity by both fixed- and random-effects models. All biological therapies improved HRQoL compared with placebo, and proportions of patients discontinuing treatment were similar in active-treatment and placebo groups. The analysis is potentially limited by statistical factors and did not systematically account for different toxicity profiles, but the findings establish a foundation for head-to-head comparative trials.

Efalizumab: results of a 3-year continuous dosing study for the long-term control of psoriasis

Background

Efalizumab, a T-cell-targeted, recombinant, humanized, monoclonal IgG1 antibody, inhibits key T-cell-mediated steps in the pathogenesis of psoriasis. Efalizumab is approved for the treatment of moderate-to-severe chronic plaque psoriasis in adults in more than 50 countries.

Objectives

To evaluate the efficacy and safety of long-term, continuous efalizumab therapy in patients with psoriasis.

Methods

This open-label, multicentre phase III study enrolled 339 patients with moderate-to-severe chronic plaque psoriasis. During the initial 3-month phase, patients received subcutaneous efalizumab 2 mg kg⁻¹ weekly with randomization to receive concomitant fluocinolone acetonide or placebo ointment during month 3. The second phase was a long-term observational period; patients achieving a ≥ 50% improvement in the Psoriasis Area and Severity Index (PASI) score were eligible to receive efalizumab 1 mg kg⁻¹ weekly for up to 33 months. The final 3-month treatment period was an optional transition period for patients who completed the 33-month segment before efalizumab became commercially available.

Results

After 3 months, 41·3% of patients achieved a ≥ 75% improvement in PASI (PASI-75) and 13·0% achieved a ≥ 90% improvement (PASI-90). Continued improvement was observed: 45·4% and 24·5% achieved PASI-75 and PASI-90, respectively, at the end of the observational phase. The safety profile was stable, with no new or no increase in common events over 36 months of treatment.

Conclusions

This was the longest continuous study using a biologic therapy for psoriasis. Clinical benefit of efalizumab improved over the first 18 months and was maintained during 36 months of continuous therapy. Long-term efalizumab therapy is appropriate for many patients with plaque psoriasis.

Conflicts of interest

C.L. with 3M Pharmaceuticals, Abbott, Allergan, Altana, Amgen, Astellas-Biogen, Bristol Myers, Centocor, CombinatoRx, Fujisawa Healthcare, Galderma, Genentech, Merck Serono International SA, Schering Plough, RTL, Vitae and Warner Chilcott; A.M. with 3M Pharmaceuticals, Abbott, Allergan, Allermed, Amgen, Astralis, Berlex, Biogen Idec, Celgene, Centocor, Cephalon, Collagenex Pharmaceuticals, CombinatoRx, Connetics, Corixa, Dermik Laboratories, Doak Dermatologics, Dow, Ferndale Laboratories, Fujisawa Healthcare, Galderma, Genentech, Genzyme, GlaxoSmithKline, Ligand Pharmaceuticals, Medicis, MedImmune, Novartis Pharmaceuticals, Otsuka Pharmaceutical, Protein Design Labs, QLT USA, Regeneration Pharma AG, Roche, Merck Serono International SA, Sinclair, Synta Pharma, Thermosurgery, Vertex, Warner Chilcott, Wyeth, XOMA and Zars; T.H. with Genentech; A.B.G. with Abbott, Actelion, Almirall, Amgen, Beiersdorf, Biogen Idec, Bristol Myers Squibb, Can-Fite, Celera, Celgene, Centocor, DermiPsor, Eisai, Genentech, Immune Control, Incyte, Kemia, Medacorp, Medarex, Novo Nordisk, Pharmacare, Roche, RxClinical, Sankyo, Schering Plough, TEVA, UCB, Warner Chilcott and Wyeth. All income derived from these sources goes to her employer. I.C. and B.X. are employees and stockholders of Genentech.

Psoriasis in the elderly

Psoriasis is one of the most common chronic skin diseases, and unprecedented increases in the elderly population will make diagnosis and management of geriatric psoriasis increasingly important. Management of psoriasis in the elderly requires consideration of several important factors. Many commonly prescribed drugs can precipitate psoriasis or aggravate pre-existing psoriasis. In addition, elderly patients are at increased risk of adverse drug reactions due to polypharmacy, adverse drug–drug interactions, adverse drug–disease interactions, incorrect use of medication and concomitant comorbidities. Psoriasis is a highly variable disease that requires individualized treatment. The major classes of topical medications include topical corticosteroids, coal tar preparations, calcipotriol, tazarotene and salicylic acid. Phototherapy, including narrowband ultraviolet B, photochemotherapy, psoralen ultraviolet A and excimer laser treatment, can be effective in properly selected patients. Systemic therapy for psoriasis in the elderly should be reserved for severe, extensive cases that have failed to respond to topical treatment, and may include methotrexate, systemic retinoids and immunotherapy.

Transitioning patients from efalizumab to alternative psoriasis therapies: findings from an open-label, multicenter, Phase IIIb study

BACKGROUND

Rebound in psoriasis is, by definition, a rapid worsening of disease following the discontinuation of therapy for psoriasis; it occurs following the abrupt discontinuation of many therapies. To prevent rebound on discontinuation of efalizumab, this study evaluated the effectiveness of transitioning patients to an alternative psoriasis therapy.

METHODS

Patients (n = 130) received subcutaneous efalizumab 1 mg/kg/week for 12 weeks. Efalizumab was discontinued at 12 weeks; patients were evaluated for improvement from baseline in the Psoriasis Area and Severity Index (PASI) and a 12-week transition period was begun. Patients who achieved PASI improvement of 75% or more (PASI-75) at week 12 of efalizumab treatment were observed during the transition period and treated only if psoriasis recurred. Patients who did not attain PASI-75 at week 12 of efalizumab treatment were immediately transitioned to an alternative psoriasis therapy at the physician's discretion. All patients were evaluated for signs of rebound following efalizumab discontinuation.

RESULTS

Rebound was not observed in any PASI-75 responder (n = 46). Rebound was observed in two of 32 patients who achieved between PASI-50 and PASI-75, and was more common in nonresponders (14/49). Rebound was observed in none of the eight patients treated with cyclosporine and in two of the 12 patients treated with methotrexate during the transition period.

CONCLUSIONS

These results suggest that efalizumab-responsive patients are less likely to experience rebound than nonresponders and may not require treatment until disease recurrence following efalizumab discontinuation. Efalizumab nonresponders are at higher risk of developing rebound and thus should be considered for transition to an appropriate psoriasis therapy immediately following efalizumab discontinuation.

An attempt to formulate an evidence-based strategy in the management of moderate-to-severe psoriasis: a review of the efficacy and safety of biologics and prebiologic options

Psoriasis is a chronic skin disorder affecting up to 2.5% of the world's population. Despite the myriad treatment options available, there is no uniformly accepted therapeutic approach for moderate-to-severe psoriasis. The objective of this review is to evaluate the relative efficacy and safety of available therapeutic options and to formulate general recommendations for the treatment of moderate-to-severe psoriasis. MEDLINE and Evidence Based Medicine (Cochrane) were used to perform a comprehensive search of the literature from 1986 to 2006. The most scientifically rigorous clinical trial published in the literature was selected for Psoriasis Area and Severity Index (PASI 75) comparison. Only information from clinical trials, human subjects and English language journals are reported in this study. The percentage of PASI 75 reduction at approximately 12 weeks obtained by the following treatment options were: Goeckerman and RePUVA, 100%; calcipotriene plus PUVA, 87%; ciclosporin, 78.2-80.3%; infliximab, 80%; adalimumab 40 mg every other week, 53% and 40 mg/week, 80%; PUVA, 63%; methotrexate, 60%; NB-UVB, 55%; acitretin 52%; etanercept 50 mg twice weekly, 49% and 25 mg twice weekly, 34%; efalizumab, 31.4%; and alefacept 21%. Psoriatic treatments with safer profiles compared with other agents include bath PUVA, Goeckerman and RePUVA. Based on the literature review of efficacy and safety of biologics and prebiologic treatment options for moderate-to-severe psoriasis, the risk:benefit ratio seems most favorable for Goeckerman and RePUVA, followed by either etanercept or adalimumab.

Clinical usefulness and patient satisfaction for treatment with low-dose cyclosporin administration in patients with moderate psoriasis vulgaris

The Japanese guidelines for psoriasis therapy with cyclosporin microemulsion preconcentrate (CyA MEPC) has been revised, and the clinical application of CyA MEPC is being expanded to include mild to moderate psoriasis. In this study, we aimed to confirm the clinical efficiency of low-dose cyclosporin therapy in patients with moderate psoriasis vulgaris. After informed consent was obtained, 19 patients with psoriasis vulgaris were enrolled in this study. Each patient basically administrated CyA MEPC, 2.5 mg/kg/day, orally over 12 weeks. When the psoriasis area and severity index (PASI) score showed a 75% reduction from the initial value, the dosage of CyA MEPC was reduced to 1.5 mg/kg/day and added a topical application of active vitamin D3 ointment. We interviewed the patients as to their satisfaction for the usefulness and cost of the treatment. All patients obtained improvement within 12 weeks. In 10 patients whose PASI score reduced over 75%, we could reduce CyA MEPC dosage. No adverse effects were noted in any patients during the treatment. It is of note that the cost for 1.5 mg/kg/day administration of CyA MEPC was accepted by all the patients. In conclusion, this preliminary study suggests that the CyA MEPC is effective, safe and would provide patients with acceptable costs.

Psoriasis treatment in the United States at the end of the 20th century

BACKGROUND

Psoriasis presents many management complexities. A cornerstone of therapy has been topical corticosteroids, although over the past 10 years there have been many additions to the medication armamentarium. Furthermore, various combination regimens and approaches have been advocated.

OBJECTIVE

We sought to characterize various patterns of psoriasis health care delivery and the changes associated with these patterns from 1990 to 2001.

METHODS

Visits for psoriasis were identified using National Ambulatory Medical Care survey data, a representative survey of visits to physician offices in the United States. We determined basic demographic characteristics, specialty of the physician provider and medications listed at these visits over the 1990-2001 interval.

RESULTS

There were more than 13.5 million visits for psoriasis during the 12-year study period. Dermatologists were responsible for the majority of the visits over the study interval (82%) although there was an overall decline in the proportion of psoriasis visits to dermatologists. As a category, the most common medications used for psoriasis were topical steroids. Topical calcipotriene was the single-most listed medication. There was no observed use of non-corticosteroid topical agents at visits to non-dermatologists. Non-dermatologists were as likely as dermatologists to list a systemic medication at a visit as well as use a systemic as monotherapy.

DISCUSSION

In conclusion, the primary topical therapies for psoriasis remain clobetasol and calcipotriene. The decreasing role of dermatologists in the treatment of psoriasis is probably a complex issue, but may relate in part to the difficulty of obtaining access to dermatology care.

A randomized, multicenter study of calcipotriene ointment and clobetasol propionate foam in the sequential treatment of localized plaque-type psoriasis: Short- and long-term outcomes

BACKGROUND

The merit of topical sequential therapy involving clobetasol foam and calcipotriene ointment has not been experimentally demonstrated.

OBJECTIVE

We sought to assess the short-term efficacy of twice-daily clobetasol foam plus calcipotriene ointment compared with either agent alone as monotherapy and to compare long-term use of weekday calcipotriene ointment with or without clobetasol foam weekend pulse therapy.

METHODS

Eighty-six subjects with plaque-type psoriasis received twice-daily treatment with clobetasol foam plus calcipotriene ointment or either agent as monotherapy for 2 weeks. Subjects in the combination group who achieved remission received weekday calcipotriene plus weekend pulse therapy with either clobetasol foam or vehicle for 6 months.

RESULTS

After 2 weeks, psoriasis scores were significantly lower (P < .001) in the combination therapy group (adjusted trunk lesion score = 0.67) compared with monotherapy with either agent (lesion scores = 1.40 calcipotriene, 1.13 clobetasol foam). During the follow-up "weekday-weekend" phase, after 6 months, weekend pulse clobetasol foam was associated with a trend toward greater maintenance of remission compared with vehicle (92% improvement of trunk lesion vs 62%).

LIMITATIONS

Small sample size may have hampered the detection of statistical significance during long-term therapy.

CONCLUSION

The combination of clobetasol foam and calcipotriene ointment is significantly more effective than monotherapy for short-term treatment. Weekday calcipotriene plus weekend pulse clobetasol foam shows a consistent trend toward greater maintenance of remission.

Consistent control of psoriasis by continuous long-term therapy: the promise of biological treatments

Psoriasis is a chronic, incurable disease that frequently requires long-term treatment. Although many patients benefit from effective traditional systemic therapies, namely methotrexate, cyclosporin, retinoids and fumaric acid esters, and some patients achieve long-term disease control, unrestricted long-term administration is not recommended due to the potential for cumulative toxicity. In order to diminish the risk of toxicity, physicians have adopted various treatment approaches (e.g. rotational, sequential, intermittent, and combination). However, these approaches may not provide continuous disease control or a stable treatment regimen. The recent advent of targeted biological therapeutics such as etanercept, infliximab, adalimumab, alefacept and efalizumab may offer physicians and their patients treatment options with improved safety profiles that may permit continuous disease control.

Methotrexate plus narrowband UVB phototherapy versus narrowband UVB phototherapy alone in the treatment of plaque-type psoriasis: A randomized, placebo-controlled study

BACKGROUND

Combining phototherapy with topical and oral agents allows clinicians to treat recalcitrant psoriasis with reduced number of treatments and cumulative UV exposures.

OBJECTIVE

This study was designed to determine the number of treatments necessary to clear plaque-type psoriasis when narrowband (NB) UVB is administered with methotrexate (MTX) or placebo in a randomized, controlled fashion.

METHODS

MTX (15 mg/wk) or placebo was administered 3 weeks before standard NB UVB phototherapy was started. Treatments with the oral agent and phototherapy were continued until Psoriasis Area and Severity Index scores were reduced to less than 10% of the original scores or 24 weeks. Follow-up was performed until lesional scores returned to 50% of the original ones.

RESULTS

A total of 24 patients were enrolled and 19 patients completed the study. Kaplan-Meier analysis revealed that the median time to clear psoriasis in the MTX/NB UVB group was 4 weeks, which was significantly less than that for the placebo/NB UVB group.

LIMITATIONS

Our sample size was relatively small (24 patients) with 5 dropouts. In addition, the study was conducted in skin types III to IV, Asian patients. Follow-up was limited to 4 to 6 months after completion of phototherapy.

CONCLUSION

MTX pretreatment allows physicians to clear psoriasis in fewer phototherapy sessions than when phototherapy is administered alone.

The cost-effectiveness and cost of treatment failures associated with systemic psoriasis therapies

BACKGROUND

Psoriasis is difficult at times to treat and treatment failures are not uncommon regardless of approach. With the advent of expensive biologic therapies for psoriasis there is increasing discussion on the cost efficacy of a given systemic or biologic agent. An alternative and overlooked aspect of cost efficacy is the cost that accrues from treatment failures.

METHODS

We review the literature and develop a model to analyze the cost-effectiveness and the cost of treatment failures per success for various systemic psoriasis agents using a 12-week treatment period.

RESULTS

For continuous-dose agents, the cost-effectiveness results are: methotrexate $623, acitretin $2729, cyclosporine $2969, nUVB $3692, PUVA $4668, etanercept $16 312, and efalizumab $17 196. The cost of expected treatment failures to achieve one success for the same agents were: methotrexate $187, cyclosporine $505, PUVA $767, nUVB $1034, acitretin $1310, etanercept $8319, and efalizumab $12 897.

CONCLUSIONS

Methotrexate appears to be the most cost-effective agent for the treatment of severe psoriasis. However, greater efficacy can be achieved with cyclosporine and PUVA, albeit at a greater cost. Because of the high cost of treatment failures, access to a wide array of therapies and combination regimens should not be discouraged by physicians or insurers.