Barriers to guideline-compliant psoriasis care: analyses and concepts

Combination Therapy for Psoriasis with Methotrexate and Other Oral Disease-Modifying Antirheumatic Drugs: A Systematic Review

INTRODUCTION

Although the introduction of biologics and targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) has reshaped the treatment paradigm for immune-mediated inflammatory diseases (IMIDs) such as psoriasis, oral conventional synthetic DMARDs (csDMARDs) remain the cornerstone in their treatment. Combinational use of DMARDs is common in rheumatological practice, but for the treatment of many skin diseases, dermatologists typically use a single oral DMARD, with methotrexate (MTX) being the most commonly prescribed csDMARD for psoriasis.

METHODS

To better understand the potential benefits of MTX combination therapy in psoriasis, a literature review was conducted using Medline (PubMed), Embase, Web of Science, and the Cochrane Library, covering articles published from inception until October 2022. Randomized controlled trials, cohort, open-label, and observational studies, and case reports with efficacy and safety results for combination therapy with MTX, csDMARDs, and tsDMARDs or comparisons between MTX monotherapy and combination therapy with other oral DMARDs in psoriasis were included. Studies involving MTX monotherapy alone or sequential treatment with MTX and other oral DMARDs were excluded, as were non-English articles. The results are presented as a systematic review, and the risk of bias was assessed by the corresponding author using the Cochrane Handbook for Systematic Reviews of Interventions, version 6.3, and confirmed by an independent assessor.

RESULTS

Eleven studies comprising 494 participants were included in the review. Overall, combination treatment with MTX and other oral DMARDs exhibited good efficacy and tolerability in psoriasis. However, the included studies were primarily small scale or retrospective, and larger prospective randomized trials are needed to provide stronger evidence.

CONCLUSION

This literature review suggests that combination therapy with MTX and csDMARDs may serve as an efficacious treatment for psoriasis patients with an inadequate response to oral DMARD monotherapy.

Elevating the Standard of Care for Patients with Psoriasis: 'Calls to Action' from Epicensus, a Multistakeholder Pan-European Initiative

INTRODUCTION

Despite advances in treatment options and the management of patients with psoriasis, considerable unmet needs remain. Our objective was to identify ways to elevate the standard of care for patients with psoriasis by combining the perspectives of three important stakeholders: patients, clinicians and payors, and define 'Calls to Action' designed to achieve the identified changes.

METHODS

Eight themes relevant to elevating the standard of care were identified from an insights-gathering questionnaire completed by all three stakeholder groups. A modified Delphi exercise gained consensus on statements informed by the insights. Statements were then used to inspire 'Calls to Action' - practical steps that could be taken to realise the desired changes and elevate the standard of care.

RESULTS

In total, 18 European experts (10 dermatologists, 3 payors and 5 patient representatives) took part in the Delphi process. Consensus was reached on statements relating to all eight themes: improve healthcare systems to better support multidisciplinary team working and digital services, real-world data generation and optimal use, improve patient access, elevate quality-of-life measures as the most important outcomes, involve patients in patient-centred and personalised approaches to care, improve the relevance and reach of guidelines, education, and multistakeholder engagement. 'Calls to Action' common to all three stakeholder groups recognised the need to capitalise on the shift to digital healthcare, the need for consistent input into registries to generate real-world evidence to support guideline development, and the necessity of educating patients on the benefits of reporting outcomes to generate real-world data. The enormous quality-of-life burden and psychological impact of psoriasis, as well as the clinical needs of patients must be better understood, including by healthcare commissioners, so that funding priorities are assessed appropriately.

CONCLUSION

This unique initiative identified a practical 'Call-to-Action Framework' which, if implemented, could help improve the standard of care for patients with psoriasis.

[Regional variations in healthcare for patients with psoriasis and atopic dermatitis in Germany]

BACKGROUND

Psoriasis (Pso) and atopic dermatitis (AD) are chronic skin diseases that result in significant physical and psychological impairment, financial burden, and loss of quality of life. According to previous data, there are regional differences in healthcare.

OBJECTIVES

The aim was to analyse the epidemiology as well as the treatment of insured people with Pso and AD in Germany in a regional comparison.

METHODS

Data of the insurance company Techniker Krankenkasse for the year 2019 regarding treatment prevalences as well as drug prescriptions on the regional level for all physicians were examined.

RESULTS

In 2019 the overall prevalence of Pso was 2.5% (about 2 million insured people in Germany) and AD was 4.2% (about 3.6 million insured people). In Pso, new guideline-compliant drugs were frequently utilised, yet systemic glucocorticosteroids (GCS) were still disproportionally prescribed. Regionally, there were pronounced disparities with higher prescription rates of the new drugs in the north and east. Insured people with AD most frequently received topical GCS (approx. 88%), of which most were class III (66%), and significantly less frequently calcineurin inhibitors (< 10%), which also conform to guidelines. Systemically, GCS were by far most commonly used (about 25% of all insured people with drug prescriptions). Dupilumab, the only long-term drug approved in 2019, was very rarely prescribed, accounting for less than 1%. Again, large regional differences similar to Pso were found.

CONCLUSION

Pso and AD show relevant disparities and gaps in drug care in the regional comparison despite uniform national guidelines and patient needs. The barriers to appropriate modern pharmaceuticals need to be clarified and mitigated.

Alcohol in Psoriasis-From Bench to Bedside

Alcohol affects the symptoms, compliance and comorbidities as well as the safety and efficacy of treatments in psoriatic patients. In this review, we aim to summarize and link clinical observations with a molecular background, such as signaling pathways at the cellular level and genetic variations, and to provide an overview of how this knowledge could influence our treatment selection and patient management.

Quality of psoriasis care in Germany - results from the nationwide health care studies PsoHealth 2004-2017

BACKGROUND

In the study series PsoHealth first data from 2004/05 showed a poor quality of health care for psoriasis in Germany. Most patients lacked sufficient care and only a minor proportion received systemic drugs. Since 2007, a national psoriasis programme has been conducted.

OBJECTIVES

(1) To analyse the quality of health care for psoriasis in the most recent PsoHealth4 survey 2016/17, (2) to compare health care quality indicators with prior assessments since 2004/05.

MATERIALS AND METHODS

The recent cross-sectional PsoHealth4 survey was conducted 2016/17, and three preceding studies were performed in 2004/05, 2007 and 2013/14, each including at least 1500 patients. The common set of quality indicators included disease severity (PASI and proportion of patients with PASI > 20, indicating high severity), quality of life (DLQI and proportion of patients with DLQI > 10, indicating strong impairments in quality of life), systemic therapy and inpatient treatment of the last five years.

RESULTS

Between December 2015 and December 2017, n = 1827 patients from 93 dermatological centres were included in the most recent survey (mean age: 50.8 ± 14.6 years, 45.2% female). 7.3% showed a PASI > 20, compared to 17.8% in 2004/05. 21.4% reported a DLQI > 10, compared to 34.0% in 2004/05. 57.6% of all participants stated to have received a systemic therapy at least once within the last five years, compared to 32.9% in 2004/05. 18.0% received inpatient hospital treatment at least once within the last five years, compared to 26.9% in 2004/05.

CONCLUSION

A remarkable improvement in the health care quality for psoriasis patients in Germany within the past 12 years can be assumed. Major determinants could be the innovation shift which included programmes such as the S3 guideline, a consensus on treatment goals, national health care goals for psoriasis and higher utilisation of innovative drugs.

People-centered care for psoriasis and urticaria: Are we overlooking Internet addiction while only considering patients and physician settings?

Psoriasis and chronic urticaria (CU) are chronic skin diseases with a high impact on individuals' life and mental health. Some studies indicate a high prevalence of Internet addiction and many affected individuals seem not to utilize healthcare, but rather search for health-related information online. The aims of the study were to assess Internet addiction as a potential comorbidity in both diseases as well as identify differences in healthcare utilization between individuals with psoriasis and CU. This cross-sectional study is based on self-reported data from individuals with psoriasis and CU living throughout Germany using the framework of an online survey from 12/2018 to 01/2019. Advertisements on Google and Facebook were used to address Internet users who searched online for information on psoriasis or CU. The study questionnaire comprised questions on demographics, current contact with physicians, and disease history as well as validated screening tools for well-being and Internet addiction. Overall, 1686 participants (74.0% female, 38.5% psoriasis) with a mean age of 36.9 ± 12.9 years were analyzed. Participants with CU were more likely female (89.2% vs 49.8%, P < 0.001) and not in medical care compared to participants with psoriasis (60.3% vs 45.9%, P < 0.001). Sixteen percent of the participants overall were screened positive for Internet addiction. Furthermore, not utilizing medical care showed a significant association with being screened positive for Internet addiction in participants with CU (adjusted odds ratio [aOR] = 1.49, 95% confidence interval [CI] 1.10-2.02), but not in those with psoriasis. The study revealed a high proportion of affected individuals not being in medical care and a high prevalence of Internet addiction, with individuals with CU not utilizing medical resources having a higher chance of being screened positive for Internet addiction. This underlines the approach of people-centered care and highlights its importance for further research.

Gaps in moderate plaque psoriasis management: A survey of Saudi dermatologists

Background:

There are many barriers that usually lead to under-treatment of moderate psoriasis patients, with subsequent unsatisfactory results and clinical outcomes.

Objective:

Given this lack of consistent guidelines on treating moderate plaque psoriasis patients, the aim of the current study is to define how Saudi dermatologists define and treat such cases in the real-world clinical setting.

Methods:

We conducted an online cross-sectional survey from May 2020 to October 2020, involving all eligible dermatologists working at different academic, governmental, and private sectors in Saudi Arabia.

Results:

Finally, a total of 260 dermatologists were included in the final analysis; out of them, 140 (53.8%) were males and 120 (46.2%) were females. Regarding the tools used by participating dermatologists for diagnosis of moderate psoriasis, most of the participants (86.5%) used Body Surface Area (BSA), 7.3% used Physician Global Assessment (PGA), and 6.2% used Dermatology Life Quality Index (DLQI). Cutoff scores for defining moderate psoriasis varied widely among surveyed dermatologists. The surveyed dermatologists reported that 46% of their patients with moderate plaque psoriasis were receiving biologics as their primary therapy, while 24.1% were receiving prescription topical treatment, 20.3% were receiving an oral systemic therapy, 4.9% were using over-the-counter topical treatment, and 4.7% were receiving phototherapy.

Conclusion:

There is a pervasive lack of consensus regarding the definition of moderate psoriasis, with reported wide ranges among the commonly used severity tools in psoriasis patients.

Patients' and Doctors' Beliefs about Treatment and Long-Term Adherence in Rheumatic Diseases

Objective:

The aim of this study was to explore the beliefs of rheumatologists and patients about treatment-related factors, long-term adherence, and their communication with regard to rheumatic diseases.

Methods:

In a multicentre, observational study conducted in Greece, a structured questionnaire was administered to 75 rheumatologists and 398 rheumatic patients from different regions. Five domains were investigated: i) effectiveness of treatment, ii) choice of treatment, iii) change of ineffective treatment, iv) long-term adherence, and v) the quality of communication between doctors and patients. Descriptive data, confidence intervals, t-tests and factor analysis were employed.

Results:

Examining the patients’ and rheumatologists’ beliefs and attitudes about treatment profiles and long-term adherence, a statistically significant convergence in their views on effectiveness and safety as the predominant factors concerning choice of treatment and long-term adherence was found. Although patients reported high trust to their doctors, a divergence of views is recorded regarding communication of the two parts. Statistically significant differences in the views between patients and rheumatologists were found with regards to access (p<0.001), time per visit (p<0.001), mutual understanding (p<0.001), and overall communication (p<0.001).

Conclusions:

Our study shows a great rate of agreement between patients and rheumatologists regarding the factors determining the efficacy, choice, switching and adherence to treatment while there was significant divergence in the views regarding the quality of communication between the two parts. Co-ordinated efforts are needed in order to improve the communication level between rheumatic patients and rheumatologists.

Always Online? Internet Addiction and Social Impairment in Psoriasis across Germany

With the World Health Organization (WHO) demanding further investigation of the social impairment and psychosocial burden of psoriasis, a first study identified a high prevalence of Internet addiction. The aim of this study was to assess social impairment and estimate the occurrence of Internet addiction along with depression, cigarette smoking, and alcohol dependency in individuals with psoriasis recruited online in a people-centered care approach. A cross-sectional online survey was carried out across Germany between March 2019 and June 2019. The questionnaire contained information on social impairment, smoking habits, as well as validated questionnaires on Internet addiction, depression, and alcohol dependency. Overall, 460 individuals (62.4% female; mean age: 45.9 ± 13.7 years) with psoriasis were included. Of those, 406 (88.3%) stated to be at least rarely socially impaired. The positive screening rate for Internet addiction was 8.5%. Furthermore, 40.0% had positive screenings for depression, 17.1% for alcohol dependency, and 32.6% for daily smoking. Positive screenings for Internet addiction and alcohol dependency were substantially more frequent in individuals with psoriasis than in the German general population. In order to meet the demands of the WHO, Internet addiction could be considered as a potential comorbidity in psoriasis and a focus on people-centered care is advisable for further research.

Associations between disease education, self-management support, and health literacy in psoriasis

BACKGROUND

Patients' ability to perform self-management may be compromised if they are unable to fully comprehend their diagnosis and treatments. Weaknesses in health literacy (HL) pose a considerable health concern and may negatively influence SM, as well as interactions with health care professionals (HCP) and peers.

OBJECTIVES

To investigate possible associations between comprehensive HL and psoriasis education from HCPs in a cohort of patients with psoriasis. Another aim was to examine essential sources for psoriasis information and how these are evaluated.

METHODS

Cross-sectional questionnaire data, including the comprehensive Health Literacy Questionnaire (HLQ) from 825 patients with psoriasis who had participated in Climate Helio Therapy (CHT).

RESULTS

Participants having received HCP education scored significantly better in all HLQ scales compared to participants who did not receive such education (Cohen's effect size: 0.24 to 0.44). The CHT program, peers, and dermatologists were the most important sources of psoriasis information. People having participated more than once in CHT presented better HL scores and also higher self-management (skill and technique acquisition) and more psoriasis knowledge (effect-size: 0.75).

CONCLUSIONS

Psoriasis education by HCP seems important for HL and psoriasis knowledge. Patients may need multiple approaches and repetitions over time to be health literate and effective self-managers.

The first nation-wide study revealing epidemiologic data and life quality aspects of psoriasis in Romania

Psoriasis is a chronic, immune mediated, inflammatory condition, which primarily affects the patient's skin. It is known to associate a variable array of comorbidities such as cardiovascular, metabolic and psychiatric ones, with an important impact on the patients' quality of life. The purpose of this study is to provide a first image of the prevalence, comorbidities, as well as the social impact of psoriasis in Romania. We devised a questionnaire, and with the aid of general practitioners throughout the country, delivered it to patients seeking medical care in their office. The questionnaire assessed demographic criteria as well as patient-related issues. It was completed in the presence of the general practitioner, and clear written instructions for completion were included. After statistical analysis, the resulting data formed the basis of this study. The reported prevalence of psoriasis in Romania is 5.18%. Almost half of the subjects who completed the questionnaire stated they knew somebody affected by the disease, yet almost a third believed it is a contagious condition. Cardiovascular and psychiatric comorbidities, as well as negative impact on social interactions were reported by the subjects in the study. These findings indicate the clear need for better quality of life for patients in a social context and increased awareness of the disease. All these could, in turn, help decrease the rate of psoriasis complications in Romania.

The prevalence of ADH1B and OPRM1 alleles predisposing for alcohol consumption are increased in the Hungarian psoriasis population

Alcohol intake affects in great the symptoms and life of  psoriasis patients, although the association of SNPs related to increased alcohol consumption with psoriasis has not been elucidated. Therefore, to investigate the association of psoriasis with established alcohol consumption and dependence-related gene variants we conducted a population-based case-control study including 3743 subjects (776 psoriasis cases and 2967 controls from the general Hungarian population). Genotyping of 23 SNPs at ADH1B, ADH1C, ALDH1A1, ALDH2, SLC6A3, DDC, GABRA2, GABRG1, HTR1B, MAOA, TPH2, CHRM2, GRIN2A, POMC, OPRM1, OPRK1 and BDNF were determined and differences in genotype and allele distributions were investigated. Multiple logistic regression analyses were implemented. Analysis revealed association between C allele of the rs1229984 polymorphism (ADH1B gene) and psoriasis risk (OR_additive = 1.58, 95% CI 1.23-2.03, p < 0.001, OR_recessive = 1.58, 95% CI 1.22-2.04, p = 0.001). Furthermore, the G allele of rs1799971 polymorphism (OPRM1 gene) increased the risk of familial aggregation (OR_additive = 1.99, 95% CI 1.36-2.91, p < 0.001 OR_dominant = 2.01, 95% CI 1.35-3.01, p < 0.001). In subgroups of psoriatic patients with history of early onset and familial aggregation effect allele 'C' of rs1229984 showed association in the additive and recessive models (OR_additive = 2.41, 95% CI 1.26-4.61, p < 0.01, OR_recessive = 2.42, 95% CI 1.26-4.68, p < 0.01). While effect allele 'G' of rs1799971 (OPRM1) also associated with increased risk of early onset and familial aggregation of psoriasis in the additive and dominant models (OR_additive = 1.75, 95% CI 1.27-2.43, p = 0.001, OR_dominant = 1.82, 95% CI 1.26-2.63, p = 0.001). Our results suggest that genetically defined high-risk individuals for alcohol consumption are more common in the psoriasis population.

Patient experiences of using Chinese herbal medicine for psoriasis vulgaris and chronic urticaria: a qualitative study

Background: Psoriasis vulgaris and chronic urticaria are common skin conditions with a significant health burden. Achieving long-term control remains a challenge, and some patients choose Chinese herbal medicine (CHM) to meet this need. Little is known about the motivators and experiences of using CHM for these skin conditions.Objectives: To determine the motivators for choosing CHM, and experience of using CHM for psoriasis vulgaris and chronic urticaria.Methods: We conducted semi-structured interviews with participants who had previously used CHM for these conditions. Interviews were transcribed for data analysis.Results: Twenty participants completed the interviews in Guangzhou (n = 16), China, and Melbourne (n = 4), Australia. Motivators included wanting an alternative to conventional medicine, beliefs about CHM and previous experience. Participants expected that CHM would be safer and could prevent relapse; this expectation was met for some participants. Preparing CHM decoctions was onerous, and CHM granules were more convenient.Conclusion: Beliefs, previous experience of using CHM, desire to prevent relapse, and safety are important motivators for choosing CHM in people with psoriasis vulgaris and chronic urticaria. Further clinical evidence is required to enable patients to make informed clinical decisions. Patient preferences should be considered in the context of available evidence when prescribing CHM.

Complementary and integrative therapies for psoriasis: Looking forward

Despite the great advances in our understanding of disease pathogenesis and a rich variety of therapeutic options, including the availability of newer biologic agents, there is still no cure for psoriasis. Based on low levels of satisfaction in the treatment they receive and their overall care, it is not surprising that a substantial part of patients turn to complementary and alternative therapies. Integrative medicine is an exciting new approach to health care. The dermatologist should recognize this growing trend and become familiar with the current literature on integrative therapies for psoriasis. Several complementary therapies, those that have been found to be safe and effective, can be recommended as part of an integrative treatment plan.

Pathophysiological basis of systemic treatments in psoriasis

Over the past 15 years, the spectrum of systemic antipsoriatic treatments has dramatically expanded. Until the end of the last millennium, systemic therapy had been restricted to four oral agents: methotrexate, cyclosporine, acitretin, and fumaric acid esters. Today, there are additionally seven biologics and one new oral antipsoriatic drug, as well as the first available biosimilars. Six more biologics with novel target structures and at least four biosimilars are currently being developed (phase III). This progress has been based on new insights into the pathogenesis of psoriasis, in which tumor necrosis factor and especially Th17 immune responses with their associated cytokines interleukin 23 and 17 play a key role. The development of new-generation biologics as well as immunomodulatory small molecules can be attributed to these pathophysiological findings. Phosphodiesterase 4 inhibitors, dimethyl fumarate, and Janus kinase inhibitors all interact with Th17 immune responses. Some of these drugs are in advanced clinical development and are also beneficial in psoriatic arthritis. Today, psoriasis and psoriatic arthritis therefore rank among the most readily treatable inflammatory autoimmune disorders. Dermatology is increasingly becoming a specialty of modern targeted immunotherapies.

Barriers to treatment: describing them from a different perspective

BACKGROUND

Poor adherence is the result of many barriers. Most of the adherence research has focused on the patients' hurdles to adherence, instead of the responsibility the physician has for assuring adherence to treatment.

OBJECTIVE

The purpose of this review is to identify barriers to medication adherence and refocus how we describe those barriers in terms of physician behavior hurdles.

METHODS

PubMed was systematically searched for systematic reviews published between January 01, 2010, and December 06, 2017, that provided barriers to medication adherence. The searches were limited to reviews having adherence to medication prescribed in the outpatient setting as the main topic.

RESULTS

Thirty-one reviews were included in this review, covering 13 different disease categories. Fifty-eight different barriers to adherence to medications for chronic conditions were identified. Nineteen barriers were cited 6 or more times, and these were further categorized based on the World Health Organization's 5 dimensions of adherence and the number of times cited.

CONCLUSION

This review provides clear evidence that adherence to medication is affected by multiple barriers. To facilitate this, adherence barriers can be framed as physician/health system hurdles. With that focus in mind, we may put the responsibility where we have the most control.

Addiction: an underestimated problem in psoriasis health care

BACKGROUND

Psoriasis is a disease of enormous socio-economic impact. Despite approval of numerous highly efficient and costly therapies, a minor proportion of severely affected patients actually receives sufficient treatment.

OBJECTIVE

To investigate whether addictions are associated with psoriasis and to develop evidence-based recommendations for dermatologists in their daily clinical practice in order to improve medical assessment of psoriasis and patients' quality of life.

PATIENTS AND METHODS

Psoriasis patients at the University Department of Dermatology were asked to fill out a paper-based self-reported anonymous questionnaire with 92 questions of validated screening tests for the six most common addictions in Germany (alcohol, nicotine, drugs and illegal drugs, gambling, food). Body weight and height as well as current Psoriasis Area and Severity Index (PASI) were documented as well.

RESULTS

Between October 2015 and February 2016, 102 patients (65 males, 37 females; mean age 49.7 years (SD 13.4), range 18-83 years) participated in the study. Fifty-seven of the 102 patients showed addictive behaviour. Of these, 23.8% were high-risk drinkers, 41% regular smokers, 11% at risk of drug abuse, 4.1% at risk of food dependency and 19% compulsive gamblers. Compared with the general population, these results are significantly higher for alcohol abuse (P < 0.005), nicotine (P < 0.001) and gambling (P < 0.001). Body mass index was significantly higher in the study population (P < 0.001).

CONCLUSION

Addictions and gambling are more prevalent in patients with psoriasis compared with the general population. Respective screening measures are recommended in daily practice for doctors treating psoriasis patients, and PeakPASI is suggested as a score to document patients' lifetime highest PASI. Parallel to new drug approvals and even more detailed insights into the pathomechanism of psoriasis, public health strategies and interdisciplinary approaches are essential for a general sustained psoriasis treatment.

Topical medication utilization and health resources consumption in adult patients affected by psoriasis: findings from the analysis of administrative databases of local health units

AIM

The objectives of this study were to: 1) analyze the drug utilization pattern among adult psoriasis patients who were newly prescribed with topical medication; and 2) assess their adherence to topical therapy and the possibility of switching to other strategies in the treatment process.

METHODS

An observational retrospective analysis was conducted based on administrative databases of two Italian local health units. All adult subjects who were diagnosed with psoriasis or who were newly prescribed for topical medication with at least one prescription between January 1, 2010, and December 31, 2014, were screened. Only patients who were "non-occasional users of topical drugs" (if they had at least two prescriptions of topical drugs in a time space of 2 years) were considered for the first and second objectives in the analysis. The date of the first prescription of topical agents was identified as the index date (ID), which was then followed for all time available from ID (follow-up period). The adherence to therapy was assessed on the basis of cycles of treatment covered in the 6 months before the end of the follow-up period. The mean health care costs in patients who switched to disease-modifying antirheumatic drugs (DMARDs) or biologics after the ID were evaluated.

RESULTS

A total of 17,860 patients with psoriasis who were newly prescribed for topical medication were identified. A total of 2,477 were identified as "non-occasional users of topical drugs", of whom 70.2% had a prescription for a topical fixed combination regimen at ID. Around 19% adhered to their medication, whereas 6% switched to other options of psoriasis treatment. Multivariable logistic regression model shows that patients on fixed combination treatment were less likely to be non-adherent to treatment and less likely to switch to other treatments. The annual mean pharmaceutical costs were €567.70 and €10,606.10 for patients who switched to DMARDs and biologics, respectively.

CONCLUSION

Our findings show that the use of fixed combination topical treatment can lead to improve the likelihood of patients being adherent to treatment and can decrease the likelihood of switching the treatment to DMARDs or biologics.

Psoriasis

Psoriasis is a chronic, immune-mediated disorder with cutaneous and systemic manifestations and substantial negative effects on patient quality of life. Psoriasis has a strong, albeit polygenic, genetic basis. Whereas approximately half of the accountable genetic effect of psoriasis maps to the major histocompatibility complex, >70 other loci have been identified, many of which implicate nuclear factor-κB, interferon signalling and the IL-23-IL-23 receptor axis. Psoriasis pathophysiology is characterized by abnormal keratinocyte proliferation and immune cell infiltration in the dermis and epidermis involving the innate and adaptive immune systems, with important roles for dendritic cells and T cells, among other cells. Frequent comorbidities are rheumatological and cardiovascular in nature, in particular, psoriatic arthritis. Current treatments for psoriasis include topical agents, photo-based therapies, traditional systemic drugs and biologic agents. Treatments can be used in combination or as monotherapy. Biologic therapies that target specific disease mediators have become a mainstay in the treatment of moderate-to-severe disease, whereas advances in the treatment of mild-to-moderate disease have been limited.

The German National Program on Psoriasis Health Care 2005-2015: results and experiences

In 2005, the first national psoriasis survey in Germany revealed large deficits in health care particularly in patients with moderate to severe disease. The consecutive goal was to improve health care for psoriasis countrywide. For this, a large-scale national program was initiated starting with a comprehensive analysis of structures and processes of care for psoriasis. Patient burden, economic impact and barriers to care were systematically analyzed. In order to optimize routine care, a S3 guideline, a set of outcomes measures and treatment goals, were developed. Implementation was enforced by the German Psoriasis Networks (PsoNet) connecting the most dedicated dermatologists. The annual National Conference on Health Care in Psoriasis established in 2009 consented National Health Care Goals in Psoriasis 2010-2015 and defined a set of quality indicators, which are monitored on a regular basis. Currently 28 regional networks including more than 800 dermatologists are active. Between 2005 and 2014 7 out of 8 quality indicators have markedly improved, and regional disparities were resolved. e.g., mean PASI (Psoriasis Area Severity Index) dropped from 11.4 to 8.1 and DLQI (Dermatology Life Quality Index) from 8.6 to 5.9. A decade of experience indicates that a coordinated nationwide psoriasis program based on goal orientation can contribute to better quality of care and optimized outcomes.